Since I’m working both as a consultant and as an employed physician/CMIO, I have the opportunity to interact with quite a few different hospitals, health systems, physician organizations, and vendors. Maybe it’s the Supermoon effect, but it feels like some of the organizations and teams I’ve been working with have lost their rudder. It’s resulting in unpredictable situations that create challenges all the way around.
With one organization, I feel like I’ve been immersed in a spy novel. They’ve been planning to switch EHR vendors for quite some time and are well down the contract negotiation pathway with another vendor. Still, they keep stringing the legacy vendor along, demanding that executives be flown to the client site to address the issues and the relationship so that they can demand discounts and credits for perceived software inadequacies. I say perceived, because I’ve been working with them for well over a year and know firsthand that they haven’t implemented the legacy system correctly and refuse to take my advice or the advice of the other two consulting firms they have on site.
I wish there was some kind of whistleblower hotline to let the legacy vendor know they’re being played, as well as to warn the incoming vendor of the kind of people they’re dealing with. Maybe there is already some level of understanding of the situation, but in working with the earnest and dedicated sales and client management teams, the individual folks working hard to save the client don’t seem to have been clued in and are taking it personally when they figure out the client is lying to them. Client leadership is open about how much they can get out of the legacy vendor on their way out the door and it’s sickening. I’m grateful my contract with them expires at the end of the year because I won’t be offering them a renewal.
Another organization recently engaged me to do some coding education with its providers. In the decreasing world of fee-for-service, they’re eager to get every last dollar out of their problem-oriented encounters. The first thing I did was to look at the coding distribution across their providers, which was fairly close to what I expected. There were two physicians who were significant outliers, but the rest fell nicely along a curve that didn’t vary much by patient mix or payer mix. I figured my task was to first work with the high-end outliers, to find out whether they were over coding and putting the organization at risk. When groups get caught in that situation, the penalty is calculated by extrapolating the overage as if all visits had been handled that way. It’s to an organization’s benefit to rein that in so they don’t have a huge penalty in an audit.
In fact, the group wanted me to address those they perceived as under coding and get them up to the level of their outlier peers. I’m sorry, but if you’re a walk-in primary care clinic that isn’t even addressing complex chronic conditions or significant comorbidities, it’s hard to get a viral upper respiratory infection up to a 99214 E&M code without at least documenting the chronic conditions and how the infection might impact them. Just because you add a prescription medication to the plan or perform a 40-point physical examination doesn’t mean it was medically necessary or that the higher level of coding was justified. I was happy to provide the nuts and bolts coding education. but if they want to encourage up-billing. they’re going to have to use their own physician executives to explain how they want that done.
Another group who engaged me to do a workforce evaluation is being crippled by ineffective management and poor human resources policies. Workers routinely fudge their time cards to make sure they reach 40 hours a week, even though they’re exempt employees who aren’t necessarily required to document 40 hours a week. Unfortunately, they’re damaging their team’s reputation and creating risk for their company. Some of the workers are adding the time to administrative buckets, which negatively impacts the team’s productivity. The worst offenders are padding time on client-facing projects, in effect stealing from their clients six minutes at a time as they increment the billings almost imperceptibly to make up for their own shortages. I recommended that the 40 hours requirement be removed and time be monitored over the next few months to see if there are weeks that people are working more and weeks that people are working less, and to see if they were averaging 40 hours a week as expected. HR cited company policy for the 40 hours requirement, and failed to address the outright dishonesty by their client-facing employees.
I was raised in a world where people should be prepared to face the consequences of their actions, but in these situations, it’s clear that there have been no consequences to date and that those involved don’t even worry about the potential consequences. My business career has been under leadership that expected people to deliver what they said they would deliver, but to do it ethically and in a way that keeps the client at the front of their thoughts and actions. I’ve worked for leaders that were tough but fair, and were honest about the decisions they were making and the potential impact on downstream employees and clients. It’s what I’ve tried to be in my work, but sometimes I feel like the idea of “greed is good” has come back into vogue.
I don’t want to think that so many organizations are spiraling into the muck, and just as I was starting to feel that way, I had a company impress me with its integrity. I helped them with an extremely sensitive project and they made sure that as it unfolded I was in no way compromising my principles or proceeding in a way that didn’t make me comfortable or interfered with my other clients or responsibilities. They didn’t assume that just because I was a consultant and being paid a good amount of money that I was on board for anything they requested. I’ve never worked with a group that was quite that deliberate in how they handled their business relationships, but it was certainly refreshing. It was the kind of engagement that makes a consultant hope that if they eventually want a full-time resource, they’ll keep you on their short list.
I like working with people who say what they mean, mean what they say, and do what they say they are going to do. Are you fortunate enough to have that in your workplace culture? Email me.
Email Dr. Jayne.