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Curbside Consult with Dr. Jayne 2/1/16

February 1, 2016 Dr. Jayne 6 Comments

A wise man once told me to take as many business and finance classes as I could, even though I planned to go to medical school. That advice has served me well over the years, particularly as medicine has become more of a business and less of a calling.

Although my residency program provided solid education in practice management, it still didn’t fully prepare me to run my own solo practice. I was lucky to have some good advisors who could point me in the right direction and were willing to mentor me in learning more about healthcare economics.

As we move into the realm of value-based care, the ability to understand economics and finance will be critical for physicians and other care providers if they want to remain solvent. There has to be a return on investment — not only on technology and infrastructure expenditures, but also on staff.

The latter seems to be the hardest for some organizations to understand. I have worked with quite a few employers over the last several years that don’t have a working knowledge of productivity benchmarks. I’m not saying that everyone needs to go out to national sites and compare their staff right off the bat, but at a minimum, organizations should understand productivity within their own site, practice, or location. If they’re serious about operating in the value space, they’re going to have to get very cozy with benchmarking and determining the total cost of various episodes of care.

It’s hard to reconcile complaints about the EHR being too clicky or too cumbersome when you have physicians seeing dramatically different numbers of patients. I was recently at a site where providers were seeing 16 patients a day in the primary care setting. Personally, I haven’t seen that few patients since I was a first-year resident and still had to review every patient visit with a supervising physician. After getting them past their initial arguments about how their patients were sicker or more complex than anyone else’s, the physicians in question were eager to blame everything on the technology, when a careful review of their office process revealed otherwise.

I spent several days in the office observing workflows and what I saw was shocking. Staff were blatantly surfing the Internet on their phones and ignoring patient-related tasks that were waiting for their attention. The amount of gossip and chatter reminded me of a middle school lunch room.

The Hawthorne Effect poses that when people are observed, they change their behavior simply because they are being studied. I couldn’t help but think that if this is what they were doing in front of someone observing them, the amount of waste when they weren’t being observed might be staggering. And yet the physicians felt that they couldn’t give the staff any more work because they were “too busy” and therefore were taking on more non-value-added work for themselves, such as filling out forms and looking for missing lab results.

After documenting the current state thoroughly with not only summary statements but actual time studies, I presented my case to the physicians and practice managers. Generally, I expect a little push back, including concerns about being able to hire better staff or that staff will leave if they are confronted with a lack of productivity or with rising expectations.

This organization, however, had worked its way into a seriously co-dependent state, with the physicians mounting a strong defense of the status quo even though it was adding to their misery. They continued to blame the EHR and government mandates even when presented with data from high-functioning practices using the same EHR under the same government mandates. The practice’s leadership was unwilling to accept the possibility that the staff (and lack of management thereof) was a significant part of their problem even though it was directly impacting physician satisfaction and the bottom line.

After presentation of a proposed set of future state workflows, we had several hours of discussion. I used all my Jedi mind tricks, but was unable to get them to consensus around what needed to be done to take their practice to the next level. They have it in their minds that they want to achieve Level 3 Patient-Centered Medical Home recognition. How are they going to create a highly functional team care structure when they are unwilling to take the time to even discipline a staff that is obviously goofing off?

They also want to join an Accountable Care Organization because they’ve heard it’s the way of the future. Don’t get me started on changing your model of care just because you read somewhere that you should. Furthermore, if they’re not willing to address both staff and provider performance issues, how do they think they are going to use data to address patient compliance issues and drive outcomes?

Knowing that I was getting nowhere fast with the idea of practice accountability, I tried to appeal to their understanding of economics. We discussed the money they are losing by not making the most of their existing resources as well as the potential cost of hiring incremental resources to accomplish their goals. Again, they tried to throw the technology out as a cause, citing what they perceive as a high cost of ownership of their current client-server EHR.

One of the doctors mentioned that they were considering chucking the system in favor of the free online EHR that he saw an ad for in one of his journals. I asked how much they thought it would cost to migrate 10 years of data from their existing system to a new one and how much they might lose in the transition. It was clear that those thoughts had never crossed their mind.

I know they have at least a minimum desire to move to a better place. Otherwise, they would not have hired me to come in and do an assessment. I have to say, though, that I was grateful that my engagement with them only included the assessment and the creation of a report with basic findings, and not the actual optimization effort. Without committed leadership that “gets it,” they are doomed to stay right where they are.

Frankly, I don’t think I can handle another train wreck client right now. I know they’re going to push me to provide a proposal for the next phase, but I think I’m going to have to respectfully decline for my own sanity.

There is at least one health system in the area that is in acquisition mode. I wonder if this practice will become a potential target. Despite the mess they’re in, they have a fairly large patient base and a decent location. Stronger leadership with a better understanding of the big picture and a willingness to ruffle some feathers (if not getting rid of the chickens all together) could turn this into a much more successful situation.

Although some of the practice’s leadership thought I would be able to force change from the outside, I had told them that it rarely works that way and played out exactly as I had predicted. Unless they’re willing to give an outsider control of their staffing or are willing to take charge themselves, they’ll likely just keep running in circles. Worst case, they’ll run themselves into the ground if they attempt to do an EHR replacement no matter how “free” they think it is. I’ve never seen that turn out well despite the claims of the vendors.

What do you think about free EHRs? Email me.

Email Dr. Jayne.

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Currently there are "6 comments" on this Article:

  1. We are often our own worst enemies.

    And you didn’t even get into practice/ facility ownership, governance, internal physician compensation formulas, management structure, succession planning and sustainability. I will anticipate they are treated in a similar manner.

    There is a reality out there where properly-scaled, professionally managed/ operated, technology-enabled primary care stands a chance– at least I want to believe that. But I wonder whether it needs to be a fresh start, rather than a conversion of existing practices.

    My hope is that the doctors who get these ideas will break away from the practices currently being bought by the hospitals, and enable primary care to rise from the ashes, so to speak.

    Keep up the good work.

  2. Oh Dr. Jayne, you are singing my tune here! I’ve been doing practice assessments for many, many years (and question my sanity often!). I too don’t understand a doctor defending the $25/hr receptionist who refuses to do certain tasks because she’s ‘too busy and stressed’, and complaining to me the consultant that they have no positive cash flow. Too often solo providers and small groups are afraid they won’t find qualified help, and even throw $1/hr raises at their existing staff every time they get upset and make noises about leaving.

    I too walk away from engagements where it seems that nothing I say or do will make a positive impact on the practice. We are workflow efficiency experts. We sell and support an EHR not to make a bunch of money on sales, but to help providers master their EHR and become proficient beyond the first week of training. We apply our consulting model to our EHR support, so we don’t have a ton of clients but have very high functioning clients (mostly). However, the ones who complain about the EHR the most (too clicky) are the ones who refused any meaningful training.

    Doctors can be their own worst enemies in private practice. I honestly think your formal education needs to have more information about running a successful practice, not everyone is going to stay in academia or large hospital owned groups. It becomes a public health issue when practices fold under the weight of poor management.

    Management of these practices is the first place I’d look for failure. Many doctors have a manager who started at the front desk, never got any formal education or certifications like ACMPE, but because she’s (usually she) been there the longest, she should be the manager of their multi-million dollar business. No understanding of healthcare economics at all! Can’t balance the books (why would you tie down your AR to your bank account?) etc. HR violations all over the place, and staff that knows they can skate and whine and tell the doctors how they want their jobs to go.

    Regarding free EHR, well nothing in life is free, and in this case, you get what you pay for. I have walked away from deals and told them to get the free product, because I knew they were never really interested in making this tool functional, it’s all about the money. The tool that runs your office should not be chosen solely on cost, period. But that’s another soapbox…

    I am passionate about my work. Assisting doctors achieve success in their business can be rewarding. By and large, I have a lot of really great success stories. But I often wonder, if the patients waiting in the lobby had any idea how poorly some of these practices are run, would they have faith in the doctor’s clinical skills? When I hear that we are in a big system acquisition phase, people ask me if I’m worried about our book of business for new practice start-up consulting. However, our requests to start new independent practices goes up. I believe there will always be solo providers and small independent groups, and because of supply and demand, patients will continue to see those very low functioning practices which keeps them in business, limping along.

  3. Very well written article and compiled article. I can imagine that the sequence of events that you described were pretty haphazard and bounced all over the place, but you assembled it in to clean, easy to follow, and very insightful story. Well done!

  4. I was sadly struck by your statement below —

    “I was recently at a site where providers were seeing 16 patients a day in the primary care setting. Personally, I haven’t seen that few patients since I was a first-year resident and still had to review every patient visit with a supervising physician. After getting them past their initial arguments about how their patients were sicker or more complex than anyone else’s”

    In these days of factory based medicine there are still practices that do “good work” by seeing this number of pts.

    Maybe this is why some docs are abandoning national initiatives and going to “concierge” 600 pt practices.

    I’m able to survive on 60 pts/4 day weeks, although I do contract work for the fifth day.

    BTW I have a practice base of 1300.

    Comments welcome, at matlev@comcast.net

    Dr Matt Levin
    Solo since 2004
    FP residency completed in 1988

    PS and YES I do use an EMR.

  5. Dr. Jayne: I agree completely that this practice sounds like it was run more by the staff than by the doctors, and as long as those doctors don’t listen to you, nothing in their practice is going to change for the better.

    However I would like to point out to you and to Julie McGovern (above) that while you may know a lot of doctors, remember that you are seeing a skewed sample, ie, practices in trouble. You never see folks like Dr Levin (above) and me, who are managing just fine (free EMRs, keeping our staff in line, prompt electronic billing, etc) and who, yes, are able to keep the lights on while providing excellent care to fewer than 20 patients a day.

    By the way, my pet peeves revolve around the words “value” and “quality”, because they are never independently defined (ie each is always defined in terms of the other.) I firmly believe this whole sojourn into “the realm of value-based care” is yet another poorly conceived attempt by non-physicians to rein in costs at any cost. It will not succeed either in reducing costs nor increasing “health” (whatever that is; just another undefined term that gets thrown around a lot.) I’m sitting tight and riding out the storm, just like I did in the 90s (managed care) and the 00s (the collapse of managed care.)

    I’ve blogged about this many times over the years on my blog at dinosaurmusings.wordpress.com.

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