My guest on my January 12, 2018, American Journal of Managed Care Podcast was Dr. Richard Baron, the president and CEO of the American Board of Internal Medicine (ABIM) and the American Board of Internal Medicine Foundation. We talked about the role the Foundation has been playing in fostering professionalism in medicine.

You can listen to the Podcast below:

Or, you can read a transcript of the podcast which has been edited for better readability:

 

The mission and focus of the ABIM Foundation

Richard: The mission of the ABIM Foundation is to improve healthcare by strengthening medical professionalism. Although that sounds like kind of a hokey airy-fairy thing to talk about, the core assumption is that one of the ways that healthcare could be a lot better is if policymakers and leaders and administrators thought more about the role of medical professionalism and the intrinsic motivation of clinicians who go to work and want to do the right thing.

A lot of the conversation that goes on in healthcare is about trying to optimize performance or figure out what’s the right payment system, right staffing model, or regulations to have. Our foundation spends a lot of time thinking about what approaches could be used that would appeal to professionalism and then use that as an intentional policy lever to make healthcare better.

Pat: Interesting. I bet most non-physicians already think that all physicians are professionals. What really is the problem you’re trying to solve with the focus on professionalism?

Richard: In 2002, ABIM together with the American College of Physicians and the European Federation of Internal Medicine created a document called a Charter on Medical Professionalism. It was meant to be a 21st-century code of ethics. Quite frankly, I began my service on the board in 2001 around the time the Charter was being developed and I was pretty unenthusiastic about it. I wondered, “Why do we need one more code of ethics reciting various kinds of expectations?

The Charter talked about patient welfare and patient autonomy, which are old concepts, but it also called out social justice as a core responsibility of physicians, which was a major new focus. It enumerated a series of commitments, one of which related to stewardship of finite resources as a core professional obligation.

 

Choosing Wisely

Richard: The strongest example of how the foundation does its work is its signature campaign, Choosing Wisely. Choosing Wisely was developed to help address the issue of responsible stewardship of scarce resources.

We now live in the world where patients have high deductible health plans and significant co-pays. They may be bearing much of the cost of their healthcare. We know that patients are very interested in knowing whether they really need that test.

We are interested in ways that don’t feel to physicians like something the CFO or the head of the practice group wants them to do. You don’t want to go into a roomful of doctors and say, “Gosh, if you guys can reduce MRI scans, we can make a fortune on this new value-based contract we have.” That’s an unethical, unprofessional, and terrible conversation to have. If you said, instead, “You know, there are things we do more than we should do and we shouldn’t do those things,” it is better. An example is getting MRIs for low back pain early on. Most people with low back pain are going to get better.

The Foundation asked medical societies to come up with a list of 5 things that physicians do too much of. The work was guided by four simple rules:

  • It has to be in your area of practice.
  • It has to be consequential either because it has a high impact on patients’ costs or complications or it’s frequently done.
  • It had to be evidence-based.
  • The process had to be transparent.

The Foundation worked with 80 different subspecialty societies to generate lists of five things that you should question—not that you should never do them but that you should question them.

Choosing Wisely is an example of taking the abstract concept of professionalism and stewardship and creating an activity that professional societies could engage in. It resulted in the creation of tools that doctors at the point of care could pick up and use.

It really took off. It’s now in 20 different countries and 80 different societies and it’s had two rounds of funding from the Robert Wood Johnson Foundation for dissemination strategies. It’s been a very high impact, high visibility campaign. And it’s all based on the appeal to doctors to do the right thing. It gives them a way to actualize their own professional impulse not to harm patients by doing unnecessary services.

 

Stewardship challenges

Pat: I think that stewardship is absolutely one of the professional responsibilities that we have. But I have to say that there has been some criticism of the Choosing Wisely campaign, particularly the issue of whether the tests or the focus areas that were chosen were actually the ones that were going to have the biggest cost impact. It would be easy for me to throw out five things that won’t affect my bottom line, but I may be hesitant to throw out things that generate the revenue that sustains my practice. How have you been responding to that criticism?

Richard: There is some legitimacy to that criticism. If you were the chief medical officer of a health plan or someone else managing costs, you would start with the highest cost, highest impact things, and you would have various tools in your toolbox to try to make that happen. Choosing Wisely didn’t go that route. Instead, we said to the medical societies, you need to own this, you are the experts. The Foundation is not going to peer review what you do. We’re counting on you to do the right thing here.

As you might expect with the involvement of 80 societies, some didn’t go very deep or get very aggressive in some of their recommendations. But there were other societies, like my own, the Society of General Internal Medicine that advised giving up the annual physical, an important part of how general internists make a living. So, there were societies that went very deep and took real risks, but the important thing from our point of view was that it was physician-owned—there was a ton of buy-in and legitimacy. The recommendations were not coming from a financial savings framework. They were coming from a harm reduction framework (i.e., don’t do unnecessary things that may hurt people).

There’s definitely a trade-off by not picking what you might call the most aggressive things. But I think the other side of that is we activated a lot of attention and engagement. The societies had to appoint committees to do this work. They have to devote resources to disseminating it. They were brought in and we’re proud of that. It is an example of how activating professionalism gets you things that you might not have gotten if you tried a “let’s find the highest cost things” approach instead.

Pat: It’s always a balance between getting people to buy into doing the right thing and then recognizing that at some point, at least in some areas of medicine, there’s a real conflict between stopping the things that don’t bring a lot of value and the success of a particular profession.

For example, we know that there’s a lot of unnecessary back surgery going on. However, first and foremost, orthopedic professional societies are trade associations that have, as one goal, the protection of the financial and mental health and well-being of their physician members. You can see how this creates a conflict and starts to raise questions in the mind of health policy people who are focused on the things that we really need to do to get costs under control. I know that Choosing Wisely has been documented to lower some costs but overall healthcare costs are still wildly out of control.

Richard: For sure! Choosing Wisely is not a panacea. It’s a tool in the toolbox. So, the price is also a part of the issue as is the impact of a fee-for-service reimbursement system that drives volume. Payment structures make a difference in what people do and what people don’t do.

Some people advocate that it’s all about transparency. They think if patients had access to prices and quality data that would be a very powerful lever. I think all of those things are powerful levers, but for something that is 17% of the GDP and rising, it isn’t going to be about one thing.

But, when system people decided to focus on a particular Choosing Wisely recommendation and organize things like electronic health record alerts, data reporting, and patient education around it, they were able to document substantial cost savings. A lot which may have come from the buy-in of the clinicians who were told The American College of Cardiology thinks this is something that doesn’t have a lot of value and we shouldn’t be doing. So, it’s not our CFO. It’s not the contracting officer. It’s not even our chief medical officer. It’s what your professional society says. And, by the way, we are going to monitor and measure it.

This has led to 10-20% reductions in unnecessary antibiotic use. It has led to substantial reductions in unnecessary laboratory testing. So, in particular applications, it’s been very effective in providing a moral and professional basis for physicians to focus on avoiding harmful and unnecessary care.

 

Social justice

Pat: I want to come back to an issue you raised earlier, the issue of social justice. I’ve always thought physicians should be on the leading edge of advocating for social justice, in particular, social justice around the issue of healthcare, itself.

And yet I’ve felt that some physicians have been reluctant to jump into the healthcare debate and willing almost to turn a blind eye to having so many people in our country that don’t have access to affordable healthcare insurance. Do you think doctors are doing as much as they should? And what’s the foundation doing in this arena since they pointed out that social justice was important?

Richard: As a personal matter, this was the issue that got me out of community practice. I had an incredible opportunity at the CMS Innovation Center to lead a group that focused on developing new models for payment and/or service delivery that increased quality and decreased cost. I worked in what was called the Seamless Care models group and was right in the middle of developing the comprehensive primary care initiative and the Pioneer ACO model. I was so involved in the work that I had to leave my practice. I did that because I think it is one of the critical issues of our time.

I also learned when I was at the Innovation Center, that the only thing that comes out of the CMS building is checks. Money flows out of the CMS building. That doesn’t take care of anybody. It is the way frontline clinicians practice and optimize the systems that they work in that are important. Everybody has the opportunity to lead from where they stand. If you’re in a small community practice, you can improve the service quality and efficiency of that practice. If you work in a hospital, you can serve on committees and try to upgrade the way the community hospital does its work.

I know that physicians are feeling overwhelmed and alienated, and kind of beaten down by electronic health records and various regulatory fiats that feel are descending upon them. But in the middle of all of that are physicians and patients. Patients have needs. They come to us because of our expertise. We’re in a position to offer service and help for that. That is a deeply meaningful work that we do.

Physicians, wherever they’re working in the healthcare system, have opportunities to improve it. And we need to encourage our colleagues to do that. We need to create systems where they are encouraged to do that and where they don’t feel disempowered.

Pat: I want to say that this idea of encouraging doctors to get involved as leaders in their own communities and organizations and even at the state and national level is really important. It certainly is a way in which docs could enact the mandate for social justice.

But, there was just a really interesting article in the New York Times called, “For Doctors, Age May Be More Than a Number,” that pointed out that a fifth of American doctors are now older than 65 and they are not leaving the field, they are sticking around for a long time. It doesn’t leave a lot of room for young physicians to step into leadership positions because those leadership positions are filled by older doctors who stay on and on and on.

But how do you think we can address that? Is there a way ABIM could encourage some of these older docs to not keep their leadership positions for 25 years and to understand that part of their obligation in terms of professionalism is to help young docs go up the ladder and acquire not only leadership skills but leadership positions?

Richard: There’s a lot going on in leadership. Doctors who are leaders and managers have had a career that took them from the bedside to the C-suite. They understand that those are very different ways of looking at the world. And they understand that some of the skills they have as a bedside clinician are absolutely foundational to successful management and some are lethal to successful management and leadership.

So, the first thing I would say to young physician leaders is that leadership skills need to be acquired by practice in the same way clinical medicine skills need to be acquired. People shouldn’t start by assuming, “I’m the one who really knows how to fix all this and everybody else should just get out of the way“.

My first leadership job was as the chief medical officer of a large Medicaid HMO in the late 80s, when the words Medicaid and HMO in the same sentence guaranteed that people would move away from me at a cocktail party, for sure. My friends would say, “We’re so glad you are there because everything’s going to be okay because you really understand what this is all about.”

I said, “Sure! It’s great that I’m there. But you know what? I don’t know how to run a marketing campaign. I don’t know how to hire people and not run afoul of the equal employment opportunities commission. I don’t know where to put a hundred million dollars tonight and find it tomorrow morning. And I don’t know how to get an HMO license. And if we don’t have people with those skills, we wouldn’t be in business as a company.” Physicians appreciating the skills that others have is a core element in leadership positions.

There are plenty of opportunities for younger physician leaders to get engaged and it’s not about paying dues, but it is about getting experience and not just assuming that because they’re doctors—and because they’ve identified a problem—that the solution that they have is the right for that problem. I often ask myself the question every time I ran into what seems like a completely insane policy, “Who could have thought this was a good idea? What problem might this have been trying to solve? What might a better way to solve that problem?

I think that’s a very helpful way for physician leaders to approach challenges that come up in clinical medicine, too. There are a lot of problems that are critical to clinical success that are being solved in healthcare every day including how to source drugs in an affordable way how to staff units to maintain an operating technology. Solving these problems is critical to clinical success. I think physicians do well to understand how many other people we need to help us be successful. How many other things have to go right for all of us to succeed in our mission of taking care of patients?

 

Physician burnout

Pat: Is there any intersection between the work that the Foundation is doing and burnout—a disturbing and widespread problem that’s leading doctors of all ages to leave medicine?

Richard: Absolutely. There are a few things that I can say about the Foundation and burnout. One, we funded Dr. Christine Sinski who was on the ABIM board and who is now on a Foundation board. She has become a national expert on physician resilience. She’s the person who coined the term “Finding Joy in Practice”. We funded the article she published on the topic.

Burnout has to do with dysfunctional systems, feeling disrespected, losing autonomy, and losing control. It is also about losing meaning and losing touch with purpose. Chris has focused a lot on re-engineering practice to create space for joy and space for the meaningful parts of medical practice. She is still in a part-time practice with her husband, an internist, but she’s also taken an administrative leadership job as a Vice President at the AMA.

Chris has developed a roundtable on the topic at the AMA. Some of those people are developing organizational metrics and formal strategies around burnout. That’s not our work, it’s her work and the AMA’s work. But we take some pride in having gotten her started in that area.

Pat: I love the idea of people working on “how to return joy to medicine?” I want to raise this issue, though, of whether it needs to be joy centered on the continued practice of medicine or whether it can apply to the many different ways that you can contribute to medicine, healthcare, and health of populations beyond being in the office. I wrote a story a while back based on my career that involved switching from one thing to another. I went from being a practicing emergency physician to a physician executive, a consultant, an entrepreneur, and now doing health media. All of this variety has allowed me to just stay in love with medicine. Do you think that there needs to be some focus on helping individuals understand that sometimes having new challenges can rekindle joy?

Richard: Well, even if you try to stay in the same field, the field changes out from under you. Any doctor who was in practice before the advent of electronic health records or email has seen the way they do their work change dramatically. So, new challenges come up all the time even if you try to stick where you are.

But I think you’re right, and your career illustrates it, that some people may get to a place where they feel there’s something else that may be more fulfilling. Nobody should feel locked into doing something that they hate. That was certainly advice I gave patients in practice whether they were bankers or lawyers or colleague physicians.

It’s important for all of us to take seriously how much joy we’re finding in work and what other kinds of the things we might find more joyful or more engaging or more rewarding. That’s going to vary by individual. Some people are going to want to stay in one place because they really appreciate the continuity. Other people are going to want more change and diversity.

Medicine is a very large tent that can accommodate all of those things. People should not stay in positions that they are miserable in and they should either take steps to try to make them more joyful or they should look for other opportunities altogether. And I think that’s true across the board, not just in medicine.

Pat: I’ve really enjoyed talking to you. I’m kind of in awe that we ended up having a conversation that included words like love and joy and happiness and fulfillment. Those are all words that at the end of the day all those people that are applying to medical school or struggling through the challenges of pre-med, medical school, or residency are hoping will be a big part of their life in medicine.

I’m delighted that you are in a position, through your role at the ABIM Foundation with its focus on professionalism, to help be sure that we keep on talking about joy and love in the context of medicine.

Richard: I think the future is bright and there is still plenty of meaning and value and human connection to be found in medical practice. I am enthusiastic about people finding pathways that do that.

You worked your fingers to the bone in college, sacrificing your Friday nights while everyone else was at the party so you could wake up fresh for the library Saturday early morning. You don’t remember your 20s because you were slaving away in medical school and residency. Now you’re finally a physician, but it’s not as euphoric as you thought. As you’re just starting out, your income is barely enough to cover your cost of living given the 6-figure debt sandbagging you.

It’s a tense situation. You can’t even shoot a round of hoops without the fear of incurring some irreparable damage to a limb that will render you unable to do the work you labored over a decade for. You know you need to put some protection in place, but you don’t know how much or where to get it from.

Here’s your dilemma. Being over-insured is a waste of money. But is throwing away more than you need in premiums worse than not having enough if you were to suffer a catastrophic event and need the coverage?

This is a constant battle that our physician clients face, and here are five clarifying questions that we use to help them figure out if they’ve got enough, a little less, or a lot less than the proper amount of disability coverage.

 

Q1: What exactly do you want to cover—some or all disabilities?

Said differently, are you worried about not being able to do anything at all for work, or just not being able to be a doctor and earn a high salary?

Let’s take, for example, Marie the surgeon. Marie earns $350k a year and wants to get herself some disability coverage. If she damages one of the tendons in her wrist and can’t perform surgery anymore, she’ll be out a large salary and will need to find a way to support herself.

If she can find a job that doesn’t require fine motor skills in her hand, then she may be able to earn enough to support herself. Let’s say she goes and becomes a sales representative at Pfizer. This work entails person-to-person meetings, some phone work, some light typing here and there but, for the most part, she’ll be okay with limited hand abilities. She may not be that badly off—do you know how much those salespeople make? Heck, she could be earning even more than $350k a year if she does well. But even if she weren’t killing it financially, the fact that Marie can still work means she’d only need to replace a percentage of her income.

However, if Marie were to become injured to the point of not being able to work at all, she’d need a sizable policy to replace all of her income.

Physicians should consider what they are willing to protect themselves against. If you’re willing to live with the risk that you could become totally incapacitated and hope that you’d still be able to work after suffering an injury, then partial coverage is for you. If you’re more conservative and want to be protected from the worst case, full coverage is the best option.

Don’t assume that all physicians are created equal. Physicians should be aware that disability coverage has to be sufficient for your specific specialty. Payout rates and amounts can vary greatly by occupation.

 

Q2: How would things REALLY change if you were to suddenly become unable to work?

Projecting your finances isn’t like balancing your checkbook. It’s not an exact science, especially when you have to model so far out into the future and assess a variety of possible outcomes. Sitting down and creating a plan can give you a starting point to work from and help you protect yourself from these risks as best possible using the information you currently have.

Not a foolproof method, but it’s the most scientific approach you could possibly take. Nobody can predict the future.

Ask yourself hard questions that probe deeply into how your disability would impact everyone else involved in your life. That is why we included the word “REALLY” in the wording of this question; because it’s got to be validated.

We commonly see that sometimes talking to the people in your life (parents, spouses, business partners) about what would happen if you were to become disabled spells out a different reality than what you thought they would say.

Our planners help our clients consider scenarios such as the following:

  • If my spouse had to increase his or her income in order to compensate for my lack of income, would he or she be able to do it? How much more money could he or she conceivably generate?
  • Is my spouse insured for a possible disability?
  • If I am a physician who owns a practice with other physicians, are they insured for disability as well? Would they want me to be insured for disability?
  • If I am cosigning anyone’s debt, are they insured for disability?
  • Would anyone who has cosigned my debt want me to get disability coverage?
  • What other levers could we (my independent practices, my household) push to generate more money if we had to?
  • What services would we have to pay for (housekeeper, driver, etc.) if I were incapacitated?
  • What is the worst possible outcome we could envision financially in this scenario?
  • What is the best possible outcome we could envision financially in this scenario?
  • How much of my assets are tied up in liquid investments such as cash or money market instruments vs. being in a 401k, IRA, or invested in a property that will be hard to liquidate?
  • What would be the tax consequences of liquidating these assets if I had to do so?
  • Would there be any penalty fees I would have to pay for doing so?

All of this leads to the larger question of overall financial strategy. Disability coverage and income are just one piece of the puzzle. Other factors, such as tax, liquid assets, savings, etc., should be taken into account. Without seeing the bigger picture, it is hard to understand any one piece of the puzzle.

 

Q3: How long could you get by without the benefits?

The way insurance typically works, the longer you can delay receiving benefits, the lower the premium. As is the case in Q2, the answer to this question depends on your financial makeup.

If you have an “emergency fund” of 3-6 months of cash, liquid, and ready for the taking, then maybe you can live with a delay. Or, if you have a spouse that supports you or other sources of income such as rental properties, then you may be able to get by for a while.

 

Q4: How long do you need coverage for?

Again, this goes into the bigger question of your overall financial plan.

Let’s say that Marie has three small children. She needs high income for the next 18 years or longer if she intends to put them through college and/or graduate school. The coverage period would be longer.

Or, let’s say that Marie expects to receive a large inheritance within the next five years. In this case, the coverage period would be much shorter.

Longer coverage period, higher premium.

This question also has implications for where you get the coverage from. If you get it through your work, you may or may not be able to take it with you if you change employers. Getting insured when you are younger means lower premiums (as does being female vs. male, by the way). Being forced to get insured at 50 could be much more expensive relative to at 20, especially if you have any health conditions that may have materialized over those 30 years.

 

Summing it up

Once you determine the coverage amount, the next step is to figure out who you should buy your policy from. There are professional organizations that sometimes will offer these policies, and your employer may as well. Some prefer to purchase an individual policy through a private carrier. There are pros and cons to each, and this is complex enough to warrant another blog post for another time.

As you can see, determining the proper amount of disability coverage is no simple task. It’s time-consuming if you want to do it right.

For physicians who don’t have the time to DIY on an analysis like this, there are online resources as well as qualified financial professionals who can be consulted with in order to find these answers. This may require you to pay a fee, but it will be well worth it in the long run if it means you avoid not having enough insurance or the right insurance.

Communication breakdowns are a frequent risk management finding in malpractice claims. The Doctors Company identified communication as a contributing factor in 27% of claims closed from 2012 through 2016. Of those claims, communication was further subcategorized into communication between patient or family and providers, communication among providers, and communication involving technology, including telephone, e-mail, facsimile, Internet, and telemedicine.

 

Communication with patient or family

Ten days post-hospitalization, an elderly woman with an indwelling urinary catheter presented to the clinic with her daughter to have the catheter removed. As the patient was leaving after the nurse removed the catheter, the daughter asked the nurse if something could be done about her mother’s back pain from lying in bed. As the nurse ushered them out of the room, she assured the patient and her daughter that she would discuss the complaint with the physician. The nurse failed to pass on the complaint. Later, the patient fell at home and was admitted to the ICU with septicemia from an upper urinary tract infection.

The nurse’s communication lapses included failing to ask the patient questions about her back pain and failing to communicate the message to the provider. Had further communications with the patient and the provider taken place, the cause of the back pain could have been explored and a timelier diagnosis could have been made on the upper urinary tract infection.

An essential part of effective communication is taking time to educate patients and families about medications, activities, follow-up appointments, and contacting the physician if concerns arise, such as the continuing back pain in this case example. Developing thorough communication takes practice and time. It is more than relying on others or going through mechanical motions.

When possible, speak with the patient when the family is present. Implement Ask Me 3, the National Patient Safety Foundation’s time-efficient, effective tool that encourages patients to participate in their own healthcare by understanding the answers to three questions:

  1. What is my main problem?
  2. What do I need to do?
  3. Why is it important for me to do this?

 

Communication among providers

Communication failures among providers may be attributed to ineffective closed-loop communication, information lost in the transition of care, or failure to establish clear lines of responsibility. The examples below illustrate these types of errors.

  • Closed loop communication: A patient was scheduled for shoulder surgery. The informed consent was obtained, and the arm was marked by the surgeon to identify the correct surgical area. In the operative suite, the perioperative nurse placed the blood pressure cuff on the patient’s left arm, covering the identifying mark. Fortunately, the correct shoulder was reidentified during the time-out procedure and a wrong-site shoulder surgery was averted.
  • Transitions in care: A radiologist identified a mass on a patient’s kidney; he called the rural clinic and left a verbal message with a staff member to have the provider return his call as soon as possible. The staff member forgot to relay the message. Later, the radiology report was faxed to the clinic and was promptly filed in the patient’s chart for review at the next visit scheduled in six months. The radiologist assumed the clinic had received and reviewed the faxed report.
  • Clear lines of responsibility: An anesthesiologist and a surgeon failed to communicate regarding oxygen use around the surgical field with the simultaneous use of electrocautery during a procedure. The patient sustained extensive facial burns requiring skin grafts. The defense expert was adamant that it was the shared responsibility of the anesthesiologist and the surgeon to protect the patient from a potential fire injury by communicating verbally, rather than simply assuming that the other practitioner recognized the fire hazard.

Communication, both verbal and written, requires repetition and continuous evaluation to identify failure points for refinement. Implementing The Joint Commission’s Universal Protocol to reduce the possibility of wrong site, wrong person, or wrong procedure may help minimize errors, but it should be reviewed periodically for consistency and application as habits and staff change. Policies should require marking the specific surgical site, such as the shoulder, instead of marking a general area, such as the upper arm.

When performing the time-out immediately before starting a procedure or making an incision, all procedure team members should actively participate in discussing the patient’s care. This should include any anesthesia concerns for the patient during the procedure rather than making assumptions based on prior experience and circumstances. Every caregiver has the responsibility to speak up.1

Inadequate lab and diagnostic test tracking is another leading cause of patient injury. Processes should be evaluated frequently for improvement in communication from the time the test was ordered until the time the results were reviewed, documented, and shared with the patient. Not only should an internal system and process be implemented, but we also recommend that providers engage patients to follow up by calling the clinic if they do not receive results.

Related Content: Actors and the Art of Better Patient Communication

Communication involving technology

While performing a procedure to repair a torn tendon, the surgeon inadvertently severed a small nerve. A subsequent surgery was scheduled for the nerve repair. When the patient became dissatisfied with the results of the nerve repair, it was discovered that the chart had no notes documenting discussions of the risks, benefits, and likely outcomes of the nerve repair surgery. No formal office visit had occurred. The discussions had taken place via text messages sent to the physician’s cell phone. The messages had not been entered in the patient’s medical record.

Review or develop clear communication guidelines when using technology (telephone, e-mail, facsimile, the Internet, or telemedicine) while keeping patient privacy in the forefront. All communications involving patient care must become part of the patient’s medical record.

To enhance efficient communication among providers of a patient’s status, consider using the SBAR (Situation Background Assessment Recommendation) format. SBAR is a standardized communication method that provides for the transfer of vital, clear, and relevant information about a patient’s condition in an organized manner in any setting.

By identifying and eliminating the most frequent communication breakdowns in the healthcare setting, errors leading to a patient injury can be reduced.


Reference
1. The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. The Joint Commission website. httpss://www.jointcommission.org/assets/1/18/UP_Poster1.PDF.

This post was sponsored by The Doctors Company, the nation’s largest physician-owned medical malpractice insurer.

Let’s be honest here…something needs to change. The “care for health” model is flawed! Preventive health issues are increasing annually and something good needs to happen.

  • Heart disease is the leading cause of death in the United States.
  • A third of the country is obese.
  • Type 2 diabetes is on the rise, but preventable.

The American Cancer Society is projecting over 1 million new cancer cases in 2017.

Many of the leading causes of death in the United States can be prevented or delayed by society making healthy lifestyle choices.

But let’s look at their situation first.

Unhealthy lifestyle options are everywhere and much easier! You drive down main roads and fast food options are every few blocks. Going food shopping takes time! Working a full day leaves little motivation for additional activity. As a society, we are tired. Family responsibility, commuting, work, and the need for more sleep all tend to take priority over health.

Most people don’t have the fortitude to make these changes by themselves. Some make the decision to find other health-related professionals for help, but this is a small percentage compared to the whole.

Ultimately, everyone checks back in with their doctor for something—whether it’s a check-up, to get regular blood work completed, or to address an acute issue. As a medical professional, this is your opportunity to help.

The value of the doctor visit is you get to provide hard data to represent health concerns.

“Your blood pressure is high.”

“We need to lower your BMI level.”

“You have to watch your LDL.”

“Stop smoking.”

“Your blood sugar has gone up.”

These statements, and many others like it, are based on tried, tried, and proven research that allows you to provide very specific information. As a medical professional, you know when the test results require more intervention from you.

However, this is where the level of care goes from very specific to extremely general. You know lifestyle change is required. You know your patients need to do more or they will be dealing with very serious issues in the future.

But, in many cases, what you say or recommend next does not have the substance a patient requires to change. The recommendations made next are vague and general and, unfortunately, leave too much room for interpretation to the patient.

“You need to lose some weight.”

“You have to eat better.”

“Try and be more active.”

“Stop smoking.”

“Eat more fruits and vegetables.”

Let’s take a look at these two sets of examples again. You will see the criteria for tests and office visits is very specific. However, the recommendations for change do not match the same level of specificity.

Here are the 2 main reasons why this strategy does not work.

 

Reason #1 – Too vague

The general recommendations you can make during an office visit are too vague. Using the examples above “lose weight”, “eat better”, “and be more active”, the first question to ask is “How”.

It is often not practical to answer the “How” during the office visit. It requires more detail and, to be fair, this is not the strength of most physicians. You cannot design a complete strategy during that time.

You could refer the patient to a partner health professional such as a fitness professional, gym, nutrition center, etc. But, from experience as being one of those professionals and collaborating with doctors for years, only a small percentage of patients follow through with this option.

Patients need more detail!

 

Reason #2 – Only hearing your recommendation during office visit

How many times per year do you see the average patient, 1-2 times? Even if it’s a couple more, it is a low number of visits.

Take a moment and think about a change you might have made in your life, whether it be personal or professional.

Did you immediately hear or think of an idea and immediately act on it?

Think about this for a second. Marketing experts say it takes a consumer more than 8 times to see an advertisement before they make a purchase. Using that analogy, how many times does it take you to hear or think about a new idea before implementation?

Now let’s go back to your patients using this logic. Although your in-office recommendations are right, your patients need to hear them more frequently for the change to occur.

Here are a couple of questions for you…

  • Do you want to build the doctor-patient relationship?
  • Do you want to improve the patient experience?
  • Do you want to be the trusted doctor your patients can always rely on to help?

If so, you need to increase your touch points with your patients outside of office visits. To be fair, the changes you are recommending, and they need to take, will happen during the other 364 days a year (assuming you see patients once a year). It is the time between office visits that consistent healthy strategies need to be implemented if real change is to occur.

 

How do you increase the touchpoints?

So how do you do this? Don’t worry. It’s easier than you think. Send consistent emails containing healthy lifestyle recommendations.

As a society, we are glued to our phones. Are you reading this on your phone right now? Don’t ignore this form of communication…embrace it!

By emailing your patients with consistent frequency, they will begin to depend on seeing your name in their email box. It will be a regular reminder for them to be healthy, and your recommendations will have more substance and directions for patients to follow.

You don’t have to overcomplicate this. Determine an email sending strategy…weekly, bi-weekly, or monthly. The internet is full of information you can use and send to patients.

Research topics including:

  • Meal plans
  • Recipes
  • Studies on healthy eating strategies
  • Healthy daily habits (i.e., drinking water, writing in a journal, etc.)
  • Exercise routines
  • Stretching
  • Benefits of exercise
  • Motivational messages

You can also send reminders for more frequent screens which help to increase accountability between office visits.

Are you getting the idea? This does not require too much time. If you have an office staff, you can designate one person to handle this responsibility and the content gets approved before it is sent out. If you are a small office or want to be more directly involved, this may require 1-2 more hours per week to set up.

But the result is more touch points with your patients. This means they are seeing your name consistently. They will associate your name and email with a reminder to do more every day to lead a healthy life.

Instead of just treating illness, which is invaluable to your patients, you are now incorporating a proactive level of care that they truly need.

The “culture of healthy” starts in your office, but the daily changes required to achieve this will happen when your patients are not with you. They need you more outside the office. Adopt this easy strategy, embrace technology, and have a better connection with your patients.

You will be more fulfilled and make more of an impact.

At some point, there will come a time to sell your practice. It could be in part to a partner or as a whole to another group or hospital. In any case, the practice will need to undergo a valuation, which is a detailed and complicated process, oftentimes confusing because let’s face it, it is not like you sell your practice every year.

In general terms, the process of determining the price that a medical practice will be sold, or bought, for is referred to as valuation. You are literally putting a specific value on the business, or certain parts of it, so you can sell it. We cannot just randomly assign numbers on how much a medical practice is valued at, or how much an owner’s interest in a practice is worth. There has to be a valid basis behind the estimate of the economic value of a business. In the same vein, there is a set of procedures on how these estimates are arrived at. This is called a medical practice valuation. One thing that can help you on your path is to understand some of the basic tenants of practice valuation.

 

Understanding terminology

If you are considering selling your practice, make sure you understand terms and appraisal definitions. Oftentimes, a physician will ask their accountant to appraise the business, but the physician may be surprised to find that the “book value” given by the accountant is far different than the “Fair Market Value (FMV)” that he could actually receive at the time of sale. It is not that the accountant is incorrect at all. Rather, the accountant and the physician may be operating under a different set of terms and definitions, without knowledge of each other’s perspectives. Realizing that there is no absolute sales price is the essence of FMV. When determining valuation, look for a price range with a reasonable floor and ceiling.

 

Understanding value

For starters, value isn’t an absolute number. A medical practice’s tangible and intangible assets can be grouped into two broad categories: physical assets and non-physical assets. Examples of physical assets include accounts receivable, leaseholds, medical equipment and furnishings, medical records, and real estate. Examples of non-physical assets include buy/sell agreements, goodwill, managed-care contracts, restrictive covenants, and staffing. Estimates of value differ significantly, depending on the purpose of the appraisal, the acumen of the appraiser, etc.

Astute appraisers will consider a host of questions:

  • What is the value of the practice for purchase or sale?
  • What is the value of a practice for merger?
  • What is the value of practice assets for a joint venture with a corporate partner?
  • What is the value to establish buy-in or buy-out arrangements for partners?
  • What is the value of practice assets for purchase or sale, apart from ongoing operations?

To answer these questions, physicians must understand how practices are valuated.

Related story: A Guide to Strategic Diligence for Physician Practice Mergers

 

Informal terms of valuation

The “asking price” is often arbitrary and difficult to substantiate and typically is reduced by a significant percent during negotiations. The “creative price” is derived by way of creative financing. For example, the practice may provide the down payment. The “emotional price” may involve either a motivated buyer or seller, who pays an under- or overinflated price for the practice. The “friendly price” is reserved for associates, partners, or other colleagues. The “realistic price” is one that both buyer and seller believe is fair.

 

Formal terms of valuation

Practice appraisers use FMV as the standard to derive a reasonable value for a practice. FMV means an arm’s length transaction between an unpressured, informed buyer and an unpressured, informed seller. The “business enterprise value” of a practice equals a combination of all assets (tangible and intangible), and the working capital, of a continuing business. The value of “owner’s equity” equals the combined values of all practice assets (tangible and intangible), less all practice liabilities (booked and contingent). The “working capital value” equals the excess of current assets (cash, A/R, supplies, inventory, prepaid expenses, etc.) over current liabilities (accounts payable, accrued liabilities, etc.).

 

The big picture

Valuing a medical practice is more of an art than a science and you must always keep in mind that the “Asking Price” is NOT the purchase price. Quite often, it does not even remotely represent what the practice is truly worth. Naturally, a buyer’s valuation is usually quite different from what the seller believes their practice is worth. Sellers are emotionally attached to their medical practices. They usually factor their years of hard work into their calculation. Unfortunately, this has no business whatsoever being in the equation. Never, ever buy a practice just because the price is right; first and foremost, be certain that the practice itself is right for you and that it is integral to your future strategy. Remember that valuations are not scientifically based; they’re subjective!


Related: More Practice Management articles on TDWI

In recent years, there has been noticeable increase in practice mergers among physician groups. Undoubtedly, with the ever-evolving reform of the U.S. healthcare industry, there is a lot of uncertainty for private practice physicians. Some practices are content with no organizational changes and some have decided to be acquired by hospitals. Others have gone the route (or are pondering) of merging with another private practice (either same specialty or different specialty). The decision to buy, sell, or merge a medical practice is more complicated than ever, and determining a medical practice’s worth is just one element crucial to this process. For those that are considering merging with another private practice entity, there are many things to strategize about—and that’s assuming there will be a windfall of benefits by consummating a merger. Applying a systematic approach to strategic due diligence can yield huge returns to practices considering mergers.

Seek validation

Is the strategic vision for the agreement valid? Physician owners must have a clear rationale for a transaction or truly understand a deal’s impact on their practice’s long-term financial future. Too often, however, there’s a misguided sense of why the merger should take place at all, and there’s far too little time spent defining how the merger enables them to beat competitors and increase organizational value. Those that fail to take this into account contribute to the failure rate of physician group mergers.

For many physician groups, the link between strategy and a transaction is broken during due diligence. By focusing strictly on financial, legal, tax, and operations issues, the typical due diligence around a proposed merger fails to test whether the strategic vision for the deal is valid. To do so, physician groups should bolster the usual financial due diligence with strategic due diligence. They should test conceptual rationale for a deal against more detailed information available to them after signing the letter of intent. They should also see if their vision of the future operating model is actually achievable.

Seek confirmation

When analyzing a practice, looking at historic and current performance is relatively easy. But what about looking further into the future? What are the strategic issues ahead? A strategic diligence should explicitly confirm the assets, capabilities, and relationships that make a buyer the best owner of a specific target acquisition. It should bolster the physician owners’ confidence that they are truly an “advantaged buyer” of an asset. Advantaged buyers are typically better than others at applying their established skills to a target’s clinical and business operations. They also employ their privileged assets or management skill set to build on things like a target’s practice reputation, patient experience, or relationships with referring physicians. Naturally, they also turn to their special or unique relationships with vendors and the community to improve performance, leading to advanced synergies that go beyond what’s normal.

Seek mutually reinforcing advantages

When change comes suddenly, it can turn strengths into weaknesses and sweep away dreams of success. The aim of a merger should be to achieve mutually reinforcing advantages. Michael Porter wrote that competitive advantages stem from how “activities fit and reinforce one another…creating a chain that is as strong as its strongest link.” By undertaking strategic diligence, physician owners will be able to not only define their main objectives, but also gain greater control over the desired direction of the new entity after the merger is consummated. Some of the strategic diligence questions to ponder include:

  • What are the strengths of each practice?
  • What could our practice be doing better?
  • What opportunities exist as a result of this merger?
  • What threats do we face by completing this merger?
  • What is the current culture of each practice?

As part of the process, you should consider the scope for further growth, efficiency, improvement, etc. It is critical for physician owners to be honest and thorough when assessing their advantages. Ideally, they develop a fact-based point of view on their beliefs—testing them with anyone responsible for delivering value from the deal, including physicians, physician extenders, clinical staff, and front and back office personnel. Above all, when it comes to the merger of two physician groups, culture is a key decision criterion. Culture should be evaluated and discussed prior to any financial considerations. In my experience, this is of paramount importance for practice-to-practice mergers and is meticulously examined only through strategic diligence.

The results from the strategic due diligence process provide the acquiring practice with the strategic information it will need to manage the target practice. Often, the seller knows more about the practice and its patients than the buyer. This asymmetrical knowledge can have long-lasting negative effects post-merger. Strategic due diligence accelerates this learning process and expedites the achievement of the long-term goals. Of course, nothing in the future is certain, but using a strategic and diligent approach provides far greater understanding of the issues ahead, and forms one further part of the jigsaw when assessing a potential physician practice merger.

When it comes to healthcare, apparently there’s no trust anywhere. This sad conclusion is based on the results of a survey published by ReviveHealth, a full service agency focused on healthcare delivery, finance, and innovation. ReviveHealth partnered with SMG Catalyst Healthcare Research to survey hospital and health system executives (n=117), practicing physicians (n=600), health plan executives (n=48), and consumers (n=604). This is the 11th year ReviveHealth has been doing such surveys, but the first year in which consumers were included in the process.

Survey participants were asked, via online web surveys, to indicate their level of agreement on an answer scale (below) with statements that reflect their feelings in each of three domains: reliability, honesty, and fairness.

ReviveHealth Trust Index Instrument (650 x 335)

The statements were:

1. Reliability – This organization makes every effort to honor its commitments.

2. Honesty – This organization is accurate and honest in representing itself and its intentions.

3. Fairness – This organization balances its interests with ours and doesn’t routinely take advantage of us.

Participating health systems executives and physicians rated each of the 5 major health plans: Aetna, Anthem, Cigna, Humana, and United. The results for the various Blues plans were presented as an aggregate score.

Composite scores were calculated as an equally-weighted mean of all three individual Trust measures. The surveys were all filled out between June 6 and August 11, 2017

 

How do industry stakeholders feel about each other?

The results show that trust in health plans was low for both health systems and physicians. Health plans level of trust in health systems was higher but still pretty mediocre.

ReviveHealth bad grades slide (650 x 362)

Drilling down on the data, they found that hospitals’ and health systems’ level of trust in the various health plans had a widespread. UnitedHealth was rated the lowest (36.3) as it has every year for the 11 years the survey results have been reported. Cigna captured the highest score (68.0) this year by a narrow margin, but Brandon Edwards, the CEO of ReviveHealth, told me that for the last five years, Cigna and Aetna have been alternating the number 1 and number 2 slots. The average score of 52.0 reflects the mean of the remaining four plans. According to Dan Prince, the President of Catalyst, the participating hospital system executives were individuals who were responsible for negotiating contracts, so they had first-hand knowledge of the issues related to health plan-health system contracting.

The spread for physicians’ level of trust in health plans, on the other hand, was much narrower with a low of 52.8, a high of 58.4, and an average of 55.8. Brandon Edwards thinks this is because physicians, by and large, are not involved in the business side of their practices, so their responses may reflect what they have heard from staff and their patients.

Health plans were asked to rate health systems by category (e.g., for-profit hospital systems, non-profit systems, Children’s hospitals, and so forth). By and large, their level of trust in such systems ranged from a low of 59.4 to a high of 75 with an average of 68.4. Brandon told me health systems tended to rate systems with lesser degrees of power higher. Based on my experiences working with health plans, that rating makes sense. In healthcare, negotiating is all about who has leverage. A small hospital in a multi-hospital community wants the health plan’s business and will do what it takes to get it. A large system or a system that is the only game in town, on the other hand, will use their leverage in ways that can make life difficult for health plans (e.g., refusing to let nurses have access to hospitalized patients, not allowing concurrent review, and so forth).

The authors of the study concluded, rightfully, that no one was really a winner because everyone received bad or failing grades.

 

What did industry participants have to say?

In addition to survey responses, the authors of the study shared the comments from each of the stakeholders. Here is a representative sample of what health system executives had to say about health plans:

“‘Good faith’ and ‘trust’ have significantly eroded with some payers. It is evident that …there is no intent by the payer to honor the terms put into place.”

We have noticed greater frequency of [insurance] companies implementing policies in conflict with contract terms, then not honoring the terms of the agreement.”

“There’s very little commitment to the concept of ‘win-win.’ Payors that have market power will exercise it to their own advantage, exclusively.”

Health plan executives, on the other hand, had this to say:

Not all organizations are really committed to doing the right thing, without using monetary gain as their first motivation—very few really are interested in people’s well-being.”

“Economic pressures on both sides of the equation have resulted in relationship erosion. In public, health system executives will vocalize strong support for integrated health, quality, and transparency, but at the negotiation table, this completely evaporates…there is often little regard for members/patients and [their] costs…”

 

The transition from volume to value

Health plan and health system executives were also asked about the transition from volume-based payments to paying for value, something we desperately need to get done if we are ever going to tame costs and improve outcomes. In answer to a question about where they are at on this issue in 2017, here is what they said:

Revive Volume to Value (650 x 364)

 

Health systems think they are about half of the way to a value-based system, but their providers, the health systems are still getting their revenue from volume, the old “heads in beds” model. At first glance, it may be hard to understand how health plans think they are doing so well when the people they pay are saying they are still primarily getting paid by the piece. It is likely that the explanation lies in how each of the stakeholders views the transition to value-based care.

In a very interesting series of graphics, you can see that the driving forces to transition to value are very different for health plans compared to health systems. The strongest drivers for health plan executives are gaining a competitive edge, increasing trust with partners, being able to participate in government initiatives, and gaining support in the physician community. They feel hindered by lack of data, technologies, and processes.

Health plan transition to value (650 x 365)

Health system executives rank support from physician and community leadership as the strongest driver followed by a gain in reputational or competitive advantage. Restraining them is caution by their leadership to take a risk or move too quickly as well as a lack of technologies and processes.

Health system transition to value (650 x 365)

Brandon Edwards, CEO of ReviveHealth says that

“No matter how you look at it, trust is an important factor as the healthcare tries to transition from volume to value.”

 

What about the real customer?

Consumers were fairly unified in their responses. They trust doctors the most with a composite score of 78.8 (I would say that’s a B-), but they don’t trust their health plans as much (composite score of 69.9). Their trust in hospital systems is somewhere in the middle (composite score of 74.7). Here is a more granular view of their responses. Of note, they think the least of health plans fairness. Hmmm. Why do you think that is?

 

ReviveHealth healthcare leg question (650 x 368ReviveHealth healthcare leg question (650 x 368)

 

The future of healthcare

Consumers were also asked about the future of healthcare and these answers were really interesting. Remember, people were answering the questions between June 6 and Aug 11, 2017, well before the latest round of Repeal and Replace known as Graham-Cassidy failed in the Senate.

ReviveHealth healthcare leg question (650 x 368)

In retrospect, we can see that they were wrong about the first question, partially right on the second, and hopefully prescient on the third. When I asked Brandon Edwards what he thought about the very positive response to Medicare for all, he cautioned that there was a slight skew towards Democrats in the consumer group, but he said that despite that,

“Something has really changed here and I think this is why: My personal experience with private plans has been a disaster. My parents’ experience with their Medicare plan, on the other hand, has been very positive because Medicare is a program that is easy to navigate and clearly understandable.”

Maybe we are finally ready to do the right thing after trying everything else and failing.

What is it about physicians? The stereotype of the brilliant and bold surgeon who reigns over the operating room whose mantra is “A chance to cut is a chance to cure.” The ever-smiling pediatrician wearing a bow-tie with a small elephant on his stethoscope. And the pipe-smoking psychiatrist, steeped in Freud and saying little. None of whom listens to anyone without an MD, and often not to them.

Many physicians have life and death in their hands—literally. As physicians, our training is to “fix it”. Jerome Groopman shares with us that doctors usually get it right, but sometimes they don’t.

“Most errors are mistakes in thinking. And part of what causes these cognitive errors is our inner feelings, feelings we do not readily admit to and often don’t realize.”

 

Show them the evidence

My work in coaching physicians lives at the interface of what they know—getting it right—and what they often don’t realize, that being an effective executive leader requires additional skills and moving from linear to complex thinking. Once they realize the value of coaching in getting them there, they are ideal clients. Meet them where they live, in science. Show them the evidence, the research and they’re ready to go.

Years ago, I coached an energetic, fearless surgeon who was failing badly in a new role. He was a skilled technician, performing procedures on desperate patients, often saving their lives after other surgeons had given up. He had been a rising star in an academic medical center where surgeons ruled and often were less than tactful with their colleagues, surgeons and non-surgeons alike.

I met this doctor after the CEO of a more cordial medical facility recruited him to be a department chair. Intra- and inter-professional relationships mattered at the new organization. Employees stayed forever, dedicated to the mission of putting patients first.

He was tasked to turn a failing department around, to update technologies and offer new services—big and important challenges. My coaching client had started his tenure by immediately making changes, without spending (one of the first books I asked him to read) or learning the new culture and its people. His approach came from the stereotypical academic medical center, which means it was long on telling and short on listening.

He had been hired to “turn the department around” and he was doing just that in the style of the organization he had been recruited from. That old methodology of succeeding wasn’t working in the new system. He was bewildered by the switch in attitude toward him, by his colleagues complaining about him and his style. When I met him, I was the latest in a series of coaches, some of whom believed he was misguided and others who believed he was uncoachable—a lost cause.

During our coaching engagement, he grilled me at every step—what was the data? Where was it published? Without the proof of peer-reviewed articles, he seemed unenthusiastic and minimally engaged. A turning point came when I mentioned that Coursera offered a free online course in emotional intelligence, taught by Dr. Richard Boyatzis, an excellent and brilliant teacher with a world-class academic pedigree. Four weeks into the course my client said to me, “I didn’t realize there was so much science, such a body of literature, in motivation and leadership.”

And so our coaching continued, as did his questioning, with a difference. Now he had become deeply interested in the process. He met with each of his direct reports, apologized for his behavior and asked all for their suggestions on the future of the department. He began asking “what” questions and then listening for a maximum of three minutes before commenting. He learned to solicit opinions without appearing to attack the offerer. Eventually, and with the help of carefully chosen Harvard Business Review and medical journal articles, he learned to modulate his style to fit the organization and the importance of relationships.

 

Behavioral science is different from chemistry

I tell this story to illustrate the importance of evidence and of research to those who are schooled in hard science. Behavioral science is different from, say, chemistry, at least at the beginning levels. Variables in “soft sciences” are often measured in a more qualitative, or descriptive manner—measuring behavior, which is open to interpretation. In the “hard sciences” in which physicians train, variables are more amenable to a quantitative, or yes/no, manner of measuring things.

A quantitative conclusion is more concrete and often not open to interpretation. For example, “The elements combined to make a compound weighing 20 grams” compared with “When the subject was confronted with x he did y and the explanation is z.” There are 20g whether you measure in ounces or kilograms; there are 20g whether you use a digital scale or a balance. On the other hand, the explanation of behavior has a lot to do with who explains it—what their training and assumptions are. The explanation is subject to variability depending on the observer, just like coaching, and that is what causes the physician to hesitate, to overthink. Just as they don’t want to risk someone’s life on untested treatments, they are trained to be deeply skeptical of interpretations that are not thoroughly understood.

To get physicians, and other clients, to invest in coaching, I often have to explain the theory and research behind the practice. It is not enough to point to the results and say “It works!” I have to show why they want to see the data and the interpretation. Doctors want to know the difference coaching can make in their success as leaders.

We know from research that client buy-in and readiness to change is essential for coaching to be successful. As individual coaches, how can we support physicians and other “hard-science-oriented” clients? As an executive coach for physicians, I typically start with 360 interviews to learn others’ perceptions. Throughout our coaching engagement, I share articles and books—the evidence.

Since emotional intelligence is often a critical part of my clients’ leadership development, if possible, I use the ability-based MSCEIT (Mayer-Salovey-Caruso Emotional Intelligence Test), a valid and reliable instrument that measures the taker’s emotional intelligence in four dimensions (perceiving, understanding and managing emotions, and facilitating thought) and offers suggestions to improve the taker’s emotional intelligence. Validity and reliability are foundations of the scientific method. The former refers to whether the test measures what it says it measures. The latter refers to the reproducibility of the test by other researchers. Physicians often are more trusting of instruments with these qualities.

Related:
Is Your Doctor Emotionally intelligent?

The Value of Coaching in Medicine

In the big picture, there’s a lot to do. Earlier this year, Anthony Grant, Ph.D. (a prolific publisher on coaching), at the University of Sydney, published “The impact of leadership coaching in an Australian healthcare setting.” The conclusion is that leadership coaching may facilitate goal attainment, foster resilience, and lead to greater ambiguity tolerance in those who are coached—all factors in preventing burnout and supporting personal growth. Dr. Atul Gawande proposed coaching for surgeons in a New Yorker article.

As one of my coaching clients told me,

“You’ve helped me expand my view of the world to think of consequences of my actions, take risks, and understand that it all comes down to relationships.”


First posted on Library of Professional Coaching 11/21/2014 and on TDWI on 11/26/2014. It was updated on 09/05/2017.

In my last post, I covered operational performance metrics. Here, I will cover performance metrics from a more financial perspective. Financial metrics not only help to track the performance of your practice but also can be used to increase accountability of your in-house staff as well as outsourced billing companies. The latter factor can be quite useful when it comes time to renegotiate contracts with these companies.

 

Average revenue per patient

This measure relates to the Average Cost Per Patient ratio. Your target is high revenue per patient combined with low cost per patient.

 

Average revenue per day

Comparing this ratio to your daily charges shows you if each day’s work—at least in terms of revenue production—is above or below average. In effect, it shows how busy you are. Many factors, including surgery schedules and the number of physicians working a day’s sessions, greatly affect daily charges. Investigate the reasons behind any significant variance. If your adjusted charges per day increases by more than inflation over time, it suggests your practice is growing.

 

Accounts Receivable per FTE physician

This ratio calculates an average amount owed for each physician’s work. Totaling the receivables for each doctor and comparing that amount with the group’s average may expose poor coding skills or a lackadaisical effort at keeping up with paperwork. “Dirty” and/or tardy claims will virtually always take longer to process than do clean ones.

 

First pass resolution rate

This is the share of a practice’s claims that gets paid on first submission. It is said that this should be above 90%. This calculation is a reflection of the effectiveness of your revenue cycle management processes, from pre-visit processes like verifying insurance eligibility, adding required authorizations, and maintaining accurate patient demographics to post-visit tasks like coding and billing. Getting it right the first time is critical to maximizing both efficiency and profitability.

 

Percentage of Accounts Receivable >120 Days

Accounts Receivable is generally grouped into aging buckets based on 30-day increments of elapsed time (30, 60, 90, 120 days). All A/R aged over 120 days falls in the inclusive A/R >120 day bucket. A/R greater than 120 days is a clear indicator of how effective your practice is at securing reimbursements in a timely manner. High or rising percentages are red flags alerting you of issues with your practice’s revenue cycle management that need to be addressed promptly. For example, your staff may not be acting quickly enough on denials or aged claims.

 

Days in Accounts Receivable

Tracking days in A/R helps monitor billing and collections. The greater this number becomes, the longer it takes insurance plans and patients to pay you. You absolutely must find out why that’s happening. This calculation represents the average number of days it takes a practice to get paid. The lower the number, the faster a practice is obtaining payment on average. It is said that this number should stay below 50 days at a minimum, but should generally be more in the 30-40 day range. In addition to providing insight into the efficiency of your revenue cycle management processes, monitoring this metric can help you unearth factors hurting your finances. For example, when assessing the cause of an increase, you may spot a problem with a certain payor and can then work to resolve it quickly.

Related Content: How to Evaluate Medical Billing Services

Gross collections ratio

This basic ratio simply shows how much of what you bill for, you actually receive. By itself, it tells little. But compare it with the net collection ratio which is coming up, and it will help determine whether your fees are too high or too low.

 

Net collections ratio

Due to contractual adjustments, you are undoubtedly collecting less than ever of what you charge, making it more important than ever to actually collect all of what you are legally entitled to receive. This ratio is the percentage of total potential reimbursement collected out of the total allowed amount. It is also commonly referred to as the “adjusted collection rate.” This metric lets you assess your practice’s effectiveness when all is said and done (i.e., claims have been submitted, denials processed, patients billed). It tells you objectively the share of the revenue your practice deserves but left on the table. The lost opportunity reflects factors within your practice’s control (for example, untimely filing) and others beyond its control (for example, uncollectible debt). Weak ongoing net collection rates may compel practices to replace staff, revamp processes, invest in new tools, or outsource revenue cycle management to increase profitability. Again, this calculation incorporates your contractual disallowances, telling how much of what you’ve agreed to be paid, you actually receive.

 

Benchmarking

One particular notion I like to address with my clients is benchmarking with national data.  While using national benchmarks is acceptable, that data should not be viewed as the gospel. For example, if a national benchmark is 92% but you are currently sitting at 80%, then your immediate goal should be to get to, say, 85% and then 90% and so on. If you set the bar too high initially, staff will become frustrated and see the national benchmark as unattainable. On the other hand, if your practice is at 96%, do you simply stop improvement efforts? Or do you continue to strive to make the best better?

You also have to keep in mind the extreme variability with national benchmark data (i.e., specialties surveyed, sample size, payer mix, services rendered, geography, etc.).  Consequently, this benchmark data is really little more than a ballpark number for you to look at. As I mentioned in my last post on operational metrics, you must remember to measure what matters. Find out the key essentials to your practice, not just what others in your specialty are measuring. And by all means, keep it simple…simple to operate, simple to understand, and simple to action.

Talk to anyone you know and you’ll likely find they are on some form of social media. From baby boomers to millennials to your local 13-year-old paper boy, social media is a big part of everyday life. Currently, there are approximately 2.46 billion social network users around the globe, and this number increases from month to month.

Facebook is still the social media giant, holding 18% of the market share and boasting around 1.87 million users who are active at any given time. The closest competitors don’t even touch Facebook’s numbers, with WhatsApp only having around 1 million active users and Twitter at a mere 317 million active monthly users. If you only do one thing to reach out to patients online, get on Facebook. However, there are advantages to other forms of social media as well.

There are a number of ways doctors specifically can use social media to expand business, stay in touch with current patients, and inform the public. Once you see the benefits available to your practice, you’ll see the need for a social media presence.

1. Educating patients

Social media offers the opportunity to educate patients and the general public. There are a number of ways to educate via social media. One way is to upload a link to new research about your area of specialty. For example, if you are a cardiologist, you might share a study that was just completed about the impact of high cholesterol on overall cardiovascular health.

Another idea is to record Facebook Live or YouTube videos and share them with your followers and the public at large. Do you have a suggestion that you think would improve the overall health of your patients? This is a great way to share that info.

You can also share short snippets on platforms such as Twitter to put a thought in the follower’s head. You will be limited to 140 characters on Twitter, so you might want to write something like: “For better heart #health, eat less carbs.” Twitter is the place to utilize hashtags so people who are most interested can find your information easily.

2. Better customer service

Customers expect you to be on social media, with approximately 67% heading there for customer service needs. If your competition offers online customer service options and you do not, you risk losing customers. Even though the doctor likely doesn’t have time to answer questions and deal with customer complaints, assigning the office manager or another employee to handle these issues on social media can put you a step ahead.

Imagine, instead of spending so much on an answering service that you have, a registered nurse or nurse practitioners who takes live chat online. They can let patients know if they need to go to the emergency room or if the issue is minor and can wait until the next day. Ideally, this person would be able to schedule an appointment on the spot, too.

3. Reducing face-to-face appointments

Technology is growing by leaps and bounds, and apps that allow the consumer to have instant access via live video to a mental health professional or physician are becoming more common. Some insurance companies will even cover these appointment costs. This is also beneficial for doctors, who can save time and money traveling to and from the office.

This sort of setup works particularly well in mental health, where the counselor can meet with the client via live chat. Research has even shown that using such apps can reduce depression and anxiety in people struggling with those issues.

4. Scheduling

There are few things more infuriating for a patient than a busy signal at the doctor’s office. You wake up feeling extremely ill or with a high fever, and you pick up the phone to call and make an appointment—only to be met with either a busy signal or nonstop ringing. You might even lose patients over this type of thing.

The issue at many doctors’ offices is that the receptionist taking the calls for the appointments also has to greet patients as they arrive, pull files, and do various other tasks. It’s a lot for one or two people to handle.

Offering the ability for patients to schedule their own appointments online is a viable solution to this problem that will put your practice a few steps ahead of everyone else. There are a number of software options on the market that you can customize to meet your needs, such as Practice Fusion and Appointment Quest. You’ll need to find the one that works best for you and your patients.

Even better? This type of software will send automated email or text appointment reminders to your patients. This saves your staff time and allows them to focus more on the customer service experience when the patient is in the office.

5. Increase loyalty

Having an online social media presence can help increase loyalty and engagement with your brand, a.k.a. your doctor. One university study showed that brands engaging regularly on social media have higher customer loyalty rates.

During a regular office visit, a doctor might be a bit rushed and not have the opportunity to engage with his patients the way he’d like. Social media allows him to reach out to them en masse and share his thoughts about their overall health.

It is also a good way to keep up with birthdays and big life events. Creating that ongoing dialogue that social media allows is something patients will appreciate. They aren’t likely to go to another doctor in the area if you are offering them everything they need both online and off.

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These are just a few of the ways social media can improve your business. There are many other ways to utilize social media, including targeted advertising to a local audience. With time and consistent efforts, your social media presence will grow and you’ll have tapped into an inexpensive marketing platform that will reduce your overall costs.

How do you know that the overall business is healthy? How do you know that the business processes you perform are working properly? Now, how would others in your practice know? Metrics are important for a number of reasons. For starters, if you don’t know how well you are doing, how do you know what to keep doing and what to change? Words without verifiable numbers are just opinions because what gets measured, gets done.  While metrics come in many flavors, they all have one thing in common…metrics tell the world what you think is important.

A metric is a verifiable measure stated in either quantitative terms (e.g. financial ratios) or qualitative terms (e.g. patient satisfaction surveys). Metrics provide control over processes, equipment, and employee performance, and they provide reporting of actual performance relative to expectations. Communication of what constitutes value and key success factors is accomplished through metrics. Metrics provide opportunities for improvement by showing gaps in performance and they provide expectations to a host of people (i.e. staff, patients, and referring physicians).

There are pre-defined metrics (as I will be outlining below), but some practices may devise custom metrics that are tailored to the specific needs of their practice. Regardless of the metric used, however, each should have certain characteristics in order to be a good form of measurement. The metric should be: objective/quantifiable (everyone knows how to calculate it), non-conflicting and relevant (important to doing a good job), achievable and verifiable (motivational in nature), monitored frequently/timely (feedback on recent actions), visible (accessible to all who can make an impact), comprehensible (everyone knows what it means), and actionable (information to know what to do now).

 

Overhead ratio

All practice owners want to know how much of the revenue it takes to keep their doors open. Most benchmark measures uniformly exclude physician compensation from the expense ratio calculation. But that consistency disappears when discussing non-physician practitioners. Some organizations consider nurse midwives, PAs, and similar clinical extenders as support staff and include them with practice overhead. Others exclude non-physician practitioner salaries from the overhead calculation because they’re “providers” of direct healthcare services. I prefer viewing non-physician practitioners as employee staff who free physicians for greater productivity. Following that logic, include their salaries in the overhead calculation. Whichever way you choose, make sure you calculate your practice ratio according to the same method used by any benchmark. Doing so permits a direct comparison of your data to the national statistics.

 

Staff ratio

Make sure you handle non-physician practitioners consistently when calculating this ratio.  As previously mentioned, I prefer considering such physician extenders as employees, making them part of the numerator for this ratio.

 

Individual category expense ratio

Lumping all expenses together often camouflages where a practice overspends. This ratio isolates how much you spend on individual expenses. You must fully understand the impact of such individual expenses as personnel, office facilities, and lab and clinical supplies.

 

Laboratory expense ratio

If you incorporate laboratory or other ancillary services into your practice, track whether such ancillaries continue to prove worthwhile. Use a similar ratio for all “add-on” services.

 

Average cost per patient

As with all expense ratios, make sure you consistently handle how you account for physician and non-physician practitioners.

 

Payor mix ratio

Not all insurers are of equal value to your practice. Calculating this ratio for each contract shows how the individual plan or company contributes to your overall financial success. If one or two companies dominate this statistic, make sure you develop the best possible working relationship with them. At the other end of the spectrum, decide whether you want to put up with a particularly hard-to-work-with plan if you don’t generate much revenue from it. You could also calculate similar payor ratios replacing receipts with adjusted charges. That ratio would tell what you should receive from various payors. If what you actually collect differs greatly from what you should collect, investigate problems with your collection activity and/or the payor.

Metrics drive behavior in a number of ways. They help define the practice’s business model because concrete goals are tied to precise measurements and the focus on these measurements can increase the precision of the value proposition. They help communicate strategy by documenting performance targets and creating buy-in to the metric-setting process. They, of course, help track performance and give timely and relevant feedback to those involved. They help increase accountability through practice-wide, team-specific, or individual measurements. And, they help align precise objectives, departmental functional goals, and practice-wide strategic activities as a whole.

Remember, measure what matters. Find out the key essentials to your practice, not just what others in your specialty are measuring. And by all means, keep it simple…simple to operate, simple to understand, and simple to action.

In my next post, I will go over the financial performance management of medical practices.

Bringing in a physician partner has many advantages: A partner may help your practice grow and become more successful; partners allow you to share the workload and to combine skills with another provider, and you can enrich your practice by having a solid teammate. However, business partners can become your greatest asset or worst liability. Deciding whether or not to share your practice with someone else may be one of the most important business decisions you ever make. Deciding who you go into business with can be just as important.

There is no way to guarantee a potential partnership will work. Consequently, weighing the advantages and disadvantages of having a physician partner, and carefully analyzing the reasons for choosing a partner can help ensure that you find the right person to entrust with your practice. Identify what you really need from a physician partner before you start looking for one. Once you have completed this essential first step, you can begin the process of choosing a partner.

Weighing their strengths

Draw up a set of criteria that you’re looking for and simply judge how well a potential partner lives up to it. For starters, a physician partner should bring something different to the table than you do. If you’re creative, maybe you need a more detail-oriented partner. Or if you’re shy, you might need a good “people person” to balance the equation. If they’re similar to you, it might be more comfortable, but it may not be what you need. You need someone who complements your skills and personality. Of course, you will want to weigh their standing in the referring physician community. A business partner who is adept at cultivating relationships with your referring physicians adds value to the practice. Also, consider how they interact with employees and patients.

Sharing your vision

It is very important that partners share the same vision and goals for the practice. Discuss your vision with your potential or current business partner. Evaluating a potential partner can be like trading life stories to understand if your business principles, company goals, and personalities are compatible. Take as much time as you need to make a well-informed assessment of whether your business partner is actually a suitable one. You should share a sense of vision and values but not have overlapping skills.

Considering commitment

Assess the potential partner’s expectations on the time involved. Partners don’t have to spend the same amount of time, but it is important that they are on the same page as to each other’s expected time commitments. How many hours a day does your partner expect to put into the practice, and do his expectations meet yours? Your partner’s commitment has to equal yours. A partnership—especially one between friends—can start off with fun and excitement, but within a short time, the slog of every day catches up with you. If they’re not as committed to the business as you, they may lose their enthusiasm and may actually be damaging the brand every time you open your doors.

Using professional advisors

An attorney can help you build important information into an agreement, such as how the work will be divided, what will happen if more startup money is needed, and how decisions will be reached. Although partnerships need to be written up, remember that people make partnerships work, not legal documents. And remember, the best time to address potential problems with your partner is at the beginning of your venture before emotions run high. You can’t predict every potential problem, but a good healthcare attorney and consultant can help you work through some of the common problems and put a framework in place to help address unforeseen circumstances.

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Try to evaluate potential partners without regard to emotional ties or friendship. Your potential partner should also have questions for you and should want to know about your character, reliability, and expectations. Oftentimes, I see a practice that greatly values what a physician brings but fails to consider what this same physician may want out of a partnership. What does s/he want out of the partnership arrangement (financially, operationally, and strategically)? The right partner can assist in escalating the growth of the practice and shoulder a large chunk of the workload. Conversely, a wrong partner can bring down the business. Patience, honesty, and careful considerations will pave the way for making the right decisions.