Adding a Physician?

For physicians who are new to a practice -- especially those new to practice, period -- scheduling can be a tricky subject. But surgeon Kenneth Johnson had it easy when he joined New Mexico Orthopedics in Albuquerque.

The foot-and-ankle specialist was replacing a physician who had recently left the group, meaning Johnson was practically inheriting an existing practice, diminishing the pressure for him to build a patient base from scratch. He also had previous experience, so he could handle more patients a day than a rookie. And because he was joining a group whose 19 other members were focused on different clinical areas, he didn't have to worry about internal competition.

All that made the transition smoother for him and the practice schedulers. Still, clinic manager Cathy Trujillo took nothing for granted. She planned carefully for Johnson's arrival because she knew he wanted to hit the ground running with a full load of patients.

"That's sometimes difficult" with doctors new to a practice, Trujillo says, "so we marketed it very well. We sent out information about Dr. Johnson, with his picture and his background, to referring physicians and worker's compensation case managers. And we had an open house. ...We wanted our referrers to meet him and to see what we have available here. We did all that in advance, so by the time he arrived, we had patients who'd been calling us ahead of time."

Many physicians who join new groups aren't as fortunate as Johnson. For them -- and for group administrators -- the first weeks can be challenging and delicate.

For one, new doctors tend to take more time with patients than their more seasoned colleagues; even practice veterans need some ramp-up time when joining a new group. As a result, both experienced and novice doctors sometimes find themselves making less money than they expected just after joining a group.

Meanwhile, acrimony can arise among group members when the number of providers expands too quickly. With physician compensation and practice revenues based on patient volume and payer mix, new doctors are often expected to build their practices quickly without poaching other doctors' rosters.

But the proactive approach that worked for New Mexico Orthopedics can work for you, too. Diligent planning and creative marketing will help your new doctors --  whether they're experienced or straight out of residency --  build their patient base faster and lessen dissension among the group.

Know thy colleagues

In smaller practices especially, it's imperative to know where your colleagues stand on staff additions before expanding. That means doctors need to understand the potential downside --  reduced revenue --  in addition to the potential upside of a lighter workload.

Bruce Johnson, a lawyer with Faegre & Benson in Denver who handles physician compensation issues, says he's seen cases where new doctors were hired just to reduce the number of days on call for the other doctors. A new hire can have that effect, but existing members aren't always happy with the adjustment to their bank accounts. Sometimes doctors are surprised to see the extent to which their patient volumes drop after a new physician's arrival, he adds.

"If a four-member, all-male OB/GYN group adds a 35-year-old female physician, immediately patients will start asking, 'Can I see the woman?'" says Johnson. That may be OK with the existing doctors, or it may rankle them.

Sometimes veterans of a practice will seethe silently as their patient volume dips; others will take matters into their own hands by trying to influence the schedulers, observes Lori Foley, of Gates, Moore & Co., a healthcare consulting and accounting firm based in Atlanta.
"I've actually seen a case where the physician has told a scheduler, 'I'll pay you $100 to direct a certain type of patient to me,'" Foley says.

Blatant bribery is rare, but it's not uncommon for doctors to make it known to the schedulers, even unintentionally, that they prefer to see particular types of patients, or to suggest that certain patients not be scheduled with the new doctor, according to Foley. And there are cases when schedulers, on their own, direct certain patients to certain doctors, for any number of reasons. All this can affect how much group members get paid, and such matters are complicated when the group expands.

"Often, the pie doesn't get any bigger," Johnson says, "it just gets re-sliced. And that's when things get exciting."

The first weeks

Schedulers are sometimes stuck between trying to get new physicians integrated into the practice's scheduling system and avoiding the wrath of veteran members who resent their patients being reassigned.

But assigning certain doctors to new patients or to those with particular medical problems isn't necessarily a bad thing. Depending on the nature of the practice, it's often necessary.

And it's precisely what most practices should do for their new doctors in the early weeks of their tenure. Even though it may upset veteran group members, practices should usually make a point of assigning overflow patients and the bulk of new patients to the new doctor. Not only is it the quickest way for him to build his practice, it's also the simplest way of reducing the time it takes for patients to get an appointment.

For the wise practices that add new doctors only at the right time --  when they are replacing a departing physician or when their patient load has truly become unmanageable --  physicians are more likely to be grateful for the help than annoyed by "competition."

"I've never seen them be nonreceptive," says Christine Schon, senior director of physician practice operations for Bassett Healthcare, a 200-doctor health system based in Cooperstown, N.Y. "They realize this new physician is going to make their practice life easier. They don't want to be on such a treadmill."

But just as tricky as divvying up existing patients is the challenge of drumming up brand new business for new doctors. New doctors can't live off the practice's table scraps forever, and growing physician productivity is even more important in an era of declining reimbursements.

Making this job harder is the difficulty of getting new physicians credentialed, a process that can take six months or more. Many practice managers cite this problem as their single-biggest challenge in integrating new physicians into the practice.

Make the most of it

New doctors usually have a good bit of downtime during the credentialing process. Yet practices can make the best of it by using the time to dispatch their new hires on marketing/goodwill missions --  attending medical conferences, treating patients for free at clinics for the poor, and giving health lectures at schools and nursing homes. These activities help make a name for a new doctor and give specialists a chance to meet referring physicians.

The rookies can even do a little "doughnut marketing," says Lorie Davis, clinical director of University Otolaryngologists, a 17-physician group in Columbus, Ohio.

Davis started 15 years ago sending new doctors to events where referring physicians would be, and lately she's taken to dispatching them directly to primary-care offices, pastries in hand, for meet-and-greets. The goal for new otolaryngologists, like Doug Massick, is to schmooze the office staff as much as the doctors, she says.

It may be the doctor who authorizes a specialist referral, but "it's the girls at the front desk who make those referrals," Davis reasons, "and that's why it's so important to get out and meet the staff. They're going to remember it was Doug Massick who came by with doughnuts one morning or pizza for lunch, and they're going to say, 'Let's refer that patient to Doug.'"

Neurologist Kimberley Walpert "created her own market niche" when she joined Georgia Neurological Surgery in Athens two years ago, according to Stephen Deas, executive director of the three-physician group.

"She did a tremendous job with her own public relations," Deas said. "She made it a point to meet all of the referring physicians --  discussing with them their practice ... and tried to set up a mutual trust, a mutual relationship. ... One of her strong attributes is her personality."

Look before you leap

Even before you begin interviewing candidates, determine ahead of time your goals for the new hire. Make sure all your existing doctors are at least aware of the implications of the addition --  both to their schedules and their incomes --  and try to get them on board with the idea.

Doctors considering joining a group should keep their eyes open, too. They should ask questions about how the compensation plan is tied to physician productivity and how it is measured, what the practice expects of them in terms of building patient volume, and what the group will do to help.

The Medical Group Management Association's (MGMA) cost survey provides national and regional data on physician production, based on several measures for various specialties, and the American Medical Association's physician characteristics survey offers benchmarks on daily patient-per-physician loads.

"We let them know up-front that we use the MGMA benchmarks, and that we'd like them to be at least at the median, and we'd prefer the 75th percentile," says Diane Miner, chief operations administrator at Premier Medical Group, a 43-physician multispecialty group in Clarksville, Tenn.

Still, experts caution practices to think carefully before deciding to expand. Assess patient access by evaluating average wait times for getting an appointment. Compare that with physician production in your practice. If your doctors are productive and patients still have trouble getting an appointment, you probably need to recruit, but you may find that some doctors are simply seeing too few patients.
Even if you intend to replace a departing physician, first make sure the remaining doctors in your group can't easily absorb the outgoing doctor's patient load.

"They need to have a heart-to-heart talk about what they expect the new doctor to do and how that will affect the compensation plan for everybody," says Johnson. "If a new doctor siphons 20 percent of patients from each of the [existing] members, what's the financial impact of that? Many physicians don't truly understand what the economic impact could be. They don't do any kind of assessment beforehand."

Bob Keaveney, editor for Physicians Practice, can be reached at bkeaveney@physicianspractice.com.

This article originally appeared in the November/December 2002 issue of Physicians Practice.