Giving Your Practice a 21st Century Makeover

Brooks Young, a podiatrist in Lenexa, Kan., left residency eight years ago and moved back to his home state with a few options on the table.

"I looked at physicians I knew, either attending physicians or others, who were in their prime, which I considered to be the mid 50s, and the guys who were in the position I'd like to be in at that age - either [they] started their own practice or bought out the practice of a retiring physician," Young says. He went with the latter and bought a practice from a retiring physician. At the time, the practice had multiple clinics, but all of the spaces were leased. The young podiatrist had two goals in mind: He wanted to expand the practice and he wanted to own his own building.

Five years from when he bought the practice, he achieved the second goal and bought his own space. Currently, he is still achieving the growth he envisioned in the first goal. His practice, Jayhawk Foot and Ankle, is spread across five clinics in the Kansas City  area (both Kansas and Missouri). Young works on staff with another physician and is looking to add a third in the near future.

Young says it's been a bit of trial and error in his eight years in private practice. While residency prepared him for surgical and clinical scenarios, he wasn't trained in business. Plus, there was a lot that had to be changed about the practice, other than where it would be located. He spoke with Physicians Practice about how he gave it a 21^st century makeover, lessons he has learned, and advice he has for his peers.

Below are excerpts from that interview.

Physicians Practice: What was your practice like when you got there?

Brooks Young: This physician, he was older, he was right at 70. They were still doing paper charts, his wife was doing the billing from their home. He'd basically have numbers for [clinic] locations forwarded to their home and his wife would take down patient appointments. I met him eight months before agreeing to buy and I expressed concern with the paper charts, knowing that was basically being phased out. I told him I'd want an EHR system. He attempted to try it, but he purchased a low scale, software-based system, where what he'd do is record his charts as best he could into his laptop and then bring it home to his office and download that into their master computer. That way the computers were up to date.

Scheduling was a nightmare. With one person making appointments from the home-based office and the other medical assistant making follow-up appointments from the clinic, there were multiple double-bookings and not good connection between the two.

PP: How did you get this practice up to speed for the 21^st century?

BY: Our first hurdle was an EHR that'd fit our needs and wouldn't cost too much. At that time, Meaningful Use was coming onto the scene and we were looking at that to help determine which route to go. I was used to Epic, which is what we had in residency. That was not going to happen. Too expensive. We tried the EHR the previous doctor was using, they had a web-based version. You could take his notes and plug them into the web-based version. The problem is that EHR did not have Meaningful Use guidelines, so we had to find another one.

Changing EHRs is extremely painful, but an absolute necessity if you are going to achieve Meaningful Use and going to try to maintain compliance … We ultimately decided on a free, web-based EHR. We attempted the transition a little slowly at first, but then decided to just take the plunge. Telling [your old] vendor you want your chart notes transferred to another EHR, it does not sit well with them. We tried to transfer what files we could … we basically had to transfer files by hand. It was not ideal.

We did that. That was the first step. The next step, when I took over the practice, as far as billing goes, the physician's wife who was doing the billing, I talked to her about changing the process and using a service. Her comment was, "I've been doing billing like this for 35 years; I think I know what I'm doing." It stuck with me in the fact that, insurance and billing is ever changing. If you have been doing the same thing for 35 years, you are probably not doing it correctly. That was indeed the case.

We noticed a significant improvement once we changed and had an outside service doing that. We did that for several years, but then realized the amount we were paying, we could hire our own employee to do it in-house. I like the idea of that idea anyway. We'd have an employee who is onsite and could cater her skills toward our billing procedures … now that our billing is streamlined, I find myself less and less involved in that aspect of our practice. This is what I want. I want to do what I'm trained to do and what I'm best at, seeing patients and treating patients.

PP: What were some of the lessons you have learned?

BY: Insurance is ever changing, the habits you form regarding insurance and billing have to be changeable or you could get left behind. The biggest lesson is the fact you have to keep in touch with your biller and see what procedures and practices you are doing are being covered through insurance. How much of that impacts the patient?  High deductibles are a standard part of every practice, and I have to take that into consideration when suggesting certain treatments. Patients appreciate me reviewing options because financial obligations play into what they would want to do treatment wise.

You have to be astute when it comes to the business side. Unfortunately, it's not just about one-on-one time with patients, it's making sure the business is profitable. I'm in private practice, if I'm unable to pay bills, we're done. With ever-changing insurance, we've had to work hard to make sure we are paid for our services.

PP: What would you say is your biggest ongoing challenge?

BY: The ebb and flow of [A/R days in aging] is the biggest challenge. I like to look at the numbers and the average. I am typically very busy and I know we're doing well. But, for example, knowing how much revenue comes in for the amount of work I've done in the month of May, it's hard to tell. It takes 60 to 90 days to see how that month went. You see a big difference in the early months - January, February - when patients are realizing they have a high deductible that started over. You also have a big difference in your days in aging because the patient is responsible for those months, and it's harder for them to pay than an actual insurance company. It's one of the struggles we deal with, knowing what's going to come in month to month, and realizing there is still a lag [from when you see the patient and when you get paid]. It doesn’t happen instantaneously.

PP: How would you like to improve your practice?

BY: Now that I feel like our billing and EHR are basically functioning … our weakest link is being able to check availability for certain services as quickly and effectively as possible, while the patient is here. We'd like to give them a heads up on what the cost of a procedure would be if they went that route. I don't want them to receive a bill … where the amount is astronomical. I like to prepare patients and being able to check availability helps. I try to put myself in the position of a patient and wanting to know a rough estimate. It's hard to give the exact amount, but to give a rough estimate, they appreciate it.

PP: Is there any advice you have for your fellow small private-practice physicians dealing with the struggles of an ever-changing insurance industry?

BY: I don't want to discourage anyone from doing it. If it's something you enjoy, you should know it's a challenge. If you are hired and are an employed physician, there is a certain trade off that comes with that … Everyone has their own goals. Try and find a physician who is doing what you are trying to do. But realize, the experiences that doctor may have had 30 years ago is completely different than some of the things we're dealing with now. Also, stay up on technology … it really is going to make our system better and allow us to treat patients. With that said, don't let technology replace the one-on-one art form of treating patients in a clinic.