Monday, January 31, 2022

Asset Protection and Physician Family Businesses

Physicians doing business with family members as co-owners, investors, or lenders face a variety of legal and financial risks. This checklist outlines some of the most common issues every doctor should address to protect their assets and their relationships.

Our last discussion outlined some of the reasons that physicians routinely end up as defacto family business owners and how a lack of formality in how that business is legally organized, managed, and owned often creates liability and intra-family conflict. This business relationship takes many forms including business loans to family members, hiring a family member to a run a business you own, being a passive investor in their business or co-owning a business or other asset (like real estate) with both capital and operational contributions.


Regardless of the specifics, you have more to lose than just the money you invested up front. Consider the following business planning checklist the bare minimum and then apply your own fact pattern for any industry specific risks.


Document Loans and Secure Your Interest While there are certainly many advisors that take the position that you shouldn’t do business with family members and should never lend family members money, many physicians do so out of both family obligation and in search of a return on their investment. If you are making a business loan to a family member, it’s important to carefully document the loan in a way that, as a minimum:
  1. Memorializes the borrower’s acknowledgment of the amount of the loan and the repayment term or obligation
  2. Addresses the minimum applicable interest rates and other terms of the loan required for the loan to be legitimate and legally compliant with IRS tax and gifting rules
  3. Provides a security interest for the loan that can include a collateral interest in the business’ assets, income and receivables as well a personal guarantee from the borrower
  4. Beware of Credit Obligations and Co-signing. In some cases you are lending your existing capital, in others you may be assuming debt obligations directly for capital or to finance the purchase of an asset or going business, either as a owner or partner or simply as a guarantor. Consider the risk carefully and be sure you understand if you are guaranteeing only a portion of the loan or if you can be collectible for the entire amount and if you are financially and legally prepared for and can survive a possible default.
  5. Have a conversation about money, then write it down. It’s important that both parties explicitly understand their roles and the expectations about compensation and profits. If you have a family member running a business that you own as your employee, agree to a rate of pay and make that relationship formal and legally compliant with all tax, wage and labor laws. Conflicts often arise when an operator thinks their salary is a “draw” or that their labor includes an equity position because these issues were never clarified.
  6. Formalize your ownership with paperwork. As an owner or investor you need legal documentation of your interest in the form of LLC membership interest or partnership or s-corp. shares, etc. for tax, legal and estate planning purposes. Without this paperwork the business does not belong to you despite any understanding or agreement you think is in place and will go the estates and creditors of the business’ official owners. This is especially true if your family is unaware of the details. Co-owned entities also need operating agreements that outline the owners’ agreements on operation, governance and profit sharing among other details. Your brother-in-law merely recording the LLC for the motel that you financed isn’t enough.
  7. Have a Separation Plan. Not every relationship is forever and if your family business is a partnership it needs a buy sell agreement just like any other that covers the basics like the ‘Five Ds’; the death, disability, departure, divorce or disqualification.
  8. Have a Continuity Plan. Many family businesses end or suffer when an operating partner or key employee that manages the business for their physician partner dies or is disabled. Consider how and if the business would continue and risk management like key man and disability overhead insurance.

The details of successful family business operation fill books and magazines. This covers only the most basic issues and can’t replace professional guidance about your facts that can help protect both your investment and family harmony.


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Sunday, January 30, 2022

Coping with grief: How physicians can heal after patient deaths

Physicians devote their careers to improving and preserving their patients’ health and longevity. But along with the success and fulfillment physicians often derive from practicing medicine, grief and loss permeate the profession as well. In the traditional culture of medicine, the latter emotions are not just undiscussed, but also poorly understood.

“Medicine is one of those things that you’re (culturally) supposed to do every day with a badge of honor, and just keep doing it harder,” says Mohana Karlekar, MD, FACP, FAAHPM, medical director of palliative care and assistant professor in the department of general internal medicine and public health at Vanderbilt University Medical Center. But given the risks of professional burnout, compassion fatigue and chronic stress, physicians need to take a more realistic approach to coping with loss, she says.

“As a palliative care physician, (I see) a lot of people die who are very sick, and my primary care practice has quite a few palliative care patients,” she says, noting that the grief process is somewhat different with predictable deaths and those that are sudden. Likewise, some physician-patient relationships are long-term, while some are episodic.

However, they all have an impact that’s crucial for physicians to recognize and acknowledge, she says.

Just a week before being interviewed by Physicians Practice, Karlekar cared for two young adults who died unexpectedly - one in a house fire and the other from a new onset of heart failure. “I didn’t know them before this week, but there’s grief in that,” she says. For Karlekar, it helps to talk about grief, let others know about it and to practice self-care through exercise.

However, it’s rarely possible for physicians to take those steps immediately after a loss. “Sometimes, you’ve got to get to the next patient or the next task, and you don’t have the time or space to process. Try to find some time in your life to go back and deal with it,” she says. “Because if you ignore it, it tends to come back at you in different forms.”


Create a safe space


Physician practice leadership plays a substantial role in creating an environment in which all members feel safe acknowledging their emotions, says Christine Moutier, MD, chief medical officer of the American Foundation for Suicide Prevention. Rocked by the suicide of a fourth-year medical student during her psychiatry residency at the University of California, San Diego, Moutier has spent her career training healthcare leaders, physicians and patient groups to improve the healthcare system’s approach to mental health, fight stigma and optimize care for those suffering from mental health conditions.

“It was such a shocking and jarring experience of confusion and grief,” she says of her classmate’s death. “(As physicians, we) really hold ourselves to an irrational sense of responsibility for all things. You think you should have been able to see it coming,” she says, adding that loss survivors in general tend to criticize themselves for missing a suicide victim’s distress.

In terms of preventing suicide as well as helping healthcare teams recover from grief and loss, it’s the responsibility of every school, training program and workplace to create a culture that is safe and respectful, Moutier says. “People must get ongoing signals that are not just top-down, but that are actually being lived out. (It must be clear) that this is a place where every person is valued and respected and where you can get your needs met in a healthy, proactive manner.”

Karlekar agrees, adding that there is no one-size-fits-all framework to promote emotional health. “The assumption can’t be that at 2 o’clock on Friday, let’s all talk about our feelings,” she says. Individuals have varied comfort levels and needs, which she says should be honored.

“Right now, one of my nurse practitioners is seeing a lot of 20-year-olds on the trauma unit,” Karlekar explains. To help lessen the emotional toll, Karlekar has made time to converse with her via text. “Some of it is just, ‘Hey, how are you doing? Do something nice this weekend.’”

Another technique practices can adopt is to create a quiet room in which clinicians and staff can take a few moments to reflect, meditate, complete paperwork or simply take a breather.

In some cases, Karlekar invites members of her healthcare team to gather in the aftermath of loss. “We have had some intentional debriefs when things have been really tough or when someone who touched everyone has died,” she says. “I had a patient with cystic fibrosis who died a week before his 30th birthday. Our floor team had been taking care of him for about five years. We had counselors come in and meet with the nurses.”


Normalize grief support


Leeat Granek, PhD, associate professor at York University’s School of Health Policy and Management in Toronto became interested in learning more about physicians’ grief after losing her mother to breast cancer in 2005. Throughout the nearly 20 years her mother lived with the disease, Granek says she developed very intense relationships with the healthcare team. “I started to wonder after she died what happens to all of these relationships that suddenly get severed.”



As a result of interviewing many oncologists who had lost patients in their care, Granek has gathered empirical data about the types of support they would like to help them cope with grief and loss in the workplace. Top requests included training during residency and fellowship about how to cope with patient death, having their emotions validated and vacation time to recharge.

Whatever the options, they must be non-stigmatized, Granek says. “Oncologists said they didn’t talk about this because they thought emotion was a stigma and that they would be considered weak or vulnerable if they showed emotion.”

One of her recommendations, therefore, is to have oncologists opt out of interventions rather than opt in. Examples of wellness offerings may include gym memberships, mindfulness classes or one-on-one counseling. “It reduces the stigma because it’s the expectation and the norm that everybody participates in one of these things,” Granek says.


Let go of guilt


While Granek’s work is specific to oncology, it provides a previously unseen glimpse into physicians’ thoughts and feelings about patients’ setbacks, suffering and death. In one of her studies, published in JAMA Internal Medicine in 2012, Granek and colleagues discovered that when oncologists lose patients, their sense of loss is two-fold. Not only do they experience “normal” symptoms of grief such as sadness, fatigue and missing the person who died, but they also struggle with a profound sense of personal responsibility as well.

“The oncologists were talking about things like a sense of powerlessness, failure and guilt - and those things are particular to this context where the physician really feels responsible for the patient’s life,” Granek says.

In comparison, she explains, “When my mother died, I didn’t really feel a sense of failure or powerlessness because I had no responsibility or control over whether she died.” Of course, physicians don’t bear this burden either, she says. “They do their best and hope the treatment is going to help the patient, but whether it does or not is ultimately not in their control.”

Nonetheless, physicians’ feelings of failure don’t just compound their grief. They also influence future patient care, such as by avoiding end-of-life conversations, delaying palliative care or choosing more aggressive chemotherapy, “even though, on some level, they knew that it was unlikely to be helpful,” Granek says.


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Saturday, January 29, 2022

An effective communication strategy can improve practice efficiencies

When physicians were asked to name their top challenges in a recent survey, they overwhelmingly chose “administrative burdens,” which include staffing issues, prior authorizations and ever-present issues with electronic health records systems (EHRs).

The ongoing effects of the coronavirus pandemic resonate well beyond hospital settings, impacting medical practices in myriad ways. Practices still are playing catch-up with patients who avoided visits during the initial pandemic shutdowns and who remain leery of in-person visits as variants surge.

Practice efficiency is a good news/bad news scenario, with the need for support staff down 6% in Q4 2021 when compared to the pre-pandemic Q4 2019, according to healthcare consultancy Kaufman Hall. However, an increase in expenses offsets the staff productivity gains. With unemployment nearly recovered from the pandemic crash, practices find themselves struggling to recruit and retain competent staff amid more lucrative offers and better working conditions.

Savvy practices are exploring how to become more efficient by using a communications platform that allows personalized, HIPAA-compliant, one-to-one and one-to-many communications that can help engage patients in their care while creating practice efficiencies.

Respect the Patient at Each Interaction


Small changes to practice workflows can have an oversized impact on overall organizational efficiency, a study published in 2020 shows. The study’s goal was to support the Quadruple Aim of reducing costs while improving population health, patient satisfaction and team well-being in a medical practice setting. By reducing administrative burdens, an intervention group could offer 48% more patient appointment slots than the control group.

Any practice contemplating changes must realize that patient interactions must remain the core focus. At many practices, it’s already impossible to speak with a live person after negotiating a phone tree or sending an email through the patient portal. Frustrated patients are less likely to be satisfied by their care experience and to recommend the provider to friends. Which is why it is imperative that any communications platform must put patients front-and-center, with easy and secure interactions that don’t require the patient to download yet another mobile app.

Instead of the ubiquitous appointment reminder phone call – which takes staff time away from more value-added duties and patients away from whatever they were doing when the phone rang – how about a personalized text message from the provider’s main phone line confirming the appointment? The patient can quickly confirm the appointment or call up the provider’s schedule to pick another time.

Accomplish More Through Text


Younger patients probably aren’t answering those reminder calls anyway, preferring a quick text. A communications platform with HIPAA-compliant texting can create efficiencies within the practice in numerous ways besides appointment reminders, allowing staff to have one-to-many asynchronous conversations rather than one-on-one phone interactions.

Fully 85% of American adults own smartphones that can support texts, document transmittal and video calls, up from 81% in 2019. It’s not surprising to discover that smartphone ownership is lower among older adults, but more than seven in 10 adults ages 65-74 have a smartphone.



To leverage texts in a medical setting, patients must first opt in to receive messages to comply with the Telephone Consumer Protection Act (TCPA). Practices want a communications platform that’s HIPAA-compliant and allows communications with a particular patient to become part of that patient’s medical record.

How often does your practice get calls about directions, parking or practice policies? Templated responses answered by text rather than phone will free up staff time and increase the percentage of on-time patient arrivals. One physician using a HIPAA-compliant, text-based communications platform reports that his practice has never had a patient miss an appointment or arrive late.

Onboarding and front-end practices also can be accomplished by text. Sending pre-appointment forms to be completed ahead of time can make the day-of visit go more smoothly. Practices want a platform that can track communications so only those who haven’t filled out pre-appointment paperwork, for example, receive reminders.

Provide Better, More Timely Patient Care


In a truly patient-centered practice, patients shouldn’t need to take additional steps to communicate with the practice, such as download an app or remember log-in credentials for the patient portal. Mobile devices are convenient, handy and the preferred communications method for an increasingly tech-savvy population.

A communications platform that includes secure photo and video capabilities reduces significant barriers that exist between patient needs and provider time.

Telehealth visits comprised a microscopic portion of total medical visits prior to the pandemic. Between February and April 2020, however, the use of telehealth skyrocketed by a factor of 78. While the numbers have declined since then, the use of telehealth remains 38 times higher than the pre-COVID-19 baseline. Factors cited in the sustained increase include regulatory changes that make using telehealth easier and increased patient and physician comfort with telehealth and willingness to use it.

Besides synchronous video, asynchronous communication through text or photographs can increase patient touchpoints and satisfaction while making the practice more efficient. A dermatologist can look at a patient-submitted photo and determine whether a skin condition is harmless or warrants an in-person visit. A surgeon can look at a photo of an incision and determine whether it is healing properly.

Asynchronous communications can also be used to help patients manage their chronic conditions. When the communications platform is integrated with the practice management system, personalized and templated messages can be sent to certain patient cohorts at pre-determined times. A cardiologist, for example, can request blood pressure readings for at-risk patients, or a general practitioner can request blood glucose numbers for diabetes patients. If the numbers look good, the provider can send a positive note that encourages future compliance, while negative numbers may require an appointment.

Conclusion


Medical practices have made efficiency strides during the pandemic, but those strides have been blunted by higher costs. Secure, HIPAA-complaint asynchronous and synchronous communications can help the same number of staff to manage more patients, preserve provider time for the sickest patients and create workflow efficiencies.


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