THE GREAT PRACTICE MAKEOVER: Maitland Primary Care

Vince Wilson, MD, is doing a lot of things right. His patients love him (his no-show rate is virtually nil), his staff is loyal and competent, and his accounts receivable are in fantastic shape. But as a solo family physician, Wilson feels overwhelmed by paperwork, the prescription refill and referral processes drive him crazy, and he wonders whether it’ll ever be feasible for a small practice like his to implement a full-blown EMR system. Wilson also has a chronic illness - debilitating vertigo - that forces him to cancel more than half of his scheduled appointments.

Furthermore, Wilson’s staff shrugs off many of the issues he cites, saying they’ve got them under control. What to do when you and your employees don’t see eye to eye? We’ll shed some light on the day-to-day hang-ups of this group and offer solutions that they and other practices can put to good use.

He said, she said

Maitland Primary Care has been in operation since 2000, when Wilson left a small group practice whose owner was going cash-only. His staff came along, including Ross Anne McAuliffe, LPN. She serves as Wilson’s office manager, a first-time role for her: “I’ve worked at two other offices where it was much busier, so to me the phone calls and the med refills are nothing compared to what they could be.”

McAuliffe and Gita Nayee, one of two receptionists at the practice, say they have ample time to answer all calls and simultaneously deal with patients in the office. Patients never pile up in the waiting room. “I think [our schedule] goes pretty smoothly,” says McAuliffe. “We pretty much run on time, and we’re out the door by 5:00, more or less.”

Here’s where the disconnect comes in: The staff - which also includes a medical assistant and an advanced registered nurse practitioner (ARNP) - are happy to be going home on schedule (or even considerably earlier when Wilson becomes ill). But Wilson worries that their hours in the office are being frittered away on peripheral tasks, like providing specialist referrals to patients under the primary-care gatekeeper system, rather than dedicated directly to patient care.

Certainly, the gatekeeper system is a frustration, but if the practice owner sees a way for staff to handle it more efficiently, he should be able to say so and expect his staff to make changes. For example, practices might set aside a certain time in each day to process referrals, designate a single person for dealing with them, or create a form letter that can be easily customized for each case.

Maitland could ask patients to fill in what information they can (name, address, insurance number) so the provider can focus on the clinical aspects. Preplanning is key - set patient expectations so everyone is aware that referral requests require 72 hours to turn around. Alternatively, the practice itself can anticipate these last-minute requests by building time to handle them into the appropriate staffer’s day. Dealing with a need-it-yesterday situation is less annoying if you’ve planned for it than if you’re trying to squeeze it into an already-packed day.

To keep everyone on the same page, communicate your concerns openly and regularly, and make sure employees feel they have a safe, responsive environment in which to do the same. Discussions should include not only day-to-day management concerns and practice flow issues, but also your overarching vision and the direction you hope the practice will take over time.

When staff comes to you with a valid concern or solution, act on it. It’s a two-way street. Great ideas really can come from any quarter of the practice. Your medical assistant, for instance, may well have a better sense than you do about how to decrease exam room turnover time.

Something’s gotta give

Wilson has shown he does a good job of listening and responding to staff. At first, on days when he had to close the office early because of his medical condition, staff members (all of whom work on an hourly basis) simply weren’t paid for that time. When McAuliffe approached Wilson about allowing staff to use their own sick days so they’d receive pay for at least some of those hours, he instantly realized that his illness was becoming a burden for everyone. Now, staff members are paid for the number of hours for which they’re scheduled to work each week.

This seems only fair, and staff praise Wilson as a generous and thoughtful employer. But even with 90-day accounts receivable at enviable levels (according to the practice’s consultant and thanks to the efforts of the self-taught McAuliffe and her colleagues) and patients continuing to call for appointments, the question is how long this arrangement will remain financially feasible.

One solution is to schedule fewer hours from the start - painful though it may be to contemplate, base hours on the norm rather than the ideal. Over the course of a typical month or two, track exactly how many sessions are canceled - roughly 60 percent in Maitland’s case - and schedule staff accordingly. Clearly, it would be preferable for employees to know up-front to plan for reduced hours by budgeting or picking up additional work elsewhere than to suddenly find the practice going under and everyone out of a job permanently.

Finding ways to increase revenue despite limited hours is the obvious solution for keeping this practice’s finances afloat over the long haul. Don’t let your valuable employees and real estate sit idle while you’re out of the office. Put your space - and your practice’s good reputation in the community - to work for your bottom line even when you can’t be there. Plan for being out of the office.

On the recommendation of Valarie Prusia of Prusia Medical Practice Consulting, Wilson has already brought in another provider to help manage patient volume: Heather Wise, ARNP. Most weeks she spends three 4-hour sessions caring for her own patients and some of those whose appointments Wilson has been forced to cancel. Although Wise is popular with both patients and staff, she has another job. Some weeks she’s in the office for just two sessions, and increasing her time at Maitland isn’t an option.

In Wilson’s area of the country in particular - central Florida - there are undoubtedly retired physicians who might be willing to practice again for a few hours a week - either filling in on short notice when he’s sick, or according to a regular schedule - in exchange for a set fee and freedom from management responsibilities. (Malpractice costs for such a part-timer are an issue to consider, but some insurers now offer prorated plans for those who work fewer than a specified number of hours.) This provider could exclusively handle last-minute appointments like a sick child or a work physical, leaving Wilson more time to devote to annual exams.

Allowing, say, a massage therapist or a physician just starting out in practice to make use of idle exam room space could be another option, although requirements for such things as separate staff and entrances to the office can vary by state. Such arrangements can be configured in any number of ways: The provider could be an employee, or simply sublease office space at a fair market value, helping to defray overhead costs.

Streamlining solutions

Without a consistent capacity to shift appointments to another provider, all those cancellations make for significant rework - Maitland staff not only has to call patients to set up new appointments, but also file and, at some point in the future, pull those patient charts a second time. McAuliffe argues that all the office processes are already streamlined, but even a few such jobs can easily add up to enough of an employee’s time to negatively affect the bottom line. Physicians Practice research shows that the cost of each chart pull ranges from $5 to $12. And this rework isn’t offset by billable services - that is, the administrative costs happen twice, but the revenue only comes in once.

Wilson also worries about the multitude of patient phone calls that take a big bite out of everyone’s time - a concern no doubt shared by countless other solo doctors. Physicians Practice asked the office to track all the calls received to determine what issues were generating the most calls. A simple spreadsheet for each day, divided into hours to provide finer detail, gives a good overview of phone demand.

To do this for your own practice, tailor call categories to your practice: in addition to scheduling, common areas include refill requests, clinical questions (which can be further broken down by the staff member responsible for addressing the question), and requests for referrals, prescription refills, and test results. Don’t forget to include space for personal calls - depending on your staff, these can add up. Then, ask everyone who answers the phone to make a mark for every call they take - you can measure for a week or two.

The lion’s share of phone calls to Maitland - 46 percent - come from patients requesting appointments. Good news for keeping patient volume high, but frustrating, perhaps, if many of these calls are actually placed to reschedule appointments that were canceled. In general, practices should reschedule as many canceled appointments as possible at the time of cancellation.

Eleven percent of Maitland’s calls are repeats - that is, patients following up on calls they’d previously placed. The clear way to tackle these is to answer questions promptly when patients call the first time. (Maitland no doubt already heads off some repeats by listing its Web site and the tasks patients can handle there on a recorded message that all callers hear.)

If a patient needs to speak with the doctor or NP, or the staff member knows she’ll have to consult with a clinician before answering the patient’s question, try setting a callback time or at least offer some sense of how long it’ll take before the physician is free. Give the patient a concrete expectation so he won’t call back wondering what’s taking so long or will then be unavailable when the provider returns the call. Try, “I need to consult with the doctor. Expect a call back after 2:00,” or, “We don’t want to miss you, so I’m going to suggest we agree that the doctor will call your home number at 3:00, after his last patient.”

Prescription refill requests constitute another 11 percent of Maitland’s incoming calls. But thanks to significant awareness efforts that began with the inception of the practice, McAuliffe estimates that 30 percent of patients already use the practice’s Web site rather than phoning in their requests. It’s important to make clear to patients - possibly more than once during the online process - how long the process will take so they don’t call the practice wondering if they can head to the pharmacy yet.

The main point with refills is to make sure as many as possible are handled during regularly scheduled patient appointments. Many physicians write scripts to run out around the time a follow-up visit is scheduled, but some forget to actually write the refills during the visit, forcing the patient to call in. Find a way to remind yourself to get the job done - a simple note in the chart might do the trick.

Technology eases the burden

The fact that Wilson’s patient demographic is relatively young - McAuliffe says that the practice’s panel includes few Medicare patients - means that Maitland can more easily make use of its tech tools. Indeed, Prusia says, “They use their technology.”

Wilson doesn’t pay a dime for his Web site - because he’s a member of the American Academy of Family Physicians, he gets Medfusion’s basic offering at no charge. All things considered, the practice is already getting a lot out of that free site. In addition to prescription refills and scheduling, referral authorizations should be handled online whenever possible, as should confirmations of insurance coverage and eligibility.

The practice should also make sure its advertising of the Web site’s features doesn’t slack off - newer patients may not be aware of the services available online, and as time goes by more people will become accustomed to using the Internet to perform such tasks.

Medfusion offers additional options - patient tracking of test results, for example - for a fee. It’s worth exploring, but it might not be cost-effective if those issues aren’t big generators of calls to the practice.

But what about the holy grail of practice management, the EMR? “I am very computer-savvy, and would embrace an all-inclusive EMR,” says Wilson. “However, being a solo doc makes it cost-prohibitive. I have looked at many options, but have yet to find one that is reasonable enough.” He adds that the practice currently uses a company that provides scheduling, electronic billing, and so on, but he feels that upgrading to their EMR product, which has the added drawback of being relatively new, would be too expensive.

A lower cost option could be an application service provider (ASP) product. As opposed to client-server options, ASP EMRs run on a network (often the Internet) to access information and save it in a remote server. Offerings such as Advanced MDs can be had for about $400 a month. Wilson would obviously have to do research regarding integration with his existing management software. Other issues to consider include the fact that ASP systems are accessed via a browser; always-on connectivity and patient data security must be addressed.

The Tools section contains a simple ROI calculator to help individual practices determine if an EMR is a smart investment for them.

Other options

Does Maitland have any other choices for enhancing procedures - and revenues? Realistically, haggling with payers isn’t always a viable option for a solo doctor. Wilson admits he has “little leverage to bargain for increased reimbursements,” although he may have more control than he realizes given his visibility in the community - he serves as a team physician for the Orlando Magic - and the dedication of his patients. If many of those young patients work for a handful of employers in the area, Wilson could certainly point that out to his payers.

Individual practices may be able to exert more influence in other areas. Wilson hates doing all the paperwork involved in playing gatekeeper, but thanks to the expertise of his medical assistant, Patricia Talton, who handles most requests, Maitland’s referrals are rarely turned down by payers. The practice could use its track record to advantage - if you can point to data showing that, say, 90 percent of your referrals are approved by a particular insurer, ask that payer to waive preauthorizations. The result is a win-win situation, with reduced paperwork on both sides.

Aside from finding realistic ways to keep the practice viable when Wilson is ill and ensuring that staff and providers continue an honest dialogue, the practice fixes for Maitland Primary Care are largely a matter of process tweaking. And those adjustments never end, even in the smoothest-running offices.

Laurie Hyland Robertson is managing editor for Med-IQ/Physicians Practice. She can be reached at lrobertson@med-iq.com.

This article appeared in the February 2006 issue of Physicians Practice.