Healthcare Managers

2009-07-08T11:54:00.000-07:00

Coming soon!

First, I want to apologize to all of my readers. I have taken the last year off as a sabbatical and to catch up on old projects. On a more positive note, I have dedicated much of the last two months to performing an independent analysis of some of the more popular medical transcription companies with my readers. The results of this research have truly been eye-opening and I am excited to share this with my readers in the next few weeks as I finalize the analysis.

While most would think that every medical transcription company is like all the others, this is not true! I created a set of different criteria (such as customer service, technology, and accuracy) for five of medical transcription companies most popular with my readers, and then, having interviewed clients from each company as well incorporating as my own independent research into each of these companies, I ranked them from best to worst. My next blog post (soon, I promise!) will explore a little bit more of my methodology.

If any of my readers have any insight into this topic, I would love to hear from you.

2008-04-21T11:29:00.000-07:00

Casting Call

It's certainly been a while since my last post and I apologize for falling off the face of the earth! Procastinating can be quite a slippery slope. Actually, things have been very hectic for me lately and unfortunately my blogging was sacrificed as a result.

This post is a writers casting call. I'm looking for some help from my readers. Any ideas that you'd like to discuss? The state of the healthcare system is very precarious these days, where do you think it's going? I'm curious to see if a new administration might really make a difference as has been claimed.

So this is the soap-box, open-mic offering. Feel free to respond to my emails or post any thoughts that have been on your minds lately. I'd love to stir up the pot a little bit; you readers always have such enlightening insight.

I would be especially excited if anyone would like to do some guest-writing as well. Any musings that you've got - let's share!!! I've got a nice-sized audience with wonderful readers, so you could really get your thoughts out there.

Thank you, I hope this finds you all very well.

2008-03-20T10:41:00.000-07:00

You Must Be on Drugs

My good friend Mark used to shill for a big pharmaceutical company. He never liked the work much, but he was a good salesman and it paid his bills. He finally had to quit because he felt the tactics being suggested to him and the pressure being applied were too much. He would shake his head and say we are an overmedicated culture.

I thought of him as I read a review of Melody Petersen's "Our Daily Meds," a provocative new book that provides some teeth to my friend Mark's claim. By her reckoning, Americans increased their spending on prescription drugs by 17 times from 1980-2003. She notes the way the elderly are overprescribed, taking drugs that counter the reactions of each other in an endless spiral.

It's an open secret within our profession. The doctors I work for are very scrupulous about this issue, and display a strong conscience. One of the older members of our practice loves to tell the story of how he went on a drug company junket early in his career, and how everyone grumbled because it wasn't in a sunny climate. Apparently, they didn't care about the drugs or their effects so much as they did the cloudy weather.

My friend Mark felt that people were being encouraged to take medication for a variety of marginal ailments. He thought the more health-conscious our culture became, the more they were willing to seek out any panacea for what supposedly ailed them. In his mind, it obscured the real sickness out there and fostered a drug-dependent consumer culture.

Which, for him, meant boom times. But something in him wasn't up to the task. The more success he achieved--and he had a six-figure income, which wasn't bad considering he never graduated high school--the more empty he felt inside. Finally, he'd had enough. No one thing precipitated his decision, but rather it was the accumulation of a career's worth of anxiety.

The review of Melody Petersen's new book notes a very simple litmus test for whether or not a doctor has been courted by a pharmaceutical company: are their pens and tissue boxes covered with drug ads? (I was never more glad that we purchased our own pens and tissues!)

Have any of you heard of Ms. Petersen's new book? What is your experience with pharmaceutical companies? Do you think prescription drugs are out of control? As always, I would love to hear from you.

2008-03-06T10:48:00.000-08:00

Nerd Wanted

A few months ago we bit the bullet and began a search for a full-time IT person. Technology is moving so fast, and we were having too many communication problems with the company we were using. Finding someone who would cater to our specific needs seemed like the next logical step, but of course that was easier said than done.

The first person we found was extremely tech-savvy, but lacked interpersonal skills. In the extreme. He couldn't even make eye contact. Luckily, he left for a better job offer almost immediately.

The next candidate we hired part-time on a trial basis. They were referred to us by a fellow employee, and at first he seemed ideal in that he knew his stuff and could communicate effectively. Unfortunately, he was overburdened with a difficult family life and we caught him sleeping in his office more than once.

As with most things, I learned through painful trial-and-error, so my next step was to establish a solid criteria for the IT person we were looking for:

Salary - I researched what the local rates were and established a criteria for a competitive salary. To attract top talent in the IT field, you have to make it worth their while.

Job Requirements - I put in writing what we were looking for in an IT person. What our system requirements were, and what innovations we were hoping to make. Also, I summarized past problems and recurring issues.

The Future - I wrote down some goals and baselines I hoped the IT person would establish over the course of the first year or so, making it clear that the position would only expand as we incorporate more technology.

Training - I made it clear that we would gladly allow the IT person some latitude in furthering their education and attending seminars or workshops related to their field. Also, any education the staff needed to keep pace with changes would be duly considered.

The third time seems to be the charm. The woman we hired is extremely gifted when it comes to the technical, but she also has a warm, down-to-earth personality. She explains things in a direct, easy way free of jargon and attitude. She also worked part-time as a nurse's aide in college, so she has some knowledge of the medical field.

Like most practices, we're striving to become as paperless as possible, so I think having an in-house IT person is a smart move. The more intricate and involved we become in tech matters, the more important it becomes to have someone who is specific to our needs and wants.

What about your practice? Do you have your own IT person or do you outsource that work? I'd love to hear your perspective.

2008-02-28T11:15:00.000-08:00

A Spoonful of Sugar

A doctor I work with asked if I had done a blog about giving patients bad news. She said it was on her mind lately. She had to tell someone they had a life-threatening illness and the experience kind of shook her up. "I've given bad news before," she told me. "But the older I get, the harder it becomes. Isn't that strange?"

She told me her mentor was a terrific communicator, and that she learned a lot from just watching him interact with his patients. We sat down and I asked her to give me a rough list of things she felt were important regarding the topic. Here is what she came up with:

Quiet room - Make sure the place where you talk to the patient is relatively quiet and safe from interruption. Turn off your phone or beeper. Give them your full attention.

What do they know? - It's always good to get a handle on what the patient is thinking before providing any in-depth explanation. Sometimes their point of view is colored by false information that can easily be dispensed with at the start. You need to ask.

What do they want to know? - Sometimes a patient wants everything spelled out in detail, and sometimes not. Try to ascertain how much you need to say, and be mindful of their comfort level. Often, they want a family member present to verify and confirm information. Be open to their needs.

Keep it simple - Remember that your patient didn't go to medical school, and talk to them in a direct, but simple manner that lays out the facts without overwhelming them.

Listen - Give the patient time to react. Don't force the issue. Let it sink in. Let them ask whatever questions come to mind. Just...listen.

Conclude firmly - Don't make the patient feel rushed. After you lay out the treatment options and have exhausted their curiosity, reassure them that you will be there in the future. Some doctors give out their personal cell phone number, but we have a policy against that in our practice. What we do offer is to have a staff member follow up with a phone call in a day or two. Patients appreciate the extra effort.

I thanked the doctor for sharing her insight, and she confided that her recent experience with giving bad news had gone poorly. The patient became aggressive and started blaming his family for his problems. "I had to remember that he was distraught," she said. "And that we were on the same side."

Apparently, she let him rant for a few minutes, and he finally relaxed and admitted that it didn't matter. What was important was how they were going to move forward. Sometimes patience is rewarded.

I'm sure many of you have an opinion about this. If you'd like to share your perspective in the comments, I'd welcome it. Thanks.

2008-02-26T11:02:00.000-08:00

Ratings

I have previously written about online ratings services for doctors. I do a lot of work on the internet in my off-hours, and I know just how vapid and pernicious bad commentary is, so I am highly skeptical of any service that gives an anonymous forum where people can vent about medical care.

I'm sure it is empowering to many people who can feel intimidated when dealing with a medical professional, but I think it leaves a lot to be desired. After all, no patient is perfect. Many don't properly communicate their problems or follow their doctor's instructions.

Now insurance companies are getting into the ratings game, which is all part of their supposed quest for efficiency and customer service. I have to wonder where all of this judgment-passing is leading? Doesn't it create a climate of fear for the medical community?

A doctor friend of mine who works for another practice met me for lunch the other day. He was beside himself with worry, having just received a negative review online. He's a pediatrician and somebody accused him falsely of prescribing an adult medication for their sick child. He had no idea who the patient was, and couldn't recall any recent patient dissatisfaction.

He's a sensitive sort, and my kids all went to him, so I know he is a caring professional. I worked with him early in my career and I've never known any doctor who was so patient and lacking in the usual ego that can get in the way of good treatment. A few negative words on the internet and his entire career meant nothing to him--he was devastated.

"I'd like to think people take all of that with a grain of salt," he said, finally. "But the fact is I know it's there. Somebody cared enough to write it."

It's a good thing for doctors for to be aware and question their decision-making. It makes them better at their job. However, there's a point at which a course of action or a diagnosis has to happen, and sometimes mistakes will be made. The fallibility inherent in the process is what gives the medical profession a certain nobility. Every decision is a potential risk of reputation.

I'd give anything to ease my doctor friend's sorrow. He contacted the website and they are supposedly going to remove the false accusation. In time, I'm sure we'll both laugh about it. In time.

As always, I'd love to hear your thoughts. Do any of you have experience with online ratings?

2008-02-21T10:16:00.001-08:00

Addicted

I'm a trusting person by nature, and so it wouldn't naturally occur to me that someone I work with might steal drugs to feed their addiction or sell to others. Sure, I've caught a few people doing this in the past, but there is something Polyanna-esque about my worldview that allows me to revert back to trusting people shortly afterward.

I'm feeling particularly vulnerable regarding this since a dear friend and co-worker got caught this week. Another co-worker privately told me that she confessed over a few beers one night after work that she was addicted to pills. Once I was made aware of the problem, it was just a matter of waiting.

The resulting confrontation was awful. She was in full denial and claimed she was being set up. She left without collecting her things or even a wave. Five years of working together gone in a heartbeat.

In retrospect, there were warning signs. I just chose to ignore them. Here, for your benefit, are some things you might want to look for:

Are they reliable? Is the employee calling in sick more frequently? Are they arriving late and leaving early?

How efficient are they? Are they becoming sloppy in their work habits? Taking shortcuts and drawing complaints from co-workers or even patients?

What about their appearance? Are they looking more disheveled lately? How about their speech--is it noticeably faster or slower? Any weight or mood changes?

I realize, looking this over, that there were some glaring differences in the woman at work. She once had been so open and easy to get along with, and in past 6 months or so, she had become more secretive and stand-offish.

Still, I knew she had gone through a painful divorce and I strongly believe in giving people latitude to work out their problems. Her work was still of a professional enough level that I even told some people to back off when they criticized her for being short with them. I explained that she was going through a rough patch and would eventually work things out. I still hope that's true.

Any stories or insight you'd care to share would be more than welcome. I appreciate you listening to mine.

2008-02-19T11:03:00.000-08:00

Promotional Tools

As a rule, I like to promote from within. I think it gives my employees a sense that they are working toward something, and that good effort will eventually be rewarded. However, I am answerable to our doctors, and there is a standard which must be upheld regardless of who the candidate for promotion is.

The main thing I look for in someone who will be taking on a supervisory role is a certain self-reliance. Are they are a problem solver? If they need frequent management, they are not going to be able to handle the responsibility.

Another important aspect is good interpersonal skills. Not only will the right person have to be able to get along with everyone, but they will have to be mature enough to handle the shift in office dynamics from co-worker to boss. It can be a heady change, and the pressure can sometimes make even the most amiable person somewhat overbearing.

Once I've made the promotion, I provide a complete listing of what the new position entails, including the necessary training, and my goals and expectations. I want the person to feel complete comfort within the parameters of the new job, so they can stay focussed on learning.

For me, the hardest part is letting go. Usually, a person needs a few months of coaching and then they're on their own. I love being a resource, and miss it when my advice is no longer sought (it's the same way with my kids!).

How about you? Any tips or rules of thumb you care to share regarding promotions would be most welcome. Reader comments are always so helpful!

2008-02-14T10:28:00.000-08:00

It's About Time

One of our doctors' pet peeves is talkative patients. She likes people and gets along with them well, but small talk is not her forte. During one of our weekly meetings, she made a frustrated comment about how she felt some patients really slowed things down by not being direct. It got me to thinking about time management.

Of course, she was just venting, and there is no appreciable way to measure the delay caused by chatty patients. Also, even she realizes that friendly, open communication is vital to proper medical treatment. Still, there were other elements to consider regarding office efficiency. As usual, I made a list:

Study work processes - Have each staff member review their work habits to see if there is any redundancy and overlap. This will give them a greater sense of job ownership, and make them feel less threatened by the idea that they might be wasting time. Make sure to include the physicians and nursing staff as well. Perhaps there is a more streamlined way to get patients in and out of examing rooms? Have a friendly, catered lunch meeting where everyone can feel free to brainstorm.

Be specific and focused - Train your staff to answer phone inquiries as quickly as possible. If they need to call someone back, have them offer a specific time as a deadline so that the patient doesn't call again during the interim. Make sure the staff only uses their breaktime and lunches to do things like checking email or making personal calls.

Schedule according to strengths - Some folks are morning people and some need a few hours and a couple of cups of coffee to hit their stride. When possible, have the early birds open and the nightowls close.

Take it easy - Once you've made the push for greater efficiency, received staff input, and implemented everything, take a deep breath. There are limits to how efficient a group of people working together are going to be, and there is also the natural pace of your practice to consider. You don't want your patients to feel rushed and you can't fear the bottom line--volume is only part of the profit margin equation.

I recently had a staff member secretly tell me that he was grateful for one of our streamlining ideas. He said he had been covering for another employee and didn't want to make waves by complaining. When the other employee volunteered the change in our meeting, he said he nearly fainted. The ways in which people fail to communicate never ceases to amaze me.

As always, I'm very curious about tips you might have to use time more efficiently. Any tricks of the trade you'd care to share?

2008-02-05T07:06:00.000-08:00

Super Tuesday

I have tended to avoid writing about politics much in this blog due to the controversy it sometimes creates. I have learned that many of my readers are very conservative, and I am by nature quite liberal. So I try to stick to my profession and the subjects therein.

But in honor of Super Tuesday, and as a resident of California, I'm voting and wanted to share my enthusiasm. I hope you will all indulge me, and perhaps share your own viewpoints.

I am undecided at this moment as to who I prefer: Hillary Clinton or Barack Obama. Both are inspirational in their own right. I am still angry with Hillary over her votes supporting the Iraq war, but I realize that was part of her goal to play smart politics and most of the democratic party voted with her on this.

Barack Obama is solid on the Iraq war, but I feel he's vague in many other respects. In many ways, I feel his promise is what he may do if given the chance, since he's still very new to the national stage, and lacks Hillary's experience.

As many of you may have heard, there was an effort in California to try to give universal health care for all residents. Unfortunately, it failed, but I believe (or want to believe) that all of the democratic candidates will make an effort to create a more inclusive health care program for all Americans. I think this is something we as medical professionals can all agree would be a good thing.

Frankly, the republican candidates don't seem to care a bit about health care. They think the current status quo is just fine. In many ways, I admire John McCain, but how different would his administation be from the current disastrous one? Hasn't he compromised himself too much just to get where he is?

Mind you, I'm just asking. I have no desire to sway anyone's opinion. I just hope by writing about politics and sharing my own beliefs, I might inspire you to express yours. If you were part of Super Tuesday, I hope you got the chance to vote. No matter which side of the spectrum you are on, your viewpoint really matters.

I invite everyone to leave a comment. Support a candidate. Let your voice be heard. Whatever is on your mind, I'd love to hear it!

2008-01-29T10:21:00.000-08:00

Insuring Against Insurance

We all know the drudgery of dealing with insurance companies. It seems like they know every trick in the book to avoid reimbursing our physicians properly, and that's partly because they have a monopoly on the market.

Recently, I jotted down an outline of some ways to keep on top of the situation, and I thought I'd share them with you now:

Costs - The cost of running a medical practice is varied and complicated. There's overhead, personnel, rent and supplies, just to name a few components. Some of our doctors think you can make up the difference through volume, but that's a losing strategy. Even if you are just in the ballpark, knowing the overall cost of operating your office will give you a stronger bargaining position.

Your payer reps - They are the face of the insurance company and usually they get the brunt of the abuse. Become familiar with the person who does the job, and try to avoid confronting them. Remember that facts and data are a more powerful argument than emotion, regardless of how legitimate those feelings may be.

Contracts - Always--always--keep a clean storage space devoted to contracts. This should be a constant, regardless of staff turnover. Also have off-site backups and maintain all versions; you never know when someone is going to argue a fine point.

Renewal dates - Use your computer software to warn you about any upcoming renewal dates for contracts. Pay special attention to evergreen clauses. Sometimes I think insurance companies count on physicians missing these imporant deadlines.

Obtain information - Before you sign with a carrier, get a complete fee schedule and coding guideline. Also read your contract carefully, and if possible have an attorney offer their opinion as well. Insist on written notification for any changes in the contract.

Coding - Make sure to have a staff member who is coding-certified, and up-to-date on all of the current codes. Accurate information will allow you to obtain the maximum reimbursement for a given service.

Even though I will admit to some animosity toward insurance companies, I realize the folks who work for them are generally good people just trying to do their job. It's a shame we can't work more in concert for the sake of the patients, but I insist that all of our dealings with them remain on a professional level.

If you have any tips or suggestions on how you deal with them, by all means leave a comment. I enjoy hearing from you.

2008-01-17T11:37:00.000-08:00

Security Breach

The other day one of our doctors forgot his cell phone at the restaurant where he was having lunch. He rushed back to retrieve it, but unfortunately it was gone. In the meantime, an employee at our practice had text messaged his phone some confidential information about a patient.

Needless-to-say, our doctor was mortified over the situation. We all know the serious consequences of breaching doctor-patient confidentiality, and while this was an unforeseen incident, it still felt like a serious betrayal.

Naturally, I went into research mode, and now I'd like to offer some handy tips to help prevent this from happening to anyone else in our profession:

Use your cell phone autolocking feature. Practically every cell phone has a function that allows it to work only after a PIN has been entered to unlock it.

Report a missing cell phone immediately. Call your carrier the minute you think it's gone, and have it disabled. You can always have it reactivated if you should find it, and while you may lose some information in the process, that's better than having it out there for all to see.

Avoid having specific patient information text messaged. This was a particularly important lesson our doctor learned the hard way. From now on, no one in our office is allowed to text message unique patient information such as the date of birth or a social security number.

Use password protection on all spreadsheets and word documents that have confidential data. This is an obvious step on any office software, but many of us never imagine the consequences of potential hackers out there.

Another step I took recently was to ban the use of Instant Messaging in the office. It was rarely used for work purposes, and seemed like a way for many employees to chat and waste time. Also, I worried about the security issues of having a direct portal from the outside world into our computer system.

I know a few employees were shocked about the IM, as I am known for being something of an old softie. Still, my reputation is such that when I make a business decision, people know that I mean business.

Of course, I'd love to hear suggestions or input from you regarding this issue of making technology more secure in the workplace. Please don't hesitate to leave a comment. I enjoy hearing from you!

2008-01-15T07:50:00.000-08:00

Stray Cats

My husband likes to joke that I’m the patron saint of lost animals in our neighborhood, and it’s true. I have always felt an innate desire to help those less fortunate or who may be outsiders. While this can have a different dimension when you are dealing with people instead of pets, I feel an equally strong obligation to help others when I have the chance.

Several years ago, I fired a woman who had crossed the line. In our profession, a person is usually terminated either due to underperformance, excessive absenteeism or tardiness, inappropriate behavior with staff or patients, or a breach of patient confidentiality.

In this case, the employee was underperforming and failed to show up for several shifts without any notice whatsoever. Initially, I gave her a verbal warning, and she was grateful. She gave me a laundry list of personal issues and said she was so caught up in her personal drama that she didn’t realize how she was neglecting her work.

When things didn’t improve, I gave her a written warning. I also had a brief conversation with the head physician. After a sufficient length of time where she proved incapable of improvement, I had her sign a separation agreement, and she was terminated.

It should never be a surprise when someone is let go. The documentation and process involved should make all options clear, including the negative one. I try to give people as much latitude as possible, but sometimes that winds up being a case of giving them just enough rope to hang themselves.

Anyway, I thought I’d never hear from this woman again. In fact, we’d exchanged a few words on her way out, which I had always regretted. A few months ago, I got a call from her. She sounded calm and gracious, and she asked me if I would meet her for lunch. She said she was sorry for how things had turned out, and she wanted to talk to me about it.

I realize many of you wouldn’t have gone, but of course you know I did, and I’m glad for it. She was dressed nicely, and her demeanor was very different. She told me she had gotten out of her bad relationship, and finished her education. She said my firing her was a wake-up call, and that it made her determined to change her life.

She told me that she was up for a job at a medical technology company, and that she could use a good reference. It was a risk, but I backed her up. She got the job, and from all reports, is doing very well.

I realize that I took an enormous risk, but sometimes people change. I value my reputation in the local medical community, but I would be a poor steward of that authority if I didn’t occasionally use it to help people in need.

I’m not sure we’ll ever be friends, this woman and I, but like a stray cat, she wandered in and needed support. I gave her what help I could and let her go her own way. Sometimes all anyone needs is a nudge in the right direction.

As always, I’d love to hear what you have to say. Any stray cats you’ve helped straighten out from a wayward course?

2008-01-10T06:58:00.000-08:00

Maximize Your Supplies!

One common mistake I've witnessed at every practice I've worked for is the overstocking of the supply closet. Piles of unused syringes and bandages stacked haphazardly. While it can be hard to anticipate need, a good practice approaches their supply closet like a supermarket or chain store, ordering just what is needed and at a reasonable quanity.

The first step I took in maintaining some kind of order was to put ordering supplies in the hands of one employee--Sonia. A bargain shopper whose idea of a great weekend is spent perusing flea markets for a decent working lamp under $3, she also finds a great many things cheaply and re-sells them at a mark-up on eBay as a hobby. To her, saving $1.50 on an order of tongue depressors is a big deal, and when you want to cut costs and save money, that is the attitude you want.

One of the first things Sonia did was to get online mailing lists from various suppliers. Every day she scrupulously checked specials and made note of deals for future reference. She didn't just rely on where we always did business, and she was more than willing to listen to the occasional pitch of a salesman, if it affected the bottom line.

Another thing she did was canvas the employees regarding what was and wasn't needed. She called the supplier and tried to negotiate returning overstocked items, and when they gave her a hard time, she burrowed down and negotiated, letting them know that she could just as easily get future stock elsewhere.

Sonia also organized the supply area, using tubs and bins. Putting yellow placards toward the back of a given item, she had an easily identifiable way of seeing when something was almost out.

In a fast-paced medical practice, it can be next to impossible for everyone to be conscious of waste and supplies. Putting one person in charge of it was an efficient way of organizing the situation, and it put a face on the problem, which made people more conscious of the situation. Also, once given the task-at-hand, the employee--Sonia--was very pro-active at finding solutions to problems which she could readily identify because she learned the specifics of how our supplies were used on daily and monthly basis.

Anyway, that was my solution to the burdensome issue of properly stocking supplies for my practice. As always, I'd love to hear any suggestions or insight you might have regarding it.

2007-12-20T05:01:00.000-08:00

Odds and Ends

In my last blog, I mentioned that we choose an employee of the year and give them two tickets for a trip to Hawaii. An anonymous reader wrote the following: "Who decides on employee of the year and what is the criteria??"

That's an excellent question. When it was first proposed, I considered a list of specifics that someone had to meet year-round. Then one of the doctors said we should just all vote at the end of the year, and that no one can win two years in a row. Everybody seemed to feel this was fair, and more fun and less work. So that's how we decide. It's not very scientific, but so far there have been no complaints.

As a California resident, two things have made me particularly proud as of late. One is Governor Schwarzenegger's attempt to extend healthcare to all residents. The other is San Francisco mayor Gavin Newsom's proposal to charge big stores when they sell sugar-sweet soda. This is from an article about the latter in the New York Times:

The proposal, which was reported by The San Francisco Chronicle on Monday, would put an as yet-to-be-defined surcharge on all drinks with high-fructose corn syrup, which puts the sweet pop in most nondiet sodas and many other food products. The syrup also puts on the pounds, something city officials say strains the health care system.

“There’s a well-established nexus between obesity, which is caused by high-fructose corn syrup, and the increased health care costs for the city,” said Nathan Ballard, a spokesman for the mayor. Money raised by the fee would be spent on a variety of anti-obesity programs in the city, said Mr. Ballard, including Shape Up SF, which challenges residents here to exercise."

As a medical professional, I find this to be the kind of public policy I can get behind. Some day we may look back at all of the accepted bad habits and foods promoted in our culture and wonder just what were we thinking? (Mind you, I speak as a reformed junk food junkie--I know the power of bad eating!)

And finally, on a healthy note, I noticed a wonderful article in the Los Angeles Times about giving healthy gifts this season. It mentioned one of my personal bugaboos, which every teenager seems determined to have:

Many of the hottest holiday gifts will include ear buds -- which have practically evolved into a new body part for teenagers -- much to hearing experts' dismay. Because the devices channel sound directly into the eardrums, hours of listening to loud music or sounds through them (day after day after day) could cause permanent hearing loss.

Some moderately expensive alternatives are offered, and believe me they are worth it! Sometimes I think today's youth will be deaf by the time they're 30!

The article is a great resource for other ideas as well, from a Pilates Arc to reusable bags that avoid the lead which sometimes rubs off in vinyl food bags. It's nice in the midst of a season filled with sugary sweets and treats to give some consideration to health.

On that note, I sincerely hope everyone had a great holiday season. We closed down our office for the first part of last week, and I was kitchen-bound come Christmas Eve. I love to make dinner and see all of the relatives visit. For some people, it can be stressful, but to me, it's a great of remembering who I am and where I came from.

I'd love to hear how you celebrated your holiday, or perhaps hear some healthy gift ideas. Please feel free to leave a comment, and again, I wish you the very best!

2007-12-18T05:03:00.000-08:00

'Tis the Season

We had our office Christmas party over the weekend. Each year we rent a small venue and invite friends and family to celebrate. I see it as a perfect time to reward my staff for a year of good service.

I've noted here before the value of offering perks to the staff as a way to maintain loyalty and enhance company spirit. For example, at the end of the year we announce an Employee of the Year, and the winner receives a trip for two to Hawaii. This gives the party an air of expectation, and incentive for everyone to do their best.

Of course, we also provide holiday bonus pay for everyone in the middle of December, for any last minute Christmas shopping. The amounts vary, depending on length of service and work done, but the point is it's inclusive. We are all in this together.

We had a difficult year at the practice, and many of the staff went above and beyond the call of duty, so I wanted to show them special appreciation. I called them all into what seemed like a special, serious meeting. I then gave them all a certificate for a free massage at a local spa, and then provided them a catered lunch. You should have seen their faces!

Retaining valued employees saves money, and keeps a medical practice running smoothly. Doctors and patients both appreciate familiar faces. Nothing is worse than staff turnover and having to continually train new employees. That's why I make sure to reward good work.

I wonder if any of you have end-of the-year perks you offer your employees? Did you have a Holiday party? What do you think of offering extras and incentives to the staff? As always, I 'd love to hear from you.

2007-12-09T23:02:00.000-08:00

Some Things Are Best Left Unsaid

Sometimes words, once spoken, have an effect that cannot be undone. We may know about this in our personal life. A rash moment can happen without warning, and anger can carry the day, deeply affecting friends and family.

In a medical office the emotions can run equally high and the stakes can be just as personal, with the important difference being that a wrong thing said can have devastating consequences for a person's health. Or rather, how they view their health.

I once worked for a doctor with the bedside manner of a facist dictator. He was blunt and completely certain of his every utterance. He had that unmistakable air of authority that left an indelible impression on patients.

He once told the parents of a newborn that their son's future was going to be "difficult at best." The infant was incubated and the doctor's words were reflective of a true medical condition, but they were only half of the story. Those parents were devastated, but they didn't give up hope.

In fact, they eventually sought out another doctor's opinion and wound up not getting a different prognosis, so much as a different approach. The new doctor was guardedly optimistic, but he offered them hope. That boy did have a difficult childhood, but without the limitations imposed by his initial doctor, he thrived. His parents would constantly remember those dark words, whenever there was a setback, but their new doctor reminded them that change was the only constant in medicine, and that there was no reason not to believe that things would improve.

I tell this particularly story not so much as a medical professional, but as a proud aunt. You see, it's the story of my nephew. To this day, I deeply regret the influence my doctor employer had on my sister and her husband. Shortly after they found a new doctor, I did, too.

I'm not advocating bland advice that never penetrates the truth. Sometimes a patient needs to hear the tough things in an unfiltered way. "Stop eating this type of food or you will have heart disease." "Take your medication or your condition will get worse." However, it is important to never forget that medicine is not just a solution, it's a question. A way of examining a problem and offering possibility. Telling it like it is doesn't necessarily preclude hope.

What is your feeling about this? Have you ever been on the receiving end of a bad opinion?

2007-12-09T21:59:00.000-08:00

Leading by Example

I am an outgoing person, but I don't come by it naturally. At heart, I'm a shy person. When I was first given the opportunity to manage, the head doctor I was working for sat me down privately and told me that while he had confidence in my abilities, his only doubt was that if could truly lead.

At first I was taken aback, but I realized what he meant. I had a great rapport with my co-workers when I was one of them, but I had always been something of a follower. My leadership possibilities became apparent through my competence and willingness to work, but not in acting like a figurehead. That doctor did me a favor by making me aware of appearances; a crucial factor in managing people.

Back then, I made a short list of what I needed to do, and I still refer to it. I've kept it private until now, but I'll share it in the hope that it may help someone else or even reinforce their management style:

Make connections. Although I am shy, I have always liked people. I make efforts to get to know my entire staff, and learn their quirks and interests. I also take the time to share things about myself. Being a manager, I tend to be less personal in some of my details, but I don't skimp on the directness of my communication. I'd say everyone who has ever worked for me, has gotten to know me to some purposeful degree.

Name dropping. It's a technical truth that people respond favorably to hearing their own name. I make a point of stopping by everyone's work area throughout the day, looking them in the eye, and occasionally addressing them by name. I use a positive, considerate tone. I believe that no matter how familiar you become with your staff, you must always treat them with the same manners you'd show a house guest.

Perception is reality. How people view and respond to you is very important. Notice body language and tone when you interact with others. Ask a staff member you can trust their opinion on how you come across. (Questions such as how would you describe my style? What one or two things would you change about my communication style?) Their feedback could prove invaluable, since others can frequently see your blind spots with great clarity.

I've been a manager for years, and there are days when I still feel like I'm just beginning. The fact that I'm introverted by nature will always mean that I have to force myself to project. There will always be a measure of calculation in my behavior. Which isn't necessarily a bad thing.

As always, I'd welcome your input. What things do you keep in mind? How do they relate to your personality?

2007-11-29T10:49:00.000-08:00

Common Problems in a Medical Office

As the year comes to a close, I did my usual assessment of office priorities, and came up with the following list of potential pitfalls I think are important for every practice to work on:

I realize that the front desk is often staffed with underqualified, younger help who can be easily overwhelmed by phone calls and patient demands. Still, it's imperative that all patient intake information (i.e., insurance information and subsequent updates) be properly entered. It pays to go with a more experienced person on the front desk, and I make sure to never have someone new or easily flustered in the position

Make sure to update your fees and charge tickets annually.

Have a quality control procedure in place regarding charge tickets. Make sure that everyone is being properly charged for everything. Have separate personnel keep a daily tally.

Staff your office properly. Make sure the ratio of staff to physicians is adequate. Many practices tend to cut corners on this one, and the workload makes them suffer. Good medicine can't be practiced on the cheap.

Make sure to follow-up with patients on things such as mammograms and other preventive tests.

Of course, this is an incomplete list. There are endless ways to improve any business, especially a doctor's office. Last month, a patient jokingly suggested we get Starbucks coffee for the waiting room. A member of my staff took the suggestion to heart and researched it. A week later, we had Starbucks coffee in the waiting room, and the response was overwhelmingly positive.

Sometimes we forget that it's the little things which people notice, and when you make something as onerous as a waiting room experience a little brighter, you reap the reward of happy patients. I support anything which makes a visit to the doctor more user-friendly.

Anyway, I'd love to hear any suggestions or comments you might have, as the year comes to a close. Any thoughts on what to look out for in a medical practice? Ways to make it better?

2007-11-20T12:02:00.000-08:00

In Case of Emergency

As the recent fires in Southern California proved, disaster is always ready to strike when you least expect it. Because of the importance of medical records, it's vital for every practice to safeguard their information as a precaution. The following are simple steps that can and should be taken:

Always keep up-to-date employee contact information, as well as a complete master vendor list of purchased and leased equipment, both on and offsite.

Determine a separate location where you can temporarily see patients, should your practice become inaccessible. Should disaster strike, be sure to let your patients know where your alternate location is, and alert the local media.

Back up all of your computerized information on a second server that is offsite. This will ensure that you never lose any critical clinical and financial data.

Invest in business interruption insurance. Make sure your policy covers payroll, rent, and other essential bills, as well as all sorts of multi-peril incidents. (The waiting period for implementation on most policies is three days.)

Where I live in California, natural disasters seem to be a way of life, but I also know of many colleagues who suffered tremendous losses in Hurricane Katrina. God willing, most of will never have to experience such catastrophes, but it is crucial to never forget that preparation is a cornerstone of medicine. That mindset should extend to disaster readiness, for your own piece of mind as well as for your patients.

Lest we forget the lessons learned from Katrina on the volatility of having only paper medical records (see article), of course it's always a good idea to have your patients' medical records stored electronically offsite. Our medical transcription prodiver actually stores all of our records online for us, which is very handy.

As always, I'd love to hear from you. Any suggestions or points which I missed? What do you think?

2007-11-13T08:09:00.000-08:00

The Mission

Every medical practice should have a mission statement, which is simply a written document of the goals and attitudes of the physicians in charge. It needn't be a lengthy or lofty document. In fact, the more precise and to the point it is, the more effective it will be.

The key is to be succinct and clear. What sets your practice apart from others? What can be done to achieve these goals? Is the statement which results a problem-solving document? A rulebook to use when necessary?

Once written, it's important to post your mission statement in a public place and refer to it whenever necessary. Review it annually and allow input from staff members if they have a strong or important point of view that augments what you create.

As far as I'm concerned, the mission statement is a necessary lynchpin in creating a good working culture. Of course, the lead physician sets the overall tone, but as an office manager, I am constantly aware that my problem-solving abilities are crucial to maintaining order. If I keep my cool and react with good humor, I set a positive example for my staff. Ultimately, I am there to support the doctors, and I never forget that.

And our doctors are extremely gracious and loyal to our staff as well. Little compliments noted here and there are vital to morale, in addition to incentives that I've discussed here previously. (Recently, I instituted the option of employees having their birthday off as a paid day after a year of service, which was extremely well-received.)

The other culture which is important to any practice is the one you are treating. What is the general median income of the community you work in? Are your patients affluent or lower to middle class? The expectation of your customers is important. It influences the look and demeanor of your practice, and knowing something simple, like the eating habits of patients, gives physicians deeper insight on how to treat them.

Again, a mission statement is extremely useful to staying on track. It should encompass the needs of your patient culture as well as the internal one in your office. It gives your practice a spine to support major decisions, and keeps everyone on the same page.

As always, I'm curious to know what you think. Do you have a mission statement? Does it help in running your practice?

2007-11-07T03:25:00.000-08:00

Improving Patient Relations

As with any service, we want our medical office to be the best, since that's how you create brand loyalty. While medicine may seem quite different from, say, a hardware store, the fact is both are quite similar from a business standpoint. People come in seeking individual attention and expertise, and often are intimidated by the surroundings. In either case, an inviting atmosphere is more likely to entice and keep people in the fold, and it truly pays to think of ways to make the patient/customer feel important.

One of the things we started to do this past year was stop with the flimsy, paper gowns provided to patients. After listening to a sales presentation from a local healthcare linen and laundry chain, we decided to try their service. Patients immediately responded by saying they found the new garments less drafty and embarrassing, and when you factored in waste disposal, we really weren't paying that much more for the new service. Even the doctors had to admit it made us seem more like a class act.

Another easy area to improve things is the waiting room. Discard older magazines, and make sure the ones you have target the people who visit your practice. If you aren't sure what people might want to read, ask them occasionally. The Guinness Book of World Records is a great addition to any waiting room, as are coffee table books featuring art, photography, or even healthy recipes. For very little cost, you can provide a variety of materials for people to browse, relieving their anxiety as they wait for their appointment.

If you have a television in your waiting room, monitor what's playing on it. Again, it's important to keep in mind who your target audience is. If you have a lot of children in your practice, you might want to provide a small sample of current DVDs to play, whereas a more adult crowd would probably appreciate a cable news channel or even something on Turner Classic Movies.

Finally, the best way to keep patients happy is to schedule them properly, so their appointments start as close to the time promised as possible. I'll admit that is often easier said than done, and the chaos of an average workday can derail even the most punctual staff. However, I've found that when that happens, it never hurts to update the patients accordingly, so they don't feel neglected.

I think the best businesses identify with their clientele. This is especially true of medicine, which is often intimate and invasive by necessity, and works best when people are made to feel welcome and treated with respect.

As always, I'm open to suggestions. What do you do to make your practice a more welcoming place?

2007-11-02T10:13:00.000-07:00

RE: From the Mailbag

I want to thank everyone for taking the time to help out with Jennifer's inquiry. Here are a few more responses that came in email form:

From Keith:

"I'm a practice administrator in the DC area. I find the national and Maryland chapters of the MGMA to be very helpful on a lot of the questions or concerns that I have. I would recommend contacting the Maryland chapter for a referral as a starter; the Executive Director Peter can be emailed directly from the website for the chapter and he is very responsive. National MGMA does have their own consultant team; I've never used them. Many years ago I worked with the Health Care Group in Pennsylvania and found them knowledgeable and helpful.I would have no problem being called by this physician if he/she wants to bounce something off of me. My contact number is: Keith Kelley, Calvert Internal Medicine Group 110 Hospital RD #310 Prince Frederick, MD 20678, 410-414-5311"

From Stephanie:

"MGMA (Medical Group Managers Association) has a strong presence in theDC area. She should contact them online or look them up and see howthey can help her. They have great contacts! Stephanie SmithManager, The Heart Care Center, A Service of Hattiesburg, ClinicPhone: 601-425-5544"

From Chuck:

"You can suggest that the new doctor in Wash DC contact MGMA to find a localconsultant. Terms can be worked out. ChuckCharles E. Everett, MPH, Health Care Strategy and Business Development, chas2020@pacbell.net"

From Joe:

"I'm located in the NW Phila suburbs.....the problem with going to the DC area is travel time. Anyone from Philly would have to be willing to eat about 8 hours for a job that really should won't net much long term revenue. A down and dirty analysis should cost this physician no more than $1,500-$2,500, which is probably all he can afford..I don't know any consultants in the DC area. Wish I did because I've had other inquires from docs in that area but no one to referr them to. Sorry."

2007-10-31T22:11:00.000-07:00

From the Mailbag

"I'm a Rheumatologist in solo practice in the DC Metro area. I enjoy reading your blog when I can, it is always very informative. I've been in practice for about a year and a half and I'm still trying to wrap my head around the management aspect. I was thinking of having a small practice management firm have a look at my books but the first estimate I got was completely out of my budget. Do you think I need to do this and how else can I approach it? I'd appreciate any suggestions you might have."

This email came from Jennifer, and I want to thank her for taking the time to write. Of course, I completely empathize with her situation, but I am left wanting to know more. How large is her staff? What is nature of her concern--legal? Financial?

It's an important decision to involve a consultant, and if I may speak informally here, I'd say the fact that you want someone to look at your books and help you better understand "the management aspect" means you do need to seek a professional opinion. Not because you are doing anything wrong, but because the uncertainty you mention needs to be addressed.

Of course, the problem is finding an affordable solution. I am unfamiliar with your area, but have you asked around? Perhaps some colleagues might have a better suggestion? Inquire with any professional associations you might belong to and see if you can find a good management firm via networking.

A good, reliable firm will be worth your investment. It's a lot of responsibility to practice medicine and run a business, Jennifer, so I wish you luck. If you have more specific questions, don't hesitate to ask.

As always, I invite any readers who have advice to please leave a comment. We're all in this together. Perhaps someone in the DC metro area might have some names or contacts which might be useful?

2007-10-26T01:33:00.000-07:00

Risk Management

Recently, I read about a bride who was suing someone for a botched flowers on her wedding cake. When people start seeing lawsuits in the wrong frosting, what chance do those of us in the medical profession have?

While I'm not a lawyer, I've learned a few practical tips on how to practice risk management. Really, what it boils down to is common sense.

For example, physicians in our practice are very specific when it comes to follow-up visits and refills. Their instructions to the patients are clear, so that there can be no misunderstanding regarding treatment.

When we have to discontinue treating a patient due to nonpayment, we provide them with ample warning. We also word our intent in a polite and gracious way. There is no point in antagonizing a patient during such a stressful time.

Another potential landmine is patient privacy. Physicians and staff never discuss medical information with a patient in an open area. Any time an insurance company or third party requests information, we ask for it in writing, and verify it with the patient-in-question.

Of course, my main concern is with how my staff conducts itself during interactions with our patients. They are under strict orders to never offer an opinion, and only to relay information that they are given. Anything more, they are instructed to refer the patient to their physician.

I remember a woman who once worked with me. She was very pious, and after a short time on the job, started to proselytize to patients. When one of them complained to our manager, the employee was fired on the spot. It was a lesson I never forgot.

I've often noted the importance of communication as a way to avoid many pitfalls in running a medical practice. When it comes to potential litigation, a paper trail is vital. If anything, erring on the side of excess never hurts. But another key is common sense and respect for others. I'd say everything I've suggested here falls under that general category.

Of course, there's no telling what some future patient will find worthy of a lawsuit. If we're lucky, it won't be the equivalent of bad frosting!

Naturally, I'm curious about your opinion. What stories or words of caution might you offer?

2007-10-23T19:52:00.000-07:00

The Direct Approach

In my early years as a manager, I had a serious problem. The bookkeeper I had hired and supervised had embezzled a lot of money. We'd been having problems paying bills, and an accountant friend of mine audited our books on his own time as a favor.

Needless-to-say, I was mortified. I remember sitting at the kitchen table with my husband, beside myself with worry. I was certain I would be fired for this person's misdeeds. There was no way to tell the physicians this news and make it less awful.

My husband was in the Marines, and he can be less than subtle. He looked me straight in the eye and said the only way to deal with the situation was to be direct, and to tell the doctors first thing in the morning. He pointed out that I had already fired the bookkeeper and would have to call the police anyway.

The important thing, he said, was how I told them. He said it's important to make it clear that I was dealing with the situation in a pro-active way. "Doctors don't tell their patients, 'you've got diabetes, too bad.' They say, 'you've got type 2 diabetes, you'll need to meet with a nutritionist, and we'll discuss some exercising options.'"

It was great advice. Not only did I keep my job, the doctors applauded my efforts to investigate the problem.

As the years have gone by, I've had many other occasions to give physicians bad news. Recently, a doctor's poor bedside manner caused a patient to lodge a serious complaint. I told him about it without hesitation, and he admitted that his workload had been stressing him out lately. When he next saw the patient, he made amends.

It is never fun being the bearer of bad tidings, but when you're a manager, it's your job to tell it like it is. To do otherwise is to risk the trust of your colleagues and your own self respect.

Addendum: Recently, I invited readers to offer topics for blogs, and Rochelle was gracious enough to reply that she wanted to know how upcoming Medicare cuts would impact group practices. In the interests of accuracy, I think this article addresses that issue better than I ever could.

Thanks, Rochelle, for your question. As always, I welcome all comments and inquiries.

2007-10-17T09:04:00.000-07:00

The So-S0 Employee

As many readers of this blog know, I am something of a softie when it comes to my employees. It has taken years for me to build up the self confidence necessary to project the right mix of manager and friend. (Mind you, I don't necessarily mean "friend" in the literal sense, but rather as a person sympathetic to the needs and goals of my employees.)

Recently, my mettle was sorely tested by a staff member who seemed in a slump. They had been extremely efficient and reliable when they first started, but over the course of their first year, something seemed to change. They lost the fire.

Mediocre employees can come in a variety of stripes. Some have a great interviewing technique and references, but a horrible work ethic. Others wind up over their head and unable to keep up due to lack of experience or ability. But when an employee starts out wonderfully and tailspins into a less satisfactory work routine, it can be painful. You know what they are capable of, and it's difficult to see them settle for less.

Worse, it can poison office morale. The slacker employee can become a leader by default, encouraging their co-workers by example. Why worry about coming in late when someone else is doing it on a regular basis?

So I had to do something about this particular staff member. They had just had their annual review and gotten a decent increase in salary. We had discussed weak spots and areas of concern, and I thought by offering a raise above cost-of-living, I'd sent a positive message for change. Unfortunately, the employee seemed to treat it as incentve to do even less, likely since the next review wouldn't be coming anytime soon.

The first thing I did to assess the situation was examine my own behavior as manager. I had allowed some sloppy mistakes by this employee because they were having a tough time in their personal life. I also looked the other way when they were tardy consistently. Clearly, I was enabling her habits.

I called her into my office and told her enough was enough. That she was to be in work on time and that if her carelessness continued, there would be consequences. I then asked her why she was continuing to slip. What was her perception of the problem?

She wound up pooring her heart out about her personal problems. It was like a floodgate had been lifted. I listened patiently and sympathetically, but I ended our meeting by telling her that while I completely understood what she was going through, she would have to step up and do her job. I gave her some concrete goals for improvement, and since then she has made great strides. She also apologized to some of her co-workers, who were relieved that the problem was out in the open. Morale in the office has never been better.

There's a part of me that feels for anyone who works for me, and cares deeply about what they're going through. I think that is partially my strength as a manager. It's knowing the boundaries for that kind of empathy that make me an effective professional. It can seem like a fine line sometimes, but I pride myself on knowing the difference.

Of course, I'd love to hear your opinion. How do you motivate mediocre employees? Do you have a zero tolerance policy for such behavior? I'd love to hear from you!

2007-10-16T08:35:00.000-07:00

Do-It-Yourself

First I would like to start by apologizing for falling off the map recently. My professional and personal life have been a bit demanding lately, and unfortunately I feel my blog has suffered a bit. Second, given that my schedule is still quite full, I will most definitely continue to post my musings, however I would like to extend an invite to any of my readers who may be interested in doing some guest writing. Feel free to let me know if you have any topic suggestions, or would like to borrow my soap box! Ok, back to the blog...

As I've discussed before, the internet and computers are offering modern medicine a chance to interact with patients in a way that previous generations could only dream about. Recently, I read an article in the New York Times about an innovative new program by Microsoft called Health Vault (http://www.healthvault.com/) that allows consumers to create free personal health records on the web:

"The personal information, Microsoft said, will be stored in a secure, encrypted database. Its privacy controls, the company said, are set entirely by the individual, including what information goes in and who gets to see it. HealthVault searches are conducted anonymously, Microsoft said, and will not be linked to any personal information in a HealthVault personal health record."

Of course, I support any attempt to make the patient more responsible in the maintenance of their health care. Often, it can be difficult for various offices, with different levels of technical know-how and cooperation, to properly coordinate medical care. What a boon it would be to have one resource that everyone could access, and that's controlled by the person-in-question.

The Health Vault site is very simple to use, but while I think it's a good innovation from a leading computer company, I also have some doubts about it. For one thing, it's Microsoft, and even the article notes that it is an attempt by the company to make sure it is the dominant platform used. Could this be a case of something be offered to increase a market share without considering the actual consequences?

Another recent article I came across eloquently discussed the problem of patients not following their prescribed drug regimens:

"On average, half of patients with chronic illnesses like heart disease or asthma skip doses or otherwise mess up their medication, says a report being issued later this week. It calls the problem a national crisis costing billions of dollars."

The article mentions the famous example of former President Bill Clinton going off statins and later needing heart surgery. Apparently, this epidemic of carelessness crosses lines in terms of income and education; no one is immune.

Of course, this is old news to those of who work in medical offices. We know how difficult it is to get patients to properly care for themselves. Sometimes people need a major setback to realize that they are not invincible, or that a problem like high cholesterol is real.

So, naturally, this leads me to wonder if people can't be trusted to take their medicine, how on earth can they be trusted to create and maintain their own medical records? Will they omit information detrimental to, say, their chances at getting insurance? Or something which might embarrass them?

There will always be patients who are scrupulous with their care, and who will be able to build a solid personal database for health professionals to access, but I fear that the vast majority are not up to the task. I say that honestly, and without cynicism. Believe me, nothing would please me more than to see a world where patients were in complete charge of their health. It's just that my professional experience tells me the reality will always be otherwise.

I'm deeply curious about your opinion on this. As fellow medical professionals, what do you think of Microsoft's Health Vault? Should patients be trusted to create and maintain their own health records?

2007-09-18T07:32:00.000-07:00

To Lease or Not To Lease? That is the Question!

When it comes to equipping a medical practice, there are endless things to consider. Modern technology is so rapidly-changing, that it can seem like a bad investment to purchase anything except office furniture and exam tables!

Recently, I helped draw up a business plan regarding the purchase of an MRI machine. I calculated the net income, and how many patients we outsourced, and also how payments from insurance companies might factor into the equation. In the end, it made business sense, but the variables were tricky.

Some lease agreements are good bargains. For instance, there's the "buck-out" clause, which allows the practice to buy a piece of equipment for $1 after the lease runs out. This can be a good way to get a good deal and keep an item properly updated throughout the terms of the lease.

Here are some good rules of thumb regarding negotiating an equipment lease:

Can you transfer it? This is important not only in case you sell your practice midway through the term, but also if you bring on other partners who will share in the liabilities and assets.

Will it automatically renew? Some leasing companies insert an "evergreen" clause into contracts. This is a time period prior to the end of the term when the customer has to notify them of their intent regarding the equipment. If this clause is in effect, and the customer neglects to notify the company in time, the lease automatically renews for another period.

Be clear on the end costs. A leasing company will usually have a provision giving them permission to charge you for damage or unexpected depreciation on the equipment. Be sure to get specifics on this beforehand, so there will be no misunderstandings at the conclusion of the lease.

Avoid indeminfication clauses. A lease company will try to protect itself from lawsuits by including such a clause, making the practice liable should a patient sue the company due to an injury caused by their leased equipment. Never allow this in your contract!

What are the tax benefits? Some states allow you to claim depreciation from leased equipment. Ask your accountant if yours does.

Who will do the equipment maintenance? Be clear on what maintenance the vendor is willing to do on the machine. Will they repair all of the components? Again, get as specific as possible.

It always pays to negotiate. Dare to ask, and see what happens. If you can, wait until you're near the end of the company's fiscal year, when they're more ready to cut a deal. After all, a lease is a long-term commitment with nasty penalties for getting out early (if they let you).

I've tried to cover a lot of the bases here, but I'd love to know any other tips you'd care to share. Would you rather buy or lease? Any horror stories or things to avoid? As always, your comments are welcome!

2007-09-13T07:03:00.000-07:00

Some Management Tips

Today, I thought it would be nice to jot down some of my principles of management. Mind you, I am not trying to say that I know better than anyone else--anyone who reads this blog knows I am very open to public opinion--but I do think my years of experience, trial and error, have made me very good at my job.

First of all, one of my main rules is no one on my staff is allowed to feel a job is beneath them. We cross-train, and if a person has extra time to help someone else, they will do so. I am not exempt from this policy, by the way. I am usually the first person in and the last person to leave, and I make a point of helping file and take phone calls when my schedule permits. I've found that leading by example is a very potent message.

Another key tenet is that I act as an advocate for my staff. When someone has a legitimate complaint with something, I do everything in my power to rectify the situation. Also, when a clerical staff member has a problem, I tell them to blame me, so I will be the one to take the heat from the medical staff. It's crucial that my staff trusts me to act on their behalf.

Everyone has a voice. During our weekly meetings, anyone is allowed to speak their mind on anything work-related. The physicians are there as well, and it creates a real spirit of camaraderie. I've worked at places where doctors have been more aloof, and you can tell by the way their staff acts. I feel the doctors are as obligated as I am to show an interest in the people who work for them. After all, they're upper management.

This past year I have also experimented with a new system to encourage better attendance. Most people view sick time as "mental health days," but in a medical practice, it can make things much more stressful. As I've noted, we cross-train, so people are able to fill in the gaps, but to discourage unnecessary sick time, I offered bonuses of $250 for every 6 months of perfect attendance. I timed it for January (right after the holidays) and July (prior to a new school year for those with children and an extra summer bonus for others).

The effect was astonishing. At least half of our staff had perfect attendance, and the good will their financial reward engendered boosted office morale considerably.

A medical office is a fast-paced environment and change is a constant. By managing with the above rules in mind, and letting the staff know that policy changes aren't written in stone--that there is always a trial period for implementation, to smooth over the rough patches--the stress level can remain low. We feel like a real team, and that translates to a good place for patients to come visit.

As I noted at the beginning of this post, I'm very curious what you think. What management tips have helped your practice? What do you think of mine? Any comment is much-appreciated.

2007-09-10T23:20:00.000-07:00

The Danger Within

When it comes to litigation, of course doctors fear malpractice the most, but in fact their employees are also a potential source of lawsuits. A good office manager insulates the practice as much as possible from being sued through vigilance and continual consultation with outside experts such as lawyers and accountants.

For example, I know of a practice that was ruined when an employee who originally filed a lawsuit claiming discrimination. During the course of his investigation, their lawyer discovered that the doctor had been paying the employee as an exempt, salaried worker, which meant he wasn't giving them overtime. Unfortunately, this employee should've been classified as non-exempt (hourly) and so the doctor was liable for all of the overtime not just for this one person, but several other staff members as well. A good accountant would've made this clear, and the problem could've been rectified prior to it reaching such a dangerous point of no return.

Another important aspect of medical practice safeproofing from legal hassles is to maintain strict compliance with the Occupational Safety and Health Administration (OSHA) worker safety rules. Consult with a lawyer and stay on top of any changes in regulations regarding potential contamination issues such as disposing of medical waste, properly handling soiled linens, and precautionary measures to avoid contact with bodily fluids.

One of the key pieces of advice our lawyer gave me was to document everything. Not only do I have our harassment policy spelled out clearly in our employee manual, but I have every new employee read and sign an acknowledgement of it. Just doing that simple act is an important step toward avoiding conflict.

When problems do arise, I make sure to write down the source and reasons. Everyone--doctors included--has attended meetings on what is and isn't appropriate. Although we are a medium-sized practice, everyone is well aware of the rules and who they can turn to if the person directly above them is the cause of their woes. The key is to not frustrate or make any staff member feel like they have no recourse.

So far we've been pretty lucky. Situations sometimes arise, but we have dealt with them in a professional manner. That's the best you can do. Respect your employees and hope that they accord you the same courtesy.

Any good stories regarding this topic are welcome in the comment section. Have you ever had a problem which required conflict resolution? How did you deal with it? I'd love to hear from you!

2007-09-04T11:29:00.000-07:00

Open Access

There is a great article in Slate.com about "open access," which is a scheduling method that allows practices to see patients on the same day. We have been using this system where I work for a few years now, and I can tell you it works.

When I first started here, our patients had a standard wait time of roughly three weeks before they could see their primary care physician. Then I came across research that showed it was possible to minimize waiting times and do the work as it comes, and not plan for it in the future, which only frustrates the patient and causes extra work maintaining a backlog of appointments. It also reduces no-shows significantly, since a patient is far more likely to come in on the same day they call.

Mind you, it took a lot of overtime at first, and it was a solid two months before we were able to whittle the appointment book down to a managable size. We now schedule about 30% of our patients in advance, and leave the rest of the slots open for people who call that day. For us, Thursday has proven to be a particularly busy time, so we stay open later.

Here's a handy reference for anyone wishing to implement open access:

Move toward advanced access by working down your backlog of appointments.

Roll out the new system by showing, not telling, patients how it works. When we try to explain our systems, we often make them overly complicated.

Begin offering every patient an appointment on the day they call your office, regardless of the reason for the visit.

If patients do not want to be seen on the day they call, schedule an appointment of their choosing. Do not tell them to call back on the day they want to be seen.

Allow physicians to pre-schedule patients when it is clinically necessary ("good backlog").

Reduce the complexity of your scheduling system to just three kinds of appointments (personal, team and unestablished) and one standard length of time.

Make sure each physician has a panel size that is manageable, based on his or her scope of practice, patient mix and time spent in the office.

Develop plans for how your practice will handle times of extreme demand or physician absence.

Encourage efficiency and continuity by protecting physicians' schedules from their colleagues' overflow.

Reduce future demand by maximizing today's visit.

At first, some of our doctors were very skeptical about this approach. The backlogged schedule is a classic sign of success in a medical practice--proof that you are thriving. Unfortunately, it is not beneficial to the patients, and it creates a static sense of bureacracy.

This new approach actually bonded the doctors and staff, giving them a renewed sense of purpose. It also streamlined our practice, since it forced our doctors to really analyze how and when certain patients should be scheduled for return visits.

As an added bonus, word of mouth was fantastic, and we wound up with an increase in patients (every customer survey we have done nets us high marks). Personally, I enjoy the freedom of spending each day doing work that is current and in the moment. To quote the motto of one of the doctors who developed the system, we "do all of today's work today."

Does your practice use the "open access" system? If so, how is it working? If not, what do you think of it? I'd love to hear your input!

2007-08-20T05:48:00.000-07:00

How Does Your Doctor Rate?

One of the good things about the internet is the way it offers consumers a chance to interact and compare notes on a given subject. When we book our physicians for medical conferences, it is handy to have guest reviews of given hotels in places we're unfamiliar, to get a sense of the quality of service.

Reading the reviews, you can sometimes figure that a person is nursing a personal grudge or just had a bad time, or on the opposite end possibly working for the hotel in some capacity. Still, most of the reviews I've come across are pretty straight forward and helpful.

But what about applying that same consumer test to doctors? Recently, I visited the site RateMD.com, where patients can name doctors and offer their opinion as to the quality of their work. Based on a five-point scale, the categories available are Staff (poor service/good service), Punctuality (not on time/on time), Helpfulness (very unhelpful/very helpful), Knowledge (unknowledgeable/knowledgable).

There is also a space to note what insurance company was used, the amount paid, and a section for comments. The latter categories of Helpfulness and Knowledge are tabulated to give an overall score which is manifested by a either a smiley face or a frown.

The site is very user-friendly, and interesting, but as a medical professional, I will admit to a certain amount of trepidation. It's one thing for an average person to criticize the quality of, say, a hotel room, or restaurant meal, but to decide on whether or not a doctor is knowledgeable about their specialty is a completely different can of worms. Often, the patient is only looking at their narrow range of problems, and it's possible that they have misunderstood or misinterpreted something.

While it seems very easy for a doctor to be penalized, it also seems possible for the opposite to also happen. Incompetent doctors who get lucky or have a good bedside manner could get a rave review by someone who doesn't have the proper information necessary to make a good value judgment. Just listen to some of the negative and positive comments I came across:

"The doctor is a kind, helpful, and compassionate physician. He calls you in and leads you back to the examining room himself."

"Only had a consult with this doctor, but left feeling like I was putting him out. He didn't listen at all and had his own agenda. If someone has had good work done by him, consider yourself lucky. I definitely got the feeling he is an LA doc in it for the big money. I am not new to this and have had wonderful, ethical, skilled doctors before. He is not one of them!"

There is nothing wrong with making the practice of medicine more accessible to the average layperson, and I'm not condemning this site completely. I just wonder if doctors shouldn't be held to a higher standard than one that offers a smiley face as a seal of approval. As usual, I am curious what you think? Have any of your staff doctors been rated? Do you think it's a good thing?

2007-08-16T08:25:00.000-07:00

You've Got E-mail

As many of you know, I am a big advocate of using modern technology to ease the burden of office work. One of the common tools at our disposal, but which I've been hesitant to use, is e-mail. The physicians at my practice felt it would create a problem, if they were available online, and they had visions of overloaded servers as patients asked them endless questions that should be handled on a direct, face-to-face basis.

Still, I've read that patient satsifaction increased greatly when email was made available, so I continually broached the topic at meetings. A month ago, I got the go-ahead to give it a limted trial basis.

The first thing I did was skip the free stuff like Yahoo! and Hotmail. Keeping medical records private is of paramount importance, so I subscribed the office to a secure, encrypted site which charged us a set-up fee, and then a nominal monthly fee thereafter.

The next thing I did was select patients with chronic issues thar required regular check-ups and maintenance. For a fee of $25 per year, I told them they could have unlimited e-mail access. They could use it to make appointments, ask general questions, request prescription refills, and even see part of their medical records. They could also use e-mail to replace any regular phone consultations they were making with their doctor.

I emphasized to them that anything requiring actually contact, such as a change in condition or a check-up, had to be done in person. Insurance companies are notoriously difficult regarding e-visits, so thus far we've avoided any situation where a copay might be involved. It is a direction we may be headed in, but right now we are restricting e-mails to routine things.

There were a few misunderstandings at first. One patient started to describe a rash he had gotten on his backside, and the doctor had to tell him to come into the office, but overall this test run has been very successful. There hasn't been a flood of unnecessary e-mails--in fact, most of the patients became more careful through the act of putting their thoughts into words. The best part was every single patient who participated loved the process, and the satisfaction rate has made it clear that this is the direction we will be heading in for the foreseeable future.

Of course, I wonder if anyone else has taken this plunge. Do any of you use e-mail in your practice? If so, how is it working? If not, what are your concerns? As always, I'd love to hear from you!

2007-08-10T13:20:00.000-07:00

From the Mailbag

Occasionally, I get emails from some of you, and while I often answer them in private, sometimes they address something that I think would be beneficial to share here in the blog. Recently, I wrote about our office policy regarding no-shows, and a clinic manager named Sheri sent me the following email:

"I have been recently informed by DMAP that we are restricted from charging their clients a fee for missing their appointments. Do you charge DMAP patients along with everyone else? Actually, the majority of missed appointments are from the DMAP clientele. I would like to hear how others are working this out."

I would say Division of Medical Assistance Program patients are an exception to the general rule, and we have an unwritten policy not to charge them for no-shows. I'm not surprised that it's official policy--although perhaps this differs from state-to-state? However, I should also note that we don't have a large DMAP clientele, so it isn't really an issue. Perhaps other readers could offer Sheri their own experiences?

The next email comes from someone also named Ann:

"I have a question about compensation for my doctors. If a practice offers certain benefits to the partners and one partner does not want the benefit is it customary to compensate them for that benefit monetarily?"

This is an excellent question. I have never had to deal with it personally, but we have it covered in our policy manual. For us, the short answer is "yes," we will compensate a partner in lieu of benefits, if they so wish. The distinction is that we have no set rules for this, as the other partners prefer the discretion of negotiating on a case by case basis. Also, this policy does not transfer to office staff.

As with the previous question, I would appreciate those who have had direct experience with this situation to please comment. I am sure there is more to this than meets the eye, and I'm anxious to know how it has played out in the real world. Why would a partner turn down benefits? How was the compensation calculated? If compensation was denied, did that create problems?

On a final note, I'd like to address the comments regarding my obesity post. I loved the point made that if overweight people can affect thin people, why can't the opposite be true? How many fat people were reformed by their association with fit people? My own parents are a perfect example of this phenomena. Every night, after dinner, my mother drags my father out for a walk around the neighborhood. She even bought him special walking tennis shoes!

Mind you, I'm not trying to discount the value of the study I noted previously regarding the social impact overweight people have on those around them. I just think it's important to avoid stigmatizing people, and working toward productive, healthy solutions.

Thanks for reading! I hope those of you who can help with today's questions will take a moment and offer a comment. I would love to hear from you!

2007-08-07T08:48:00.000-07:00

Obesity Is Not My Friend

A recent article in the New England Journal of Medicine suggests that obesity is a social problem, and that people often gain weight when those around them are fat, as it becomes something of a cultural norm.

Being somewhat heavy myself, I took this article to heart. My husband is a large man and when we got married, I was of an average size. Of course, having children has affected my body, but I do see the way I've gained weight through the years by living with someone who is not careful about how they eat.

We've tried to diet off and on, but the truth is our busy lifestyles are conducive to bad habits. Fast food happens more often than I'd like to admit, and I will confess to making dinners that serve more as comfort than nutrition. It's no secret that food can be a form of stress relief.

Most of our friends are a bit overweight, and the study seems to imply that a good way to change things is to do so as a collective. I wonder if that wouldn't be smart, since the will of the individual can be stronger when it's part of a greater good. Still, there is the risk of alienating dear friends who may be in denial of their problem, or who may not share your zeal.

Regardless, I think the study is an important new way to look at obesity, which is an epidemic in this country. Did any of you read the article? What is your opinion? As always, I'd love to hear your thoughts on the matter.

2007-08-07T08:43:00.000-07:00

Cruel to Be Kind

One of the things I hate is when we're forced to charge for patient no-shows. There was no firm policy regarding this when I started working at my current practice, and after a spate of cancellations early in my tenure, I finally put my foot down.

We established a rule that notice must be given within 24 hours of the visit. Also, everyone would be charged a nominal fee regardless of coverage. Signs were posted prominently in the waiting area. When out receptionist called patients with friendly reminders, she also mentioned the policy.

As a general rule, we've always allowed for the rare, solid excuses (when they are offered), and every patient is allowed one time to abuse the policy. After that, however, we do charge them a no-show fee after more than one missed appointment, and even though it seems harsh, I feel it's a worthwhile policy. It reminds them that while we are in the business of healthcare, we are a business, and there is a financial impact for their failure to arrive as scheduled.

What about your office? Do you have a policy regarding no-shows? Do you charge patients for missed appointments? As usual, I'm interested to hear your perspective.

2007-08-01T07:44:00.000-07:00

It's Nothing Personal

At the last office where I worked, the staff was smaller, and there were only two doctors. One of the doctors was younger and fairly new, so much of the practice revolved around the older, more established one, and he was a handful.

We had a professional bookkeeper, but they often were unable to decipher the main doctor's credit card statements to determine which expenses were personal and which were professional. It was eye-opening to sift through the various charges--sometimes we learned more than we wanted to know--but it was also fairly time-consuming.

One year the IRS came knocking, and it wasn't pretty. Several of the expenses we listed under business got re-categorized to personal. The bookkeeper lost their job, and I was put on notice.

Afterward, the new bookkeeper we hired did a very simple thing to correct our muddle. They opened a credit card account for the practice, and forbid the doctors to use their personal cards for anything business-related. Having an account strictly for business purposes made everything clear and understandable.

It's important, especially in a smaller practice, to not let the doctors mix business with pleasure. Keeping clearly defined records are your best protection in the case of a potential audit.

Of course, I'd be very interested to learn of your experiences regarding this type of thing. Please feel free to leave a comment.

2007-07-26T08:51:00.000-07:00

A Question for You

When I started this blog, I concerned myself only with writing something that mattered to me and the people who shared my profession. It was a place for me to express myself and share what I know.

It was also a place where I could read the reactions and comments of my colleagues, and hear other perspectives. I have learned more from this blog than I ever dreamt possible, thanks to the intelligent and informed readership.

Recently, my son noticed my blog and asked why I didn't have any ads or other forms of promotion on it. I told him it didn't interest me to do so. He went on to explain that if I wanted the blog to grow and progress, it would be smart to add some things like banners and advertising, to develop it into a more official site.

I love my boy, and the fact that he wants to work with me to make my blog become more popular and savvy is exciting. It's like a project we can share, which doesn't happen often now that he's a teenager.

My question to you, dear reader, is what do you think? Would you be bothered by a few inconspicuous banners or advertising? Your opinion matters the most, so I will seriously consider whatever you have to say on the subject.

2007-07-24T08:34:00.000-07:00

A Room Without a View

Few things are more annoying than a summer flu, and last week I caught one. I felt bad enough that I wound up going to see my personal doctor, which I must confess I hadn't done in a while. Sometimes those of us in the healthcare profession make the worst patients.

Anyway, you may recall my recent post on office decor. My doctor visit was an eye-opener on that count. It's one thing to view a waiting room as an employee trying to stay within a budget, and quite another when you are an easily-irritated sick person.

The first thing that really bothered me was the uncomfortable, bargain basement furniture they used. I didn't have to wait long, but the hard chair I was in made it seem like I'd spent twice as much time. Also, the chairs and couches were poorly spaced, so the sense of personal space (for myself as well as the others waiting) was almost nonexistent. When I'd been there previously for a check-up, I hadn't noticed, but since I had made this appointment at the last minute on a Friday and I was feeling toxic, I really became aware of everyone around me.

Another thing which really bothered me was the music they played. I realize muzak is a bland choice designed not to offend anyone, but I'd really prefer no music at all if I had a choice! It made the waiting room seem like a giant elevator.

Finally, I would've loved a magazine that was published in the last five years or so to read. When you're in that situation, you crave some kind of distraction. A television discretely in the corner can be good, but at the very least some recent magazines targeted to your patient demographic are a must.

Of course, I said none of this to the staff or my doctor. The latter is one of the best in the area, and we are friends as well, so I didn't want to offend her. I just took note of everything and thought I'd discuss it in my blog. What do you think? Is your waiting room a point of pride or a means to an end? As always, I'm interested in your opinion.

2007-07-19T05:25:00.000-07:00

Office Morale

(Note: Recently, some of you responded to a post I'd written about administrative pitfalls with suggestions on improving office morale via gifts and recognition. Your comments were much appreciated, and inspired me to write today's post.)

I'm lucky. The office I manage is able to pay a competitive wage, which is invaluable in both attracting and keeping a high quality staff. However, it's been my experience that while a satisfactory paycheck is vital, it's not the only way to keep office morale high.

One of the main things I do is recognize achievement. When someone does something noteworthy or makes a valuable suggestion, I make note of it and during the next office meeting, I take the time to mention publicly just how grateful I am to that particular person. Praise, when legitimately given, is a terrific way to make an employee strive for excellence.

I also will send out the occasional complimentary email for the whole office to read, or even something as personal as a post-it on someone's computer. I'm careful not to go overboard or say too much, but I've found that people really appreciate the fact that their deed was remembered. Granted, we're all professionals, and should routinely be doing outstanding work, but that doesn't mean we don't like getting complimented for it on occasion.

Another thing I do with everyone in the office is plan small events like a dinner out together or even something informal like a bowling party. Nothing reinforces the sense of working in unison like bonding outside of the workplace. It also helps break down the barrier between doctors and office staff, keeping everyone approachable and on good working terms.

Sometimes I jokingly refer to our office as a lifeboat. We sink or swim together. It isn't necessary that we like or care about everybody on board, but it sure does help.

How about your office? What are the ways in which you bolster office morale?

2007-07-17T08:44:00.000-07:00

Some Notes on Collections

Recently, I've been giving some thought to making sure we collect OTC (short for over the counter) payments on a more timely basis. I've made it my personal quest to reduce aging accounts in accounts receivable. I've had some luck with this, so I thought I would share a few handy tips.

First, I made sure our staff knew how to use the internet to find out the nature of every patient's insurance status. For those who aren't covered, I made sure there were signs posted prominently in the waiting room detailing our policy.

When patients who had no insurance arrived, I made sure a staff member politely explained our policy so there would be no misunderstanding. This was also done prior to their visit, when the receptionist called them to remind them of their appointment. The key was persistence combined with good manners.

As many of you know, I like incentives for staff members, so in this instance I offered little perks like free movie tickets and free dinner at a great local restaurant for employees who demonstrated a commitment to our new policy. (One staff member even went to the trouble of redesigning our billing statement so that it was easier to read.)

I also reinforced with physicians the need to direct any financial questions from patients to the staff. The key again being a strong follow-through that showed this was a priority, but not at the expense of the patient's healthcare.

I must say this recent focus has met with some success. I have written previously on collections, and how draconian they can seem, but I am also well aware of the bottom line. My new approach now mimics preventative medicine. We seek to prevent potential financial crises before they arise.

Still, I'm curious what any of you are doing to reduce the dilemma of nonpayment for OTC services. Any thoughts or suggestions would be welcome.

2007-07-12T08:33:00.000-07:00

The Right Fit

We recently went through the ordeal of hiring a new physician, and so I thought I'd review some points which I feel are relevant when recruiting. I recently read a study that said doctors are most likely to leave a new practice within three years. The key to enticing someone to stay is to offer them a good fit in terms of their personal needs. Modern medicine is a rigorous pursuit, but doctors nowadays also like to give their home life the same attention and devotion. It is crucial to offer such things as flexible scheduling, and an accomodation of family life.

Although the senior staff physicians tend to do the heavylifting when it comes to hiring their own personnel, they trust me to help provide input and I usually sit in on the interviews. I always stress the importance of open-ended questions that allow the person being interviewed to give a full answer. Here are some sample questions:

What areas of clinical practice are most challenging to you?

What’s your technique for handling phone calls from your patients during the day?

What are the most important contributions you feel you’ve made to your current organization?

The key is to find out how they did something, since success in the past predicts success in the furture. I can usually tell if a doctor will be a good fit by how they answer questions like those above.

Never underestimate the social aspect when contemplating a new physician. The worst thing that can happen is when you hire someone who is a fantastic interviewee, but within the first month or two of employment, they seem to withdraw and not be a full participant in the practice.

Of course, there's no guarantee of success, but I'd be curious to know what you readers look for in a new physician. Any telltale signs or red flags you look for? As always, comments are encouraged.

2007-07-10T04:36:00.000-07:00

The Art of an Office

An important part of any medical office is the art which hangs on its walls. This rarely gets discussed, but the mood established when a patient comes into your practice is very important.

When I first started managing at my current office, they had paintings of animals and clowns. I guess they were going for a circus atmosphere.

A friend who runs a local cafe, suggested that I do what she does, and solicit local artists to hang their work. No price tags, but a card noting where they can be reached. I looked into it, and after reviewing a few people, I found some nice oil paintings that gave a warm feeling (usually featuring families, I'll admit).

I also had some photos of our doctors and staff framed and placed in the examination rooms. It was my feeling that this would humanize us to the patients, and I can't tell you how often people comment that it's a nice, personal touch.

Another thing I did recently, was to dedicate a wall to the children who come to our office. While they are waiting, we give them crayons and paper, and let them draw to their heart's content. We then display their work on a rotating basis. Sometimes the kids come in when they haven't got an appointment, just to see their drawing on the wall!

A good practice considers every aspect of its operation. Believe me when I tell you that how you decorate your office will make a difference. Yes, the quality of the medical care is what counts, but never underestimate the power of proper presentation. I'd love to hear any of your ideas or stories on office decor.

2007-07-05T07:42:00.000-07:00

e-Prescriptions

It's been said that nearly a third of doctors have illegible handwriting. From my own personal experience, I'd say it's more like two-thirds, but luckily for doctors, good penmanship isn't a criteria for medicine.

However, when it comes to filling prescriptions, the ability to read a doctor's handwriting is crucial. The sad truth is sometimes mistakes are made or directions aren't followed because of the difficulty which ensues from prescriptions that end up resembling hieroglyphics.

Luckily, modern day technology has provided us with a tool which makes this problem virtually irrelevant: e-prescription software. The doctor inputs the information directly into the system, and if the pharmacy has the proper equipment, they can immediately fill it to specification. If they lack the EDI set-up, the prescription is converted to a fax. Either way, the information is provided in a clean and legible way.

Another benefit to the electronic system is drug interaction. If a patient is on a medication prescribed by a psychiatrist--unbeknownst to their physician--the system will flag it and help prevent a potentially dangerous drug combination.

Since we've been using this software, phone calls from patients and pharmacies regarding prescription issues have been significantly reduced. The benefit of clearer communication has thus saved on staffing costs, as well as potential malpractice issues.

On a more personal, lighter note, one of our older and more beloved staff doctors, whose handwriting was so bad he once took a class in calligraphy, recently joked that he should have taken one in typing instead. He then added, "I used to feel like in order to practice medicine, I had to practice my penmanship!"

I'm curious if any readers are using e-prescription technology. If so, how is it working for you? If not, what are your experiences with the old-fashioned method of prescription writing? As always, your input is encouraged.

2007-06-25T13:03:00.000-07:00

"Sicko"

It probably won't come as a surprise to longtime readers of this blog, that I'm a fan of filmmaker Michael Moore. His politics aside, I enjoy his sense of humor and willingness to take chances and explore issues most mainstream movie makers would never even think of mentioning.

His latest film, "Sicko," opens this Friday, and I am very hopeful that it will help spark a national debate about the dreadful state of healthcare in this country. From what I've read, Moore has abandoned his confrontational approach and is now just trying to encourage a discussion about the issue. I read an interview where he said he felt his old films were divisive and he felt the issue of healthcare was too important to polarize people through politics.

The movie apparently deals with people who are insured, and yet still couldn't cope with the devastating effects of illness and the predatory practices of health insurance companies. I guess Moore also interviews employees from those companies, who admit to pushing the bottom line, and showing little or no mercy to the people covered by their organization.

Of course, this comes as no surprise to those of us in the field. We are caught in the middle, making life or death decisions not just about actual medical care, but the financial liabilities as well. I'm not sure if universal healthcare is the answer, but I'm glad Michael Moore has made a major movie asking the question. What do you think?

2007-06-13T06:22:00.000-07:00

Administrative Pitfalls

I recently read a wonderful article about pitfalls to avoid when trying to be an effective medical office administrator. I have learned many of them the hard way, so I hope this helps people who are new to the profession or in need of a refresher. They are:

Ignoring patient satisfaction while focusing exclusively on business performance. This is a huge temptation, since if the profit margin suffers, you feel like a failure. After all, you don't treat the patients medically, your job is to run the office. However, that misses the obvious fact that the patient is the lifeblood of the practice, and if their needs are ignored, you won't have a business.

Losing track of inventory. Sometimes it's tempting to take advantage of discounts and specials, but it's important to have a long and accurate record of needed supplies to avoid overstocking. Bad decisions about what to order can be like throwing money away.

Failing to maintain adequate and appropriate staffing levels. When I first started managing, I tended to hire too much staff. The fear I had was not having the proper coverage, but what I wound up with was too many part-time staffers who had virtually no loyalty to me or the practice.

Being too timid with physicians. Many doctors cultivate a presence that can be hard to get past. It doesn't matter. An office manager who fears the doctors in her practice cannot be effective at her job. Period. Whatever intimidation you feel, you have to get over it.

Communicating too little or too much with physicians. The office manager is the conduit of information for the doctors, who have their hands full taking care of patients and staying abreast of their profession. The key is knowing when to tell them important things about patients or business matters, and how much they need to know.

Much of the above is learned through trial-and-error. There is no perfect way to manage a practice. The main thing is to have a good sense of organization, and a system for things like inventory and staffing. The overwhelming nature of medicine is an exciting challenge when you have your priorities in order. Any thoughts or additions to the list?

2007-06-06T07:09:00.000-07:00

Nipping Malpractice in the Bud

One of our staff doctors just received a favorable verdict in a malpractice suit, so I thought I'd discuss that briefly today. As office manager, it's crucial that I keep the staff properly trained in risk management.

As with physicians, one of the main things I stress is courtesy with the patient. In a professional, courteous manner, make them feel like you are invested in their healthcare. Lawsuits often arise over perceived neglect, so it is important to never forget the simple rule of good manners.

For doctors, it is crucial to properly document every aspect of care, so that the thought processes that lead to a given diagnosis are crystal clear. The staff must then make sure this information is properly transcribed and stored for easy access.

Tracking lab results and informing the patient of their meaning is another step in the process. We work extra hard in our office to leave no thread hanging when it comes to any form of testing.

Follow-up care to patients with chronic care issues is also of paramount importance. We all know that sometimes a patient may neglect or refuse treatment, so it's vital that the medical staff make the effort to demonstrate the need for it. In our office, we keep detailed phone logs so that all patient contact is recorded and in black-and-white.

We live in a very litigious society, so it makes good business sense to always keep your staff current and aware of the implications of their actions. Not only does it help prevent you from being sued for malpractice, but it also helps to finetune the quality of care a practice gives to each patient. Please let me know you're thoughts!

2007-05-31T07:54:00.000-07:00

Religion in the Workplace

A few years ago, a staff member in our office became a born-again Christian. Everyone was supportive, but unfortunately she mistook their politeness for an invitation to proselytize. It got to the point where I had to privately tell her to stop, as it was interfering with work and wasn't appropriate.

Religion is a tricky thing to deal with in the workplace. We have no direct written policy regarding it, since we don't want to be seen as discriminating against anyone's protected freedoms. However, here a few good rules to follow should the issue come up:

If an employee wishes to display religious items in their workspace, consider whether or not it is in view of the public. Obviously, more discretion is required in an open area. Also, anything inflammatory should not be allowed (for example, a poster calling abortion murder).

If an employee attempts to practice their religion in the workplace, give them a polite verbal warning. (In the case of my employee, this solved the problem.) If that doesn't work, put your next warning in writing. Remember that documentation is an important way to avoid potential legal issues.

The main thing is to avoid creating hardship for the practice. If a patient or co-worker complains about an employee's behavior or what is on their desk, it must be evaluated. The key is to use tact.

If you do have to fire an employee over the issue of religion, then it's always a good idea to consult a lawyer first. Several years ago, I worked with a woman who was a Scientologist. They have specific notions of healthcare, and when this woman (who was not a doctor or a nurse--she was in billing) began offering co-workers and patients medical advice based on her faith, she was fired by a reckless administrator who was personally offended.

When this employee threatened to sue the practice, we rehired her with great embarrassment, and the administrator almost lost her job. The fact is tolerance is crucial for any successful workplace. When the limits are tested, it's important for management to isolate the problem and deal with it in a calm and professional way. What are your thoughts?

2007-05-29T08:23:00.000-07:00

How To Have More Timely Collections

Having a problem with claims that stay in accounts receivable longer than necessary? Do you have a system in place to deal with the problem? At our practice, the billing staff is small, but efficient. Still, to help them maintain their workload, I created the following criteria:

1. We have a written policy that office visits are entered by our staff into the system within 48 hours, and surgery within four days.

2. We also strictly monitor the documentation provided by physicians, since the more time which elapses after a visit, the more likely there will be errors in billing.

3. Copay collection at the time of the visit is crucial. It is an unfortunate reality that insurance companies and employers are squeezing the patient to make higher copays, but a doctor's office is a business and sympathy has its limitations. We train our staff to courteously and firmly request payment whenever possible, and to monitor every patient zealously should a past due situation occur. Sometimes, it's not what you ask, but how.

4. We also have a written policy regarding collections for unpaid patient deductibles or any out of pocket expenses. We follow a set pattern regarding statements, and an established time frame before sending any account to a collection agency.

5. The people in our billing department have clearly defined roles. The senior person runs reports every month to track appeals and maintain a percentage of which denied claims are ultimately paid. This same person is responsible for writing appeal letters and any related follow-up.

The main point is to have a system. As medical professionals, we can easily forget that without a stringent collections process, the success of our practice can be seriously affected. It's as important to have rules in place for the business side of things, as it is to have stated ethics for the compassionate, medical side. What do you think?

2007-05-25T07:21:00.000-07:00

Family Matters

One of the many issues that comes up in our office is the push and pull of family responsibilities. When I was younger, before I had a family of my own, I wasn't very sympathetic to women who had child care issues. I was a perfectionist who saw the job as paramount, and anything that interfered with it as an unnecessary distraction.

To say motherhood opened my eyes to the situation is an understatement. I learned the hard way just how difficult it is to maintain a career and raise children.

At my current office, I wasted no time implementing flexible scheduling, and time off for new parents. When working mothers request sick days or exploit the system to care for their kids, I don't judge them, but rather to help them use it to their best advantage.

The thing I never anticipated when I was younger was just how beneficial such humane policies would be for morale. People like their jobs much more when they don't have to overly compromise their lives to do them.

The great thing about working in medicine is that it makes you aware of how fragile life is, and how connected we all are to one another. It makes me proud to think I help foster a workplace environment where everyone knows their lives outside of the office truly matter.

2007-05-17T19:27:00.000-07:00

Office Romances

My sister-in-law is married to a doctor, and works in his practice. She does a terrific job and it saves them a bundle. The strength of their relationship translates into a strong practice.

Although they met in the workplace and I admire how they make it work, I admit that I am prejudiced against romance in the workplace. In my experience, it leads to many potential problems.

For one thing, we have mostly male doctors where I currently work (the two female doctors are married), so automatically any dynamic that might occur between those available for dating would be a nurse to doctor. The inequality of that relationship isn't necessarily a hindrance when things are going well, but once difficulties arise, it can be a nightmare.

In our office, the policy is to inform the office manager (i.e., myself) of any inter-office romance. There are legal and practical reasons for this, of course, but in the few instances when it has occurred, I've dreaded it immensely.

Most recently, we lost the best nurse on our staff after her relationship with one of our doctors went south. By the end, they could barely speak professionally, and the tension between them spread throughout the office like a plague. We were good friends, so it made her private conversations with me even more painful. I knew every sordid detail, and had to somehow navigate between being her friend and keeping the peace in the office.

I half-considered instituting a zero tolerance policy after she left. Then I talked with some of the doctors and senior staff. The point was made that the long hours and intense nature of the work sometimes made romances inevitable. It was decided that it would happen regardless of any perceived rule.

I called my sister-in-law afterward, and told her how I wished every office romance could wind up as blissful as hers. She laughed and told me nothing is as blissful as it seems. She then admitted that she felt overworked and that her staff took liberties because they viewed her and her husband more as family than employers.

I hung up the phone and shook my head. Sometimes there's no clear answer to a problem. Sometimes you just have to muddle through and hope for the best. What are your thoughts?

2007-05-03T18:46:00.000-07:00

Doctors For Sale

I was just devastated after reading this article about how pharmaceutical reps target physicians for sales:

"Drug reps are selected for their presentability and outgoing natures, and are trained to be observant, personable, and helpful. They are also trained to assess physicians' personalities, practice styles, and preferences, and to relay this information back to the company. Personal information may be more important than prescribing preferences. Reps ask for and remember details about a physician's family life, professional interests, and recreational pursuits. A photo on a desk presents an opportunity to inquire about family members and memorize whatever tidbits are offered (including names, birthdays, and interests); these are usually typed into a database after the encounter. Reps scour a doctor's office for objects—a tennis racquet, Russian novels, seventies rock music, fashion magazines, travel mementos, or cultural or religious symbols—that can be used to establish a personal connection with the doctor."

The article goes on to detail how doctors are rated according to their susceptibility to sales pressure, and the methods the reps use to weaken the resolve of skeptical ones. It also mentions how when the doctor is resistant, they often go after their office staff.

In our office, we do like the drug reps and their occasional meal or two, but we have a written policy regarding such things. There is a very clear line drawn, because the outside forces to push or cross it are neverending.

Pharmaceutical reps and their companies will use false information, flattery, and the all-important drug samples to influence good doctors. Often, physicians are overworked and underappreciated, and it can be tempting to see the reps as an aide in the practice, even a friend.

I think it's extra important for office managers such as myself to keep tabs on this kind of thing. I make sure our receptionist doesn't allow any calls from pharmaceutical companies to go through, unless the doctors have made a specific request. She's very well-trained as to their tricks. Our doctors actually appreciate this due diligence, as they feel the reps are a nuisance.

Read the article and tell me what you think. There are so many things which don't contribute to the practice of good medicine. I'd say this rates pretty high on that list.

2007-04-18T18:55:00.000-07:00

Nurse Vs. Doctor

There's an interesting piece in the New York Times about the hierarchy of doctors. It claims that the vanity of some older doctors could potentially jeopardize the health of their patients, and that it's important for younger, less-experienced doctors to be heard, and not feel like they're whistleblowers when they disagree with their elders.

The article discusses this problem in a hospital environment, but it can also be true in smaller, office practices. At the last place I worked, a young nurse caught a mistake an older doctor had made. On the surface, he was grateful, but there was an obvious resentment that played out over time.

She was new, this nurse, and so there were some mistakes she made as part of her learning curve. The older doctor caught many of them and often rudely corrected her in front of the other staff. He was the lynchpin of the practice, the senior doctor who brought in the most patients, so no one told him to lay off, even though we all knew what he was doing. Eventually, she quit.

There's a lot of unspoken behavior in medical offices. I'd like to think that because we all have firsthand knowledge of life's fragility, our vanity and ego could be punctured like a children's balloon. Sometimes, that's true, but more often than not we function on an obvious but unacknowledged hierarchy.

Which makes sense. After all, I'm not a doctor. My opinion regarding the health of a patient is never going to carry the same weight, nor should it. The beauty of our office (and I'd suspect most offices) is the doctors maintain their authority by listening and questioning themselves. There isn 't one among them who wouldn't lend an ear to a colleague--doctor or nurse--if they had a serious concern.

And that's how it should be. The practice of medicine is not about glorifying the doctor. It's about treating the patient, by any means necessary. What do you think?

2007-04-10T20:15:00.000-07:00

Would the Last Generalist Please Turn Out the Lights?

Came across a great article in Time about how doctors who are generalists are becoming increasingly rare. The reason cited was economic. It pays to specialize. Also, the workload is less demanding, as is the ability to know as much as possible about one particular area. When it comes to medicine, patients often prefer a specialist who can see their problem to the exclusion of everything else.

But the article makes a good case for worrying about the lack of generalists:

"So whom do you go to for what? Unless you have a close friend or relative in medicine, you still need a good generalist — someone who knows you and knows the ropes. This is going to take effort and maybe some money; there are fewer of them and HMO fees are so low that many won't take on new patients except as a favor. This is especially true for the good ones who really spend time and develop a relationship with their patients. Internists vary tremendously. Some treat everything, some just do check-ups and referrals. If competent, the former will save you a lot of anxiety, waiting-room time and money. They will treat the pneumonia or the backache themselves, instead of sending you to the pulmonary doc or orthopod."

My late doctor cousin is the reason I work in a medical office today. He was a generalist. The only doctor for miles in the rural town where he worked. We often laughed over how he accepted eggs from a chicken as payment, or perhaps some repairs to his barn, or work on his farm.

He lamented the maze and nightmare of modern medicine brought on by insurance company behemoths. To him, it was crucial to know how to set a broken ankle or treat an ear infection or whatever else came his way. That was his job--his place--in the community.

I remember him comparing himself to an auto mechanic that way, saying he expected the local garage to have the know-how and diagnostic tools to fix any make of car, so why shouldn't his mechanic expect the same of him?

I miss my cousin more and more these days.

What are your thoughts?

2007-03-26T22:15:00.000-07:00

A Sort-Of House Call

A doctor in our office just told me the funniest story, and I just had to share it with you.

Apparently, he was getting lunch at the Burger King down the street, when a patient of his noticed him. He seemed extremely glad to see his doctor at such an informal setting. "Even you eat at Burger King? It must be healthy! "

This was a doctor who usually wouldn't be caught dead at a fast food restaurant. He was actually picking up lunch for our receptionist as part of losing a bet. As part of the deal, he couldn't go through the drive-thru, either, he had to go inside. (Have I ever mentioned just how nice our doctors are?)

So he was friendly with this patient, and the lines were all long, leaving them both with plenty of time to socialize. The patient suddenly went quiet, and seemed to hem and haw. The doctor sensed the man was trying to say something but couldn't. Finally, the patient quietly said something about a rash on his genitalia.

The doctor was just about to suggest that he make an appointment, when the man dropped his trousers. Right there--in the line at Burger King! The patient immediately realized what he'd done and pulled up his drawers. He headed out of the restaurant like a shot, saying he would call the office. The doctor just shook his head and laughed it off, as did everyone around him.

When he got back to our office, the doctor gave the receptionist her lunch and said he would bet her french fries that he knew the name of the patient who just called to make an appointment. He was done eating the fries by the time he told her how he knew.

2007-03-22T21:29:00.000-07:00

Clearing the Air

First, I want to address the response to my previous blog regarding the Union Pacific decision. I make no apologies for either my politics or my opinions. I want this blog to be mainly about questions arising from the office practice of medicine, but I also feel it's fair and appropriate to discuss medical issues of the day.

I enjoy reading the opinions of my fellow professionals, and I would hope that you would all accord me the same respect that I give you. If you disagree, please leave a comment and tell me why, but not in a mean or insulting tone. I consider myself lucky to have such thoughtful people at my disposal. Believe me when I say that I know I'm not always right, and that a day doesn't go by when I don't learn (and feel humbled by) something new.

For example, in the case of the post where I considered telling a doctor colleague he was behaving in an unhealthy manner, I was reprimanded by many readers who felt I was totally crossing a line. In the end, I knew they were right. Another time a reader accused me of malpractice for the poor way I had treated a frequent patient who was a chronic complainer. While I would argue that the quality of this patient's care wasn't compromised, I cannot argue with the fact that the spirit of care was violated.

I want to be better at what I do, and this blog--and all of you, by extension--has helped me to do just that. Thank you.

Just a quick note from this article which speculates that Baby Boomers are less healthy than their middle-aged predecessors:

"Significantly, fewer such middle-aged people in 2004 than in 1992 rated their health highly. More of them rated pain as a regular problem. And a higher percentage had trouble climbing stairs or walking a few blocks."

The study was far from official, and some speculate that Boomers are just more cognizant of health issues than previous generations, so the statistics could just reflect a greater awareness. I tend to think that's probably true. America is a funny country. On the one hand, healthy lifestyles have never been so promoted to the general culture, and yet on the other, we face rampant obesity and the attendant health problems therein.

As always, I wonder what do you think?

2007-03-19T23:39:00.000-07:00

When Judges Decide Healthcare

I was appalled at the recent decision by the judges in the Union Pacific case. They decided that the two women who sought to have contraception included as part of their insurance coverage weren't entitled to it. Here's what they said:

"Union Pacific’s health plans do not cover any contraception used by women such as birth control, sponges, diaphragms, intrauterine devices or tubal ligations or any contraception used by men such as condoms and vasectomies. Therefore, the coverage provided to women is not less favorable than that provided to men.”

Somebody should get the two judges who came to this decision into a sex education course pronto! Men cannot get pregnant, so the importance of contraception for them is hardly the same. Does it surprise anyone that these two judges were appointed by republican presidents, while the lone dissenting opinion was appointed by a democrat?

This shouldn't be a turf war between conservatives and liberals. It's a common sense issue. Unfortunately, many employers don't want birth control included in health plans due to religious convictions and/or the extra cost involved. Sadly, if mistakes are made and contraception is not used, it is the woman who potentially bears the brunt of the decision.

Of course, Union Pacific had no objection to Viagra and Rogaine being included as part of their healthcare plan. After all, when it comes to contraception, looking good and being able to perform are far more important. What are your thoughts?

2007-03-14T01:38:00.000-07:00

Generic Advice

For most people, it's a given that generic drugs are vastly cheaper. However, according to a new article in the Wall Street Journal, this ain't necessarily so:

"At a time when policy makers are searching for ways to cut health-care costs, generic drugs are often viewed as one of the most straightforward solutions. But...prices can vary wildly, and may not be nearly as cheap as expected. Generics of a number of...notable drugs that came off patent recently -- including the antidepressant Zoloft, the antibiotic Zithromax and allergy drug Flonase -- have...so far failed to deliver big savings in many cases."

The article noted how the prices for the generic version of widely-prescribed Zocor, a cholesterol-lowering drug that lost its patent protection last year, were not significanly lower at major drug chains like Walgreens and CVS. 30 tablets of a 20-miligram dose cost over $100 at both places, whereas Sam's Club had it available for $6.97!

Why? Well, of course, the drug stores note that they make most of their profits through prescription drugs. I think it's telling that many of the stores contacted by the reporter changed their prices or said they would be reviewing them, no doubt out of embarrassment.

Of course, for insured people who benefit from getting the lowest co-pays for generic drugs, this isn't a noticeable problem. Insurance companies get discounts for the drugs that stores do not. It's the 46 million uninsured Americans who potentially suffer. The article suggests that people research their options online first, then call to verify the prices listed.

In other words, just because something is generic, doesn't mean it's cheap.

2007-03-07T17:28:00.000-08:00

Staff Problems

One of my employees is going to medical school. She is in her mid-40s and does a fantastic job. There is just one problem: she calls one of the younger doctors by his first name.

Outside of the office, a lot of us will socialize on occasion, and there are no formalities in terms of how people are addressed. But in the office, in front of staff and especially patients, the doctors don't go by their first names. It is Dr. ________. To do otherwise shows a lack of respect.

I've talked to the woman-in-question about this several times, and for a while she follows protocol. Then she will invariably slip, and the doctor-in-question will pull me aside to complain. I am quickly reaching a crossroads over this, as her behavior ultimately reflects on my leadership. I know it sounds crazy, but I am on the verge of firing her for not properly addressing a staff doctor. Has anyone else had a similar experience?

As if that wasn't enough, another employee who I paid an agency $4,000 in fees to hire has just given her notice after only working in our office for 5 months. I've heard of other offices who make a deal under-the-table with their potential employees to circumvent paying the agency fees. I refuse to do something so unethical, but I have to admit it's very tempting.

On a final note, I'd like to thank everyone who took the time to respond to my previous post about the doctor at my office with diabetes. I wrote it in a very emotional state, and by the next morning I realized it was something that just wasn't my business. Or rather, our relationship involves business, and that precludes me from commenting to him about something so personal.

2007-02-28T18:22:00.000-08:00

Competitive Bidding for Medical Services

I recently received this email from a concerned reader:

Anne:
I would be interested in hearing how other office are handling the following situation.

We are constantly getting requests from 3rd party carriers who are working with the insurance carriers to renegotiate fees. We have our own MRI and constantly get asked to sign contracts. Our providers are feeling that the insurance companies are sending patients to the lowest bidder. I would be curious to hear how other practices are handling this.

Kathy
Practice Admin

Thanks for your email, Kathy. On the face of it, bidding for the lowest costing service sounds like a good plan. In a capitalist market, the company that offers the best price should win out. Legislators love the simplicity of this argument when it comes to something like Medicare, because it makes them look like they are doing something for the consumer.

Unfortunately, I don't think medicine is helped by this practice. First of all, to streamline a system of healthcare to this approach costs money, and the bureaucracy it creates isn't cheap. Also, once it's determined that someone offers a service for less, the patient is usually not given any other choice.

As with many things, cheaper isn't necessarily better when it comes to healthcare. There are often legitimate reasons for increased cost, and also for letting the marketplace determine the value of something, not some bureaucrat trying to save a dollar. The favoritism that causes some services to be more lucrative is a form of rot, potentially causing other less profitable procedures to be eliminated or harder to receive.

If insurance companies in the U.S. have proven anything conclusive, it's that money decides healthcare policy, even under the guise of saving it. In the end, competitive bidding is a misnomer. It may simplify things, but it doesn't make them better.

But that's just my opinion. I would be interested to hear what other readers have to say. As always, dissenting points of view are encouraged.

2007-02-15T18:23:00.000-08:00

In Response

I got a good response to my last post about people going overseas for medical procedures because it costs less. If you don't mind, I'd like to respond to some of the comments.

"All of your articles have been written and posted by others."

"Sharing your thoughts is a good idea and marvelous use of blogging, but my curious nature wonders why you are doing this."

These were comments from two different people, but I think they both relate to my purpose in blogging. I do a lot of online research, and I wanted to use this as a forum to share information with not only my fellow medical professionals, but anyone who cares about the practice of modern medicine. I often don't talk to my co-workers about these things to keep the peace, but also because I tend to keep my private concerns private.

Because I deal in facts and usually get my information elsewhere, it's logical that I would not only cite my sources, but reprint some of their material. If someone can say it better than me, why not?

The second commenter went on to say:

"...like you, (I) entered healthcare management (twenty years in hospital administration, consulting and eight managing medical practices)to help based on my non clinical skills. I worked largely in innercity hospitals and then transitioned to medical practice management. There I became more jaundiced with the attitudes of specialty physicians. Behind the scenes the focus of a surprising number of doctors was on paying patients, although periodically altrusim did shine through. I had to look carefully for the quiet ones who took care of patients and did not bluster at the closed door business meetings. When things got tough they would speak up, but only when really pushed. Rhetorically, I wonder why organized medicine, and our lofty management societies and associations don't focus more on the caring side, the professional side, the hippocratic side."

Here again, someone says it better than I can. Another reader makes a good point based on experience:

"Why would H/care be exempt from the global marketplace? Health care services are a product that is consumed by consumers (patients). Accordingly, patients will shop for services. Consumerism in health care has been a long time coming. For instance, my family went to Colombia to get dental work done for a fraction of what it would cost here, and we managed to add in a vacation. Now the one thing to consider, is what if there are complications, is the company going to fly the employee back to resolve the complication? (Probably not)."

Actually, I don't blame the patients for taking advantage of better deals in other countries. Your trip to Colombia sounds like a marvelous combination of business and pleasure, although I wonder if your vacation wasn't affected by the dental work! Still, you ask a great question at the end, and while I'd suppose it depends on the company and the agreement worked out in advance, another reader makes this excellent point:

"You got it right when you said 'COMPLICATIONS'. Try suing the doctor overseas and see how far you get. The malpractice piece is a large part of our health care dollar."

Then there was this comment by Lifeline Medical Associates President/CEO Jack Feltz that eloquently summed up the frustrations he experiences heading the largest provider of women's healthcare in New Jersey:

"One of the biggest wastes of resources is practicing defensive medicine because of the medical liability crisis and lack of meaningful tort reform in New Jersey and elsewhere. Physicians, I believe tend to order more and more tests because they are frightened not to. If there is a bad outcome you can bet there will be an attorney and expert to say they should have ordered every test imaginable. This is tragic, making health care unaffordable. I would rather see these wasted dollars go towards cures for breast cancer, immunizing poor children, improving care and keeping healthcare in the hands of expert doctors and nurses in the U.S.A."

I think you make an excellent point, Jack (may I call you "Jack?"). If only more CEO's had your sense of compassion. I often forget the legal part of the equation because I am so frequently enmeshed in battles with insurance carriers. Or to again quote yet another reader who says it better than I can:

"Insurance carriers are problematic, and don't pay or delay paying claims, and then don't pay them according to the appropriate fee schedule. This means patients get billed eventually for services that should have been covered. Unhappy patients complain to employers about coverage. Employers decide to go elsewhere. This doesn't reflect on American physicians, it reflects on American insurance carriers. "

Exactly. Personally, I think the solution to our healthcare crisis will have to combine tort reform with insurance reform. Outsourcing illness is a symptom of a diseased system. In the end, our political representatives will have to summon the will to play doctor and cure this problem. As I noted in my previous post, their inaction on this issue is deadly.

2007-02-05T12:59:00.000-08:00

Self Diagnosis by Phone?

I was reading the online journal at MedGadget.com, when I came across an article entitled "101 Things to Do with a Mobile Phone in Healthcare." I love my cell phone, but I wound up feeling a bit nervous.

The article detailed the growing phenomena of patients diagnosing themselves:

"When sites offering medical advice first appeared on the World Wide Web few GPs believed that, within a decade, they would encounter patients who used the Internet to become specialists in a particular ailment. Before the arrival of the 'informed patient' the GP was expected to provide a diagnosis, then recommend a course of treatment. Today many patients believe they already have a diagnosis and merely wish to have it confirmed by a series of tests. The question is no longer 'Doctor what is wrong with me?' but 'Doctor when can my treatment begin?' Mobile and wireless ehealth will enhance and broaden the scope of this type of self diagnosis. "

They go on to mention the growing number of companies such as Intelligent Medical Systems and Xenetec, and the credibility their experienced clinicians are giving to the products they offer. The report they cite believes this will create "peer pressure" in the industry, causing healthcare professionals to "encourage the automation of clinical processes."

This reminds me of the old saying, "cutting off your nose to spite your face." To keep up with the Joneses, we in the healthcare field are going to surrender our work to machines? I suppose this would be an improvement in the sense that at least they wouldn't envy one another.

I found this sentence to be particularly chilling:
"Companies such as Card Guard and Vitaphone are offering suites of wireless ehealth applications - which include blood pressure, heart rate and blood glucose monitoring - to patients, with or without the support of a conventional healthcare provider."

Of course, I hope technology helps people to take better care of themselves. While some patients who read up on their illnesses online can be difficult, many use what they've learned to help their doctor figure out what's wrong. It would be foolish to condemn technology that demystifies healthcare and empowers the patient.

However, I think it is very dangerous to convince people that they know how to treat their illnesses without the assistance of a medical professional. It's one thing to offer a tool to aid a diagnosis, and quite another to push a product to replace a rigorously trained professional.

2007-01-22T18:49:00.000-08:00

Will Robot Nurses Require a Thermometer or a Dipstick?

(Before I start today's post, I wanted to thank everyone who responded to my last one about employers providing onsite medical care. I learned a lot from your comments, and wanted to say that even though I usually take a stance on something, I welcome everyone's opinion.)

This recent article in MedGadget suggests that robot nurses and doctors aren't far off in our future:

"The European Union is funding scientists to develop 'nurse bots', mechanised robots designed to perform basic tasks such as mopping up spillages, taking messages and guiding visitors to hospital beds...In the future more advanced nurse bots could even be used to distribute medicines and even monitor the temperature of patients remotely with laser thermometers or thermal cameras."

Apparently, the more sophisticated version of these "bots" would work in teams together. I didn't know this, but there are "robo-surgeons" already being employed (or perhaps "employ" is the wrong word).

The theory is these androids will optimize their services to eliminate waste and create a better, more organized method of patient care. This will supposedly give the human element a better chance to thrive, since a lot of the busywork will be handled by machines.

We've come a long way from the TV cartoon "The Jetson's" with their mechanized maid making short work of housecleaning. In some obvious ways, I am reminded of my uncle who lost his auto factory job in the 1980's to a machine. On the one hand, he hated that job and was glad to try something new, but on the other a lot of people lost their way of life.

Which isn't to say that I am automatically against these innovations in technology. For instance, when it comes to things like office computerization or insurance card scanners, I can see the direct benefits. I like the human element in medical care, but maybe that's a generational thing. Children not yet born may one day prefer a healthcare system where the only human face they see is their own.

Still, I am a practical person. Hospitals are complex environments, and once nurse-bots become commonplace, I foresee a long period of adjustment. In other words, patients shouldn't be surprised if the mechanical nurse who just took their temperature used a dipstick, and diagnosed them as a quart low.

2007-01-16T07:01:00.000-08:00

Are Doctor's Offices Going the Way of Mom and Pop Stores?

I recently came across this very interesting article in the New York Times about how many companies are now creating on-site medical facilities for their employees. Once thought to be redundant and not cost-effective, corporations such as Toyota, Pepsi and Sprint Nextel are now offering their workers medical care such as "check-ups, allergy and flu shots, pregnancy tests or routine monitoring for chronic diseases like diabetes and asthma."

The employers insist that there is a "firewall" of confidentiality between clinic records and the company, but I am skeptical. While it is doubtless a sign of good management to keep your employees healthy, isn't there a temptation to control the bottom line and perhaps weed out people who aren't with the program?

In other words, doesn't it make sense to keep the company you work for and the doctor you see separate? Isn't your health a personal responsibility and not a business obligation?

I also wonder if the mentality that is used to operate these clinics has the best interests of the patient in mind. After all, they are directly beholden to the company which operates them. Can they maintain the rigor and objectivity of a private practice? Will the quality of care suffer because medicine isn't the main priority?

Still, it's hard to deny the lure of these onsite practices, especially since they are so convenient to the patient. It takes less time out of their work day, and many companies have fully stocked pharmacies, so it's like one-stop shopping.

Finding a physician, making and keeping doctor appointments, or just living a healthy lifestyle all require some degree of effort. Making those choices easier isn't necessarily a bad thing, but we must be careful about such things as the erosion of employer to employee regarding medical care. There may come a time when having a pre-existing condition or a bad personal habit will prevent you from getting employment, as well as the treatment you may need.

2007-01-07T17:24:00.000-08:00

A Blog about Blogging

I recently came across a site that suggests a very practical solution to the constant, dull roar of medical reps: blogging. That's right. While many use the blog as a personal or professional diary, it can also serve a more practical purpose, providing medical company reps with ongoing information so you don't have to.

The site provides sample entries. For example, a list of drugs that the office currently needs. Even better is a lunchtime policy that allows you detail everything from the specialties of your physicians to the dietary restrictions of your office should catering be involved.

The medical rep is a necessary evil in modern medicine, and I've become friends with a few of them. Still, in a busy office environment where time is a budgeted item, it can be difficult to offer a detailed analysis of what's needed and how often. Why not create an online blog that you can update as needed to handle all potential questions? Once you spend the time to get it started, it would be an easy and helpful office tool.

2007-01-03T08:00:00.000-08:00

Verification Required!

Happy New Year to everyone! I hope you all had a wonderful holiday season. I am blessed with a wonderful family, and our office was closed for most of the week between Christmas and New Year's, so I was able to really spend time with them.

One of the recurring themes of this blog is the advancement of medical office technology, and how it makes the services we provide easier and more reliable. I was reading a post on www.healthvoices.com about the fundamental need to make sure every patient is covered by their insurance carrier for the treatment they are about to receive.

The post says that most offices still aren't using an electronic scanner which allows them to swipe the patient's insurance card for quick verification. People are still calling 1-800 numbers like they did back in the 1980's. I can't imagine why office managers would cling to such old and unreliable methods (the post notes that 25% of claims get rejected by insurance carriers due to faulty information).

Granted, it is difficult to start a computer network and modernize your office, but in the long run it is worth it! You not only save money, but you save time and energy as well. Having an electronic scanner installed is just the first step in making sure you and your patients are on the same page.

2006-12-22T06:52:00.000-08:00

Buyer Beware

Sometimes, when I'm at a social gathering, and people find out what I do for a living, I will often hear the complaint that doctors' offices are out to take patients for everything they're worth. What people fail to understand, is the job of being informed about cost and coverage is ultimately the patient's responsibility.

There's a wonderful guest post about this on insureblog.blogspot.com, where Office Manager Kelley A. Beloff puts an article about medical costs from USA Today into perspective. For instance, she cites the example of someone making an appointment for, say, a regular check-up, and then prior to the appointment the patient breaks their ankle. It makes sense that there are going to be further costs incurred by the visit as a result of this added complication, but you'd be surprised at how often a patient fails to understand this. To them, it's one size fits all!

She goes on to talk about Medicare vs. Medicare HMO, and how patients often have no clue about the nature of their coverage, or if they change it, what that entails. Her final paragraph deserves to be reprinted here in full:

"What this article tiptoes around, but what I tell my patients, is that the patient is responsible for all the aspects of their own health care. This means understanding the insurance policy prior to signing anything, knowing if your doctor is in-network or out-of-network (i.e. takes your insurance or does not take your insurance) and finally, you the patient are ultimately responsible for all health care costs incurred by you."

Amen! I make it a point to explain things to my patients, too, but it's like talking to your spouse. In one ear and out the other, and if you're lucky, they get half of what you're trying to tell them. I realize it's hard to navigate health care in this day and age, and people have a lot of things on their minds, but they need to understand that while we in the medical office profession are there to help them, we are just as obligated to insurance companies and rising medical costs.

Just as a good patient eats right, and exercises to maintain their health, they should also educate themselves on the technical details of their healthcare. It's every bit as important.

2006-12-18T21:38:00.000-08:00

How Much Are You Worth?

I'm often amazed at the basic information available on the internet. For instance, there's a site called www.payscale.com and it has the average salaries for people according to states. Of course, I was most interested in the one affecting my job, and was very pleased to see that I was actually ahead of the curve.

Go take a look and see where you stand!

2006-11-30T18:59:00.000-08:00

The Importance of Daily Maintenance

Veronica McGrath, M.S., has a wonderful article available here on podcast at soundpractice.net detailing the importance of accurate and up-to-date recordkeeping. She notes how patients rely upon office managers to keep complete records, and to contact them when needed for care.

She emphasizes the importance of having an effective tracking system, which I know firsthand to be completely true. The disappearance of test results can have tragic dimensions, and it only takes one irate patient to realize what it means to the person-in-question.

The courts have decided that treatment follow-up is the physician's responsibility. The article details techniques to aid the office manager in making sure this is done, such as the physician initialling all reports, a test log for referrals outside the office, and documenting telephone conversations regarding test results. She also notes the importance of keeping a solid, written record of missed appointments.

Please give the article a listen, especially if you are new to the field. It will give you terrific tips on how to have a well-run office that protects both the patient and the physician.

2006-11-13T22:59:00.000-08:00

Career Opportunities

A nurse in our office recently quit at age 58 to work for an insurance company. Apparently, her years of service in the medical field have made her qualified to do case management, which really amounts to her using her expertise to review patient care for treatment and cost efficiency.

I was sad to see my friend go, but she was burned out on nursing, and not ready to retire. So I was happy that she could find something that gave her a chance to still work and use her experience.

It seems that a lot of people are opting for this second career path. The key is to translate your abilities to a field where they would be useful. My friend told me she got offers to do legal consultation for medical lawsuits, and that her brother-in-law's architectural firm may ask her advice for a new medical facility they're designing.

We live in an amazing time, full of opportunities! I'm very happy with my present career path, but it's good to know that I will have options should I ever change my mind.

What do you think? Have you switched your career path? Do you know someone who has?

2006-11-07T10:31:00.000-08:00

We Have the Technology!

Every so often I read something like this article on C/Netnews.com that really upsets me. It says that most small doctors' offices are still filing claims by using billing agencies! Unlike large corporations, which can afford to implement cost-saving methods for accounts receivable, smaller practices lag behind. Here's a snippet that I found interesting:

"But most doctors practice in small groups, representing the majority of the nation's 750,000 physicians. About two-thirds of physicians practice in groups of eight or fewer, according to Eric Brown, principal analyst for health care at Forrester Research.

"Practices like these may only recently have installed a computer, with an office manager serving as the entire technology support department. With no compelling reason to move forward--like a hard federal deadline and sanctions to back it--they'll drag their feet on a requirement that, at least in the short term, doesn't improve their bottom line and may damage it."

That's right, when all else fails, dump more work on the office manager! The article makes the point that while the technology is there, what needs to change is the insular office culture. I am grateful that my boss is forward-thinking about this kind of thing. It's the 21st century, and people have to realize that the old way of doing things is costing them money in the long run.

2006-11-04T09:23:00.000-08:00

Transcription Pros and Cons

I recently read an article in a past issue of the Journal of AHIMA that did a cost analysis of transcription. It compared voice recognition (VR) software, as well as outsourcing and in-house services.

The costliest turned out to be in-house due to the salary of the personnel performing service, and equipment maintenance and depreciation. My office originally had a person on staff doing transcription, and it wasn't my preference. In a busy environment, it was one extra thing to police and maintain. When our transcriber was out sick or quit, we were forced into the time-consuming task of finding and training someone new.

Equipment depreciation and maintenance (as well as training time) were also factors that made VR the second costliest method of transcription. A lot of the doctors I know aren't interested in something as labor-intensive. They have so much to keep abreast of without having to be trained on a new piece of office equipment.

The most cost effective method was outsourcing, which I finally was able to implement at my office. It has helped morale immensely, and has proven to be an extremely dependable service. Still, that's just my experience. I'm open to feedback.

2006-10-19T09:44:00.000-07:00

How to Reach an Insurance Company

I mentioned in my previous post the website www.gethuman.com, which I can't recommend enough. I am a big fan of lists, since they help me to organize my time, and I've found some great ones on this site. Today, I'm reprinting their list of insurance company phone numbers. As always, if you have suggestions or additional phone numbers you'd like to share, to make the list more complete, please let me know!

AARP Healthcare
800‑523‑5800 - Press 1; wait for prompt; press 4.
Aetna
800‑738‑7674 - Say "member"; Press *0.
AFLAC
800‑992‑3522 - Press #; wait for prompt; press #; wait for prompt; press #; wait for prompt; press 3.
AIG
877‑638‑4244 - Direct to human.
Allstate
800‑255‑7828 - Press * at each prompt, ignoring messages.
Anthem Blue Cross
800‑280‑7293 - Press * at each prompt, ignoring messages.
Blue Cross and Blue Shield
877‑526‑3425 - Say "get associate" at prompt.
Centers for Medicare & Medicaid
800‑999‑1118 - Press 1000.
Ceridian Benefit Svcs.
800‑877‑7994 - Press 0 at each prompt, ignoring messages.
CIGNA
800‑849‑9000 - Press ##.
Delta Dental
888‑335‑8227 - After language option, press 2 for existing or 3 for new account.
Farmer's Insurance
800‑435‑7764 - Do not press or say anything, ignoring messages.
Great West Health
800‑663‑8081 - Press 1, 1 (for memeber) or 2 (for providers), then press 4 at each prompt, ignoring messages.
Humana Medicare Claims
800‑457‑4708 - Press *; wait for prompt; press *; wait for prompt; press 0; wait for prompt; press 0; wait for prompt; press *.
Liberty Mutual (Claims)
800‑225‑2467 - Press 10.
Medco Insurance
800‑251‑7690 - Press 0 at each prompt, ignoring messages.
Medicare
800‑633‑4227 - Say "agent."
MetLife
800‑560‑5001 - Press ####.
Nationwide Insurance Claims
800‑421‑3535 - Press 0 at each prompt, ignoring messages.
Northwestern Mutual
800‑388‑8123 - Press 0; press 1 to participate or 2 to decline survey.
NY Life Benefit Services
800‑294‑3575 - Press 0.
Principal Life
800‑247‑4695 - Press 1; wait for prompt; press 2; wait for prompt; press 0; wait for prompt; press 0.
Secure Horizons
800‑228‑2144 - Say "perspective member".
UnitedHealth
800‑585‑6586 - Select type. Say "Representative" three times.
USAA
800‑531‑6095 - Press 000#; wait for prompt; press #.

2006-10-18T09:24:00.000-07:00

Good Advice for People Trying to Reach an Actual Human Being on the Phone

If you're like me, you spend a good portion of your day on the telephone. One of my biggest pet peeves is the amount of difficulty involved in trying to reach an actual human being!

Fortunately, I recently came across an excellent site with lots of handy tips for people who don't have a lifetime to waste on hold. It's called www.gethuman.com, and below are their suggestions for how to get an actual human being on the phone. I hope you find it as useful as I did. (If you have any ideas which can be added to the list, please let me know!)

1. Interrupt. Press 0 (or 0# or #0 or 0* or *0) repeatedly, sometimes quickly. Unfortunately the same keystroke does not always work for each company. Many will connect to a human after a few "invalid entries", although some will hangup.

2. Talk. Say "get human" (or "agent" or "representative") or raise your voice, or just mumble. They might connect you to a human after one of these key or unknown phrases.

3. Just hold, pretending you have only an old rotary phone.

4. Connect to account collections or sales or account cancellation; they always seem to answer quickly. First ask them for their name and rep number (so they know you are writing it down, and thus so they are more likely to help you). Then ask them to transfer you to the department you need. Sometimes they will put you ahead of the queue, although sometimes they will send you to the end (and thus in those cases this tip is useless).

5. Toll call. For credit cards, if the expected wait time is too long, hangup and try to call back on their non-toll-free number, as they often have shorter queues.

6. Selecting the option for Spanish will sometimes get you a bilingual human more quickly than if you just waited for an English-only operator.