Monday, April 29, 2024

Practicing medicine “in the zone”

We often hear the expression "being in the zone" when referring to finely tuned athletes and athletic teams. Elite athletes like Tiger Woods, Michael Jordan, and Rafael Nadal discuss being in the zone, that magical place where mind and body work harmoniously and movements seem to flow without conscious effort. Major-league pitchers, NBA stars, pro golfers, and Olympic hopefuls dedicate their careers to the search for this elusive state of performance, devoting hours of training to "listening" to their body and "reading" their muscles—trying to construct a bridge between mind and body sturdy enough to lead them straight to athletic nirvana.1

Athletes who are in the zone identify seven characteristics of a zone experience. Athletes reported:Being totally absorbed in the activity
Experiencing inner clarity
Having a sense of ecstasy and being outside of everyday reality
Being focused on the present
Feeling a deep passion for the activity
Having a sense of serenity, no anxiety about their performance
Feeling no sense of effort2

Any athlete in this mental state of being in the zone is unbeatable at their respective level of competition—and at the elite level, you often witness world records being broken.

It is possible to practice medicine by being in the zone. Being in the zone means effortlessly practicing medicine, increasing productivity, improving efficiency, having a staff that enjoys caring for your patients, and, at the end of the day, walking away with a sense of joy, gratification, and contentment.

This sounds like a pipe dream. Especially in this era of healthcare reform, there is so much uncertainty, stress, and anxiety associated with the practice of medicine.

What can you consciously do to put your practice in the zone? This article will discuss 15 examples for practicing in the zone and making your practice more efficient and productive.
  1. You know your practice is in the zone when there are no patient cancellations or no-shows, leaving holes in the schedule. Zone practices use either automated phone reminders or have an employee in the office call the patients and remind of their appointments.
  2. Zone practices don't double-book patients for the same time slots, thinking that some patients will not show up or cancel their appointments. Instead, zone practices leave time slots each day to accommodate emergencies or patients who need same-day appointments. You know you are in the zone when you don't have any no-show patients.
  3. A zone practice has most of their account receivables less than 30 days. You have a problem when more than 5% of your ARs are more than 90 days.
  4. Consider your practice in the zone when your receptionist collects 100% of the co-pays. It becomes costly to send out bills for small amounts of money. It is also expensive to submit a bill and then collect small co-pays after you have seen the patient and they leave the office. A zone practice collects the co-pays before the patient sees the doctor.
  5. A zone practice submits "clean" and "scrubbed" claims, and as a result, there are very few or no claim denials.
  6. Your practice can be considered in the zone if you can see patients within 15 minutes of their designated appointment time. If patients wait longer than 15 minutes, patient satisfaction will deteriorate, and patients will leave the practice if you are chronically late.
  7. When you are doing what you enjoy and are good at, you know you will be in the zone. If you don't like seeing Workman's Compensation patients or taking care of patients who have STDs, then don't accept those patients and refer them to colleagues who enjoy those patients.
  8. A practice will thrive and be in the zone when it has an abundance of new patients. A new patient who needs a procedure or a workup is far more profitable than a patient who returns for a PSA test and a rectal examination. Your practice will be in the zone if you can accommodate new patients when they call for an appointment.
  9. Practices are in the zone when patients are requested to complete demographic information and the health questionnaire online or before they come to the office. When this happens, patients are not kept in the reception area for long periods of time and are delayed in being taken from the reception area to the exam room.
  10. You have a zone practice when their insurance eligibility is verified before the patient comes to the office. Patients whose eligibility has yet to be verified are notified and informed that they must pay for their visit or obtain eligibility.
  11. A practice in the zone has all the patient's information, reports, and X-rays available during the visit. Nothing is more disheartening and anxious than to have a patient who is to discuss the results of a biopsy and find that the report isn't in the medical record. Locating take 30 minutes or more. Now only does this delay result in loss of efficiency and productivity, but also results in anxiety and stress in patients waiting for the report.
  12. Zone practices have little to no staff turnover. Staff turnover is costly and results in a temporary loss of efficiency as the new staff member needs to be brought up to speed. Waiting to have a position filled when a staff member leaves results in added work and stress on your existing staff.
  13. Being in the zone means ending the day at the designated time without the doctor or the staff staying in the office and incurring overtime expenses. When you have an efficient practice, all the patients can be seen in the allotted time, and the staff leaves at the expected time. This makes for a happy staff and a happy doctor.
  14. Practices in the zone have satisfied patients whose expectations are not only achieved but exceeded. What better feeling can you have at the end of the day than to know that you have helped people achieve good health, feel a sense of accomplishment, and feel rewarded for your services? Practicing in the zone is an achievable objective. All of us can reach it regardless of the geographic location, size of the practice, and the makeup of the patients we see.
  15. Using visualization to enter the zone. What one can conceive; one can achieve.3 You might have heard this before but probably haven't practiced it like most physicians. Goals are essential for providing you with something specific to constantly work toward. Another essential to growing a successful practice is your vision. Being a visionary requires picturing what you want and seeing how it would happen.

In the 1984 Olympics, Mary Lou Retton needed a perfect ten on the vault to secure the all-around women's gymnastics gold medal. She paused and took her time before she was ready to do the vault. Mary Lou closed her eyes before starting and visualized the full vault in her mind. She pictured herself running towards the vault, executing her routine, and sticking a perfect landing. When she opened her eyes, she took off running. Her routine—and well-deserved perfect ten—earned her a standing ovation and a gold medal.

Jack Nicklaus, winner of 18 PGA championships, stated he also employed visualization techniques before every golf shot. He said that he played an entire game in his head and would picture making the perfect swing, imagining how the golf club would strike the ball. He visualized the ball's flight, landing, and even how it rolled on the green.

Other famous people have used visualization techniques to help them see their paths forward and pursue them, including:
  • Actors Jim Carrey and Will Smith.
  • Top athletes Misty May-Treanor and Kerri Walsh (Olympians in beach volleyball), Lindsey Vonn (World Cup Alpine ski racer).
  • Media personality Oprah Winfrey.
  • Body builder/actor/politician Arnold Schwarzenegger.

The fact is visualization works in tandem with your goals. It paints a picture of the "end" you're supposed to keep in mind, that all your goals are working toward. It provides you with a path forward. Much like with your goal setting, the best way to start visualizing what you want for your practice is to write it down. Start with what you have, then move to the details of your perfect practice.

What does your future practice look like, particularly compared to what you have now? Picture the walls. Will you have wallpaper or paint? Imagine the color schemes. What kind of flooring does your perfect office have? Do you have enough storage, or will you need a better organizational system for the ideal office? Don't stop there, either. How does your office smell? Will it have a fresh, just-cleaned smell? Will you have coffee brewing to have a pleasant aroma instead of the usual medicinal order?

Now, consider how your patients are greeted. Is your receptionist warm and friendly? Do they hide behind a big wooden window? Are they a perfect hostess, assisting the patients in filling out forms and offering a snack or a beverage? How do they answer the phone? Could it be better? Many medical office receptionists answer by saying, "Doctor's office" or "Dr. Jones's office." But a better way to answer the phone is by saying, "Welcome to Ocean County Medical Practice; this is Jane; how may I help you?" This makes a huge difference and creates a positive first impression on the patient.

Imagine the patient's experience in the exam room and what it would take for the patient to leave feeling like they had a fantastic visit. How can you give them that "wow" experience that makes them go out and tell others about you and your practice? What happens when the patient leaves the office? Do you call all your new patients the next day to see how they are doing and ask them if they have any questions they might have thought of since their visit? Do you send a thank you note to patients who refer a patient? Do you send a note to the referring physician with a report of your management of their patient?

The visualization process isn't just for your practice, either. It's part of working toward all your goals, whether for your family, health, finances, hobbies, or anything else. Take time to really picture what you want your life to look like and the goals that will get you there. What kind of life do you want? Do you have children? Do you want to pay for their tuition, so they don't graduate with debt?

Dream big, as this will help get you into the zone.

Bottom Line: If you talk to a finely tuned athlete and ask about their performance on a day when they have done exceptionally well, were victorious, and seemed to exceed their baseline skills, they will tell you about being in the zone. Physicians are also professionals who work harder and longer than most athletes to reach their station in life. We, too, can get into the zone and have an idealized practice where it is still fun to practice medicine.


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Friday, April 26, 2024

Why independent physicians are seeking strategic partners

In recent years, private practice physicians have faced the most difficult challenge – trying to maintain their independence while adapting to previously unforeseen macroeconomic pressures such as rising inflation, payors and retailers becoming competition themselves, and declining reimbursements; all pressures that are contributing to physician groups selling ownership of their practice to private equity and other strategic acquirers in order to better compete. Physicians, however, are made to feel as if they have committed a mortal sin by even considering a sale.

For physician entrepreneurs who have sacrificed 10-15 years becoming educated, and 10, 20 and 30 more years building a practice, my colleague Michael Kroin, CEO & Managing Partner of Physician Growth Partners, asks “Why can’t doctors be rewarded for building such a successful practice to help diversify their portfolio rather than having all their long term financial wealth tied up in their practice?” Kroin added, “In many other industries, entrepreneurial owners who build great businesses are rewarded for their sacrifice, hard work and dedication, eventually choosing to diversify their assets as they grow… why shouldn’t doctors be able to do the same?”

With private equity’s entrance into healthcare - and more specifically, physician practices - still in the early innings, can private equity be positive for doctors and patients? Why are independent physician groups increasingly partnering with private equity?

When making clinical decisions, doctors like to trust their peers when evaluating certain technologies or treatment modalities. Why should evaluating a private equity or strategic partner be any different? We had a chance to speak with several physicians who have sold their practices, and here are some insights on what motivated them to go the PE route, how things are going “after the deal” closed, and how their partnership is helping them maintain their independence while continuing to compete and grow in an increasingly complex healthcare environment.


Maintaining clinical autonomy


One of the key concerns doctors have when considering a collaboration with private equity is the fear of losing clinical autonomy. No doctor wants a non-physician directing patient care with primarily monetary interests in mind. It is important to note that most private equity firms respect the clinical expertise and judgment of physicians and prioritize preserving their autonomy.

Related to how the private equity transactions are structured with practices, Louis Glaser, a partner at Katten Muchin Rosenman LLP, notes, “The typical model employed by private equity based companies is not to employ physicians, but rather to establish management services organizations (MSO) to manage and administer the non-clinical aspects of their practices. In these structures, there is clear delineation between clinical activities/decisions and patient care, which remain within the purview of the physicians, and purely administrative or business decisions that are within the purview of the MSO. In most structures, even those decisions that fall somewhere in the middle are made jointly by the physicians and the MSO. All of this is very different from a hospital/health system or retail clinic employment model.”

In February 2023, UroPartners, one of the largest independent urology practice in the U.S., partnered with Solaris Health, the largest PE-backed urology platform in the country. CEO and urologist Richard Harris, MD, FACS, stated, “It was a long journey. We started years ago thinking private equity was not a good idea, but due to market pressures out of our control, we felt that by being a part of a larger network of private practices would be necessary and valuable to compete. A year into our partnership, and I’m happy to say we are still physician-led and there have been no clinical or scheduling changes.”

Dermatologist Mary Lupo, MD, has been married to PhyNet Dermatology since January 2019 and she said, “Our partners have never interfered with our practice style or clinical decisions in how we treat our patients. Not only that, but I can also take time off when I need to and nothing has changed in that regard. Best of all, my employees are happy, and my patients are unaware I sold since the practice name stayed the same and didn’t rebrand. My experience has been so positive that I’m extending another 3 years since my 5-year contract has ended.”

Amy Taub, MD, FAAD, owner of Advanced Dermatology, had similar things to say. “We sold to Forefront Dermatology in November 2023. We have found few changes in our day-to-day operation after our integration with PE. We have not been told to change how many patients we see, nor how to treat them. Our staff has remained intact.”

Colorado Springs Urological Associates (CSUA) began their partnership with private equity in November 2021, and senior partner Jeffrey Ferguson, MD, has seen a significant impact on many levels. “We have continued to enjoy near complete autonomy as far as scheduling, vacation, and call days. Our local board of managers has first say over all local matters and capital expenditure decisions are made jointly with our national partners,” said Ferguson.


Access to capital and resources for market expansion


In addition to finding the right strategic partner culturally, private equity can help physicians expand their practices to reach new patients by opening new locations or expanding ancillary services. This not only boosts their financial stability but also enhances their independence by allowing them to provide further access to patients.

Beginning in 2021, Orthopaedic Specialists of Austin (OSA), started becoming educated on private equity and what it could possibly mean for the practice, ultimately deciding to partner with Growth Ortho in June 2022. Senior partner Edward Seade, MD, noted, “Since the PE partnership closed, we have added two new MD’s and one PA-C from a provider perspective. We have also started our own physical therapy clinic and expanded our DME within the practice; and PE was also able to help us secure and close a two operating room same day surgery center.”

Ferguson of CSUA noted, “We were lacking the bandwidth and knowledge to take advantage of all the market opportunities that were available to us. Doctors and managers at Solaris were able to help us open a molecular clinical lab and fully acquire our radiation center more quickly and more efficiently than we ever would have been able to do ourselves.”


Centralizing benchmarking data & creating efficiencies


In healthcare, there is no shortage of data being collected, from clinical quality scores to outcome measures, to understanding physician and staff performance. Acting on data however, can oftentimes be a challenge based on disparate sources of information and/or competing interests.

Ferguson of CSUA stated, “Our partners have helped us develop our business intelligence. Prior to our affiliation, it was expensive and time consuming for us to generate meaningful performance reports. Now our data collection is centralized and organized such that any partner can access practice data to improve performance and productivity, and managers can easily generate meaningful reports and benchmark our practice against affiliates across the platform. Business improvement requires data and business intelligence and we lacked this prior to our affiliation.”


Creating long-term economic value


One of the most obvious reason business owners in any industry pursue an “exit” and sell to private equity or any strategic acquirer is the potential economic benefit of taking chips off the table and capitalizing on years’ worth of hard work and sacrifice.

Seade of OSA noted, “I received a large payout on my earnings that I have been able to put to use in different investments. Getting a modest 5% return on this investment makes it so that the portfolio growth is significantly higher than the cash I would have received in my practice without the PE deal. This all while allowing our practice to expand as previously mentioned.”

Economics, however, cannot be the sole reason physician groups transact with private equity. It needs to be the right cultural fit and long-term strategic partner.

For Taub, it’s all about maintaining the culture of the practice she has built and everything else will take care of itself with the help of a strategic partner. “What is expected is that we continue to perform similarly to how we were before, including financially. We also have experienced less expensive health insurance, access to experienced billing, strategic executives, as well as more resources for managers to interact with to foster in our next phase of growth.”

Physician practices aligning with private equity have not come without scrutiny however, and rightfully so, as not all private equity firms are created equal. The basis for many arguments against private equity’s entrance into healthcare stem from claims that, since entering the market, they’ve done nothing but raise costs and decrease quality of care, but is this the full picture? As with any industry, there are good and bad actors and it’s important to partner with private equity firms and strategic partners that will always continue to:
  • Lead with a focus on medicine and quality of care
  • Allow doctors to retain control of their clinical practice
  • Provide resources and capital to empower the practice to continue to grow and benefit from economies of scale

Regarding the THREE key pain points all physician groups are facing regardless of ownership structure, let’s examine them further:


Inflation – Labor and supply costs increasing year-over-year


In a June 2022 survey conducted by MGMA, 90% of medical practices reported that their costs were rising faster than revenues due to inflation, and one respondent noted that “Labor costs are up 30% year-over-year.”

According to Adam Levy, MD, a gastroenterologist in Macon, GA, supply costs are at all-time highs, but Medicare ASC reimbursements do not adjust or offer any flexibility, contributing to a tougher environment for specialists in private practice.

In a recent survey conducted by Morning Consult on behalf of the American Hospital Association (AHA), 94% of physicians think it has become more financially and administratively difficult to operate a practice.


Continued pressure from payors, hospitals, and retailers – Doctors are fatigued


In the same survey conducted by Morning Consult on behalf of AHA, eighty-four percent of employed physicians surveyed reported that the administrative burden from commercial health insurers and government insurance programs had an impact on their employment decision.

According to Medical Economics’ “94th Physician Report” in 2022, 39% of physicians spent 1-9 hours on prior authorizations weekly, and 17% spent more than 20 hours. Similarly, in a Medical Group Management Association (MGMA) November 2023 “Annual Regulatory Burden Report” survey, 97% of patients surveyed said they experienced delays or denials for medically necessary care due to prior authorization red tape.

Meanwhile, payors who enforce prior authorization measures, denials, and set pressure on the independent practice of medicine continue to report extraordinary results on Wall Street. Optum, a subsidiary of UnitedHealth Group, reported $59.5B in revenue for the fourth quarter of 2023, and $226.6B for the full year, a 24% year-over-year increase while its parent United (NYSE: UHG) reported a record-breaking profit (more than $20 billion in 2023) and is now the largest employer of physicians in the country (90,000 and counting).

While compounding profits on the backs of providers and patients, commercial insurers are also leveraging their excess capital and scooping up physician groups as well. Optum, a subsidiary of United Health, has been actively acquiring physician practices and surgical centers over recent years including Surgical Care Affiliates, Physicians Endoscopy, and more.

Major retailers, pharmacies, and convenience stores have also entered healthcare over the last several years. For instance, CVS Health’s acquired Oak Street Health and Signify Health, while Walgreens acquired VillageMD.

It is hard to point the finger at private equity when commercial insurance companies, hospitals, and large retailers continue to not only post record revenues and profits but have started to become the acquirer themselves. Much of the data utilized to illustrate private equity’s negative impact on healthcare has coincided with a rapid expansion and strengthening of payors’, hospitals, and retailers’ position in the market, opening the door to questions on who/what is really to blame.


Physician reimbursement is NOT keeping up with inflation


According to the American Medical Association (AMA), Medicare physician payment has effectively been cut 26%, adjusted for inflation, from 2001–2023, during a time when the “cost of doing business”, aka running a practice has skyrocketed. Over that same time period, the cost of running a medical practice increased 39 percent, including increases in physician office rent, employee wages, and professional liability insurance premiums, measured by the Medicare Economic Index or MEI.

In one example of lobbying to help independent physicians, orthopedic surgeons banded together recently in response to the episode-based payment model (CMS-5540-NC) proposed by the Centers for Medicare and Medicaid Services (CMS). A letter dated August 17, 2023, was sent to CMS by American Academy of Orthopedic Surgeons (AAOS) President Kevin Bozic, MD, in response to support the overall move to value-based care; and trying to align incentives with the quality of care, in addition to the long-established fee-for-service payment model.

When it comes to alignment of incentives and creating a strong clinical and business partnership, Anthony Romeo, MD, a world renowned orthopedic surgeon and EVP of the Musculoskeletal Institute for Downers Grove, IL-based Duly Health and Care, suggests new partnership models could be a sustainable model of the future in specialties like orthopedics. “So far value-based care has been mostly a buzzword, and in reality, costs have been going up for many physician groups and their patients,” stated Romeo. “Newer MSO partnership models that prioritize patient care first and allow the finance folks to do what they do best and physicians to do what they do best will be successful.” Romeo added, “The key with any of these partnerships is strong physician leadership, ensuring no decision that significantly impacts the care delivery model and resources necessary for high quality care is made without the approval of physician leadership. We’ve all heard the horror stories of private equity and practice partnerships in years past. New partnerships moving forward need to be formed with sustainability at their core, instead of management and operations by excel spreadsheets. I do think private equity can help groups compete but is has to be at a level of investment that won’t suffocate the group.”


Conclusion


Private equity or a strategic partnership doesn’t make sense for every group but it is important to rationally consider the objective and potential benefits of partnering with private equity, in the face of numerous headwinds physician groups continue to face.

Maintaining clinical autonomy, gaining access to capital and operational resources, centralizing benchmarking data and creating efficiencies, and creating short- and long-term economic value are all compelling reasons for physicians to explore these partnerships. It is however, essential to approach such collaborations with caution, due diligence, and the help of the right advisor.


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Thursday, April 25, 2024

Putting fun in the practice: Hire for attitude, train for skills

“Fun is taken seriously at Southwest Airlines. Life is too short and too hard and too serious not to be humorous about it,” Herb Kelleher, founder of Southwest Airlines


Healthcare is a stressful profession. Most doctors and healthcare employees must work smarter, harder, and faster than ever. It is not surprising that burnout exceeds 50% of healthcare workers. As the pace and intensity of healthcare have increased, we have often lost touch with the lighter side of life and even questioned why we went into the profession in the first place. Many medical practices have become very serious and bottom-line focused. We are asked to leave our personal and emotional baggage at the door before entering the office. We have been told that humor in the workplace is unprofessional and that silliness is for play and not for medical practices.

I think we can learn from Southwest Airlines, which believes that failure to nourish and encourage a sense of humor in the workplace not only undermines productivity, creativity, adaptability and morale can also impact employee retention, resulting in costly turnover.

Southwest Airlines hires employees, from baggage handlers to pilots, who can do their jobs well with laughter and grace. A passenger on a Southwest Airlines plane wants to engage with empathetic employees who inherently believe that serving passengers includes a healthy sense of humor, which makes the lives of the employees and the passengers more fun. Healthcare can be challenging - simply by the type of service we provide - but healthcare professionals have an opportunity and a responsibility to move out of the serious, stiff, humorless atmosphere and add appropriate levity when providing care for our patients. We need to find ways to make working in healthcare fun despite the intensity and seriousness of our profession.

How do you find those with a funny bone and as well as a crazy bone? We need to follow the example of the Southwest Airlines hiring process: “hire for attitude and train for skills.” Their hiring department looks for employees who don’t take themselves too seriously and then commits to training them on what they need to do to make the flight enjoyable for the passengers. They focus on hiring employees with the right spirit, those who are willing to work hard and have fun at the same time.

Perhaps when you are interviewing a potential employee for the first time, you might ask, “Tell me how you used your sense of humor in a work environment or tell me how you have used humor to diffuse a difficult situation.”

When posting a job opening, you might include something along the lines of, “We are looking for someone who doesn’t take themselves too seriously while taking their patient care very seriously.” You could share, “Consider Acme Healthcare if you want a future that encourages coloring outside the lines, without boundaries, the opportunity to be original, and a chance to work your tail off!” This kind of post emphasizes that your practice is committed to providing a medical practice that is serious about providing outstanding patient care while committing to having fun, building connections, and creating a culture filled with down-to-earth, charismatic people. I am not suggesting that you are looking for standup comedians or those who can dole out one-liners. The message must be clear that behind all the fun, there’s hard work.


Bottom Line:

Consider looking for future employees with a sense of humor. You should hire for spirit, grit, work ethic, and enthusiasm. You can follow up and train for skills, which is easy. Treat such an employee as a family member or best friend when you have such an employee. Don’t ever take them for granted. Finally, treat everyone with kindness and respect. They will appreciate the kindness and pass it on to your patients. As a result, you will have an enjoyable, productive, efficient, and fun practice.

Let’s end this blog with another quote by Herb Kelleher, “We will hire someone with less experience, less education, and less expertise than someone who has more of those things and has a rotten attitude. Because we can train people. We can teach people how to fly and how to be kind to passengers, but we can't change their DNA.”


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