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Marketing Strategies For Your Medical Practice

9/29/2009

Physicians that put out their shingle in the sixties and seventies have been through a lot. They enjoyed the golden years of private practice, endured the painful intrusion of managed care and have survived the somewhat tumultuous aftermath. They are strong, but some are dismayed and disenchanted with their current position. Many have reached a time when they expected to take it easy, yet they find themselves working harder than ever. Others are concerned about a continued decline in their patient base. With all their experience and still eager to work, the practice is shrinking and they don’t know what to do. Here are a few suggestions to help you jumpstart your practice.

First, take a look at the reasons you might be experiencing a dwindling practice. There are likely to be a number of reasons. Often the referral base you depend on today is the same one of 30 years ago, but not all of those physicians are still around, some have relocated and others have retired. At the same time, word of mouth referrals decline as your own patients age. You will lose some due to death and others move out of the area for various reasons. Add to this the patients that have switched to managed care plans you don’t belong to and the shrinkage becomes obvious. Solo practices are particularly vulnerable, as some managed care plans will only contract with group practices.

Once you look at the factors involved in the practice decline, you can explore various remedies.

Begin by developing relationships with young physicians that are entering your community. They need seasoned physicians to break into the medical community and to support them in the community at large. New primary care physicians want to know which specialists to send their patients to. They will gain confidence in your ability to treat their patients from both a personal and a clinical point of view once you open the lines of communication and strengthen the relationship. Younger specialists need to know as much as they can about the primary care physicians that serve the community, especially those that have been in practice for an extended period of time. They will appreciate your knowledge of the community and the politics of medicine.

Look to the medical staff office at your hospital for a roster of new staff members. Develop an approach to become familiar with the new doctors in town. If there are only a few, your job will be simple. If there are many, you will need to set a goal on how many you want to contact each month and what criteria you will use to prioritize the list.

Meet personally with each physician you have targeted, whether it be the specialty group or the primary care physicians. Invite them for a business lunch or perhaps to join you at a local Medical Society meeting to introduce them to other members of the medical community. Explore his or her personal and professional interests and begin to develop a profile on each physician.

For those that have a sports interest you share, invite them for a round of golf or to attend a sporting event of interest. For those with similar family interests, you may want to ask them to join you for a community picnic or annual event.

Your spouse may be helpful in nurturing relationships, as well. For example, both spouses may be interested in community service work, or education, or have their own private businesses. Whatever the commonality, be sure to make that connection active by introducing them and encouraging the relationship.

Stay actively involved in hospital activities and committee work, and use this as a source to work in tandem with some of the newer physicians. Hospital Grand Rounds and committee involvement can pay off big dividends in connecting with newer doctors.

It is also very effective to tap into the media. Contact the health and medicine editor of your local newspaper. Inquire about a possible by-line and invite the editors to call you for an interview whenever a hot health care topic is ready to hit the news.

It is also a good idea to develop a practice business portfolio. It should include a black and white press photo, your curriculum vitae, a copy of any recent by-line articles and a list of areas you have specialized expertise and knowledge in. You might also include a list of lectures you are willing to conduct for community groups. Such a portfolio is good for contacting both the media and community organizations.

The business portfolio is helpful in opening doors to get on a radio talk show, as well. We tend to think that they won’t be interested, but our experience proves they are most likely to welcome physicians who have something to say. It’s important to be prepared before you make the contact. Decide on a couple of relevant current health care issues you can speak about. Then set up an appointment or a telephone conference to discuss this. If it is a telephone conference, you should send your business portfolio in advance. If it is a meeting, bring it with you. Remember to be as personable as possible.

Use these tried and true tips and you will begin to see your practice reap the benefits. It can also help to encourage your office manager to be active in community organizations. Pay her fees to join a local service group as your representative and to volunteer you as a program speaker. Also encourage your office manager to become active in local chapters of practice management organizations such as the Professional Association of Health Care Office Managers (PAHCOM) or Medical Group Management Association (MGMA). If there aren’t chapters of the organizations in your community, by all means encourage your practice manager to establish one. Contact with other office managers is vital to keeping your practice alive.

If you need help into these ideas into action or exploring other ways to jump start your practice, call BAC Medical Marketing. We will make it a top priority and help you obtain the results you want.

The most important asset in your practice is the people. This includes you and your staff, as well as the patients. Be sure your service is superior and that you and everyone working for you are committed to making the patients feel important.

Do everything you can to take care of and attract patients of varying age ranges. Above all, be personable. That’s what patients really want and that’s what they will talk about among their friends and colleagues. It’s your practice; make the most of it!

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A Solution To Medicare: Doctor-Patient Price Negotiations

9/25/2009

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Recently, a physician client of BAC Medical Marketing related to me the following story. An elderly woman called him and asked for a medical appointment. She was desperate. He was the ninth doctor she had phoned and nobody was calling her back. What was the problem? When she told him that she had Medicare, he knew what was happening. Increasingly, he is seeing Medicare patients struggling to find doctors and timely appointments.

At its root, Medicare is like any other insurance, except it pays substantially worse. In psychiatry, fees differ according to where you practice. In his area, most people are paid around $160 for a 50-minute session. In 2006, Medicare limited pay to about $115 for that same session. That is a 28 percent discount. The doctors who work most closely with Medicare, those who are “participating” in the plan, are cut even deeper; their fee is reduced by 34 percent.

In order to treat those in need, doctors are often willing to accept such discounts. However, when sustained over a year, the concessions add up. Continuing with the example, assume that a psychiatrist took one hour each week and devoted it to seeing only Medicare patients. Consider this a “weekly Medicare-hour.” For each weekly Medicare-hour, the doctor’s annual income will drop by about $2,070. Doctors who participate in Medicare earn even less; their paycheck is reduced around $2,500. But, that is just one patient a week. Suppose that the psychiatrist has a full practice. In the best case, devoting one eight-hour day a week to treating just Medicare patients will decrease the doctor’s income by about 11 percent.

Though he used psychiatry as the example, the same applies to the other medical specialties. Unfortunately, Medicare is designed to financially discourage doctors from seeing the elderly or disabled. While he believes the vast majority of doctors are not in the field for money, significant pay cuts sting. Thus, it should not surprise us when the old or infirmed cannot find doctors.

Regrettably, the problem goes deeper. Medicare also disrupts the patient-doctor relationship. Although the insurance does a good job in getting treatment to the poor, it interferes in the care of those who are middle income or higher. In my experience, charging an artificially low fee to a well-off patient introduces complex and difficult issues into a treatment.

Imagine seeing a multi-millionaire at a hugely reduced fee. Emotions such as guilt, resentment, entitlement, devaluation or shame can be artificially injected into a treatment. And, resolving such issues is not easy. Medicare physicians must bill at or below the discounted government rate, without exception. Either that or they must refuse to treat the patient. Otherwise, the doctor may be guilty of fraud and face large fines or criminal charges.

More abstractly, this problem is a familiar one to economists. Consider what happens when cities implement rent control. Initially, people are pleased. Then the supply dries up and the existing apartments suffer from inattention and poor maintenance. We are now seeing similar long-term effects in our national health insurance. It suffers from artificially low fees and flawed policies.

How do we solve this problem? Not in the way the government recently acted. Congress agreed to pay doctors about $1.50 more, in exchange for data on his patients. Eventually, Medicare hopes to use the data to create outcome-based punishments and rewards. There is an astounding disconnect here. Congress’s solution solves nothing and just encourages more discontent. Medicare rates are already deeply discounted and the extra dollar is insulting. It will not even cover the costs of complying with the new federal program. Meanwhile, asking for privileged patient data is certain to upset doctors. Congress should be mindful that doctors can always opt out of Medicare, refuse to accept the insurance, and implement a sliding-scale fee structure. Provoke them and an increasing numbers of physicians will avoid Medicare, entirely.

Is there a better solution? Yes. Medicare should continue to set their fees. However, allow doctors to negotiate their own rates. If the doctor and the patient contract to a fee that exceeds Medicare’s, the government should continue to pay what it always has. However, the patient should then pick up the difference. In this way, doctors will again have financial incentives to treat the elderly, the poor will still be subsidized, and the middle class will have increased medical access. Let the patient and doctor negotiate a fair fee, without government meddling. Otherwise, Medicare patients will get increasingly frustrating healthcare with long waits and too few providers.

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Ten Things Doctors Can Do To Avoid Being Sued For Malpractice

9/22/2009

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I recently attended a lecture and one of topics covered was on malpractice prevention. There was an excellent handout that listed the ten ways to avoid litigation and liability which ultimately comes down to one very important rule: communication. I think this could be applied to all people in the healthcare field so it may be an important read even if you aren’t a doctor.

These are the ten rules that can prevent you from getting sued.

1. Good patient relationships are essential. Ultimately patients are angry because they feel that their physicians aren’t being honest with them or that they don’t care. They recommend sitting down to talk with them and also give them time to speak as well.

2. Be thorough in your clinical assessment and your treatment. Seek help if the diagnosis is difficult or the case is complex. Remember to refer back to old records to help to make a comprehensive assessment. Read the nurses note. Look at the meds and make sure it sounds compatible. Check their allergies.

3. Be as comfortable with the procedures you are performing as possible, and ask for help if you need it. Don’t do a procedure if you aren’t totally comfortable doing it and don’t be afraid to ask for help.

4. Never guarantee the result of your treatment of a patient. Don’t give promises that you can keep. It’s better to let patients know of the complications that might occur and make them understand it.

5. Be aware of the implications of informed consent. Informed consent means not only that they signed the permission to do a procedure but that they also understand it. Make sure they understand the benefits and the risks.

6. Personally confirm the patient’s identity, and the specific location (side) where/on which a procedure is to be performed. When a friend of mine had his knee operation done a few years back, he made sure that he drew a smiley face and an arrow that pointed to the right knee. I wouldn’t put an “x” because either it may mean “x marks the spot” or “x means do not go here”.

7. Never criticize another healthcare professional’s work. This is just plain unprofessional especially if done in front of the patient. Do not slight another provider in the medical record as well.

8. Respect patient confidentiality and privacy. Make sure that the elevator talk stops. If someone overhears, it’s just unprofessional and is another power motivating factor in the plaintiff’s decision to proceed with a case.

9. Document all clinically pertinent information in the medical record, objectively and contemporaneously or, as close to the time care is given as possible. Remember that there is a statute of limitations of usually a year or two that a case can be brought up. But also remember that a child has the right to sue until the age of 18 to bring a case. Its remember to keep records that are good b/c you will not remember a case that is so far back and never alter the record or add to it for self serving reasons.

10. Support the quality improvement processes of the hospital. Fill out an incident report for any unusual circumstance that may affect patient care, and route it to the risk manager or other designated recipient. It’s critical that you take advantage of the legal aid that is available to the hospital if you are in doubt of any situation or if any situation arises.

Overall, I think the general message is to ultimately develop a good rapport with your patients and with the right amount of medical knowledge and practice; you can prevent most litigation before it occurs. However, everyone will get sued at some point in their lives so make sure that you take advantage of the legal assistance that is afforded to you by your hospital or employer.

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Best Practices – Customer Service

9/18/2009

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Those of you in private practice or other business endeavors, will do well to follow examples from larger businesses in other industries. They say that success leaves hints. There is no question as to the hint this example provides.

In a recent issue of a business journal, there was an interview with Colleen Barrett, the former President and Corporate Secretary of Southwest Airlines. It is an excellent article, and I wanted to share three statements made by her that are applicable to any business of any size.

1. “We’re in the customer-service business; we happen to offer air transportation.”

I love this statement and feel that embracing its true meaning will set your business apart from other businesses. For any business, including your healthcare practices, you know how this can make a huge difference in your practice and the word of mouth referrals you receive.

For example, in your practice, you always ask people how they found you. More and more, you’re hearing Jane Doe told you to come here because you really listen to people and John Smith told you if I came here I wouldn’t have to wait for hours in the waiting room.

More often than not, the biggest complaint (unsolicited of course) you hear from patients about other practices is that they are herded through, they do not feel listened to and they have to wait for a long time to see someone for five minutes if they are lucky. (Hint, when patients complain about another business or practice, what can you do that is different and better?)

2. “You consider your employees to be your number one customer, your passengers your second and your shareholders your third. If you give great customer service to your employees as leaders, they will in turn provide it to their customers, who are the passengers. And the reward will be there for your shareholders.”

If you have staff, you know they can make or break your practice. It is important to empower your staff to ”own” their job if you will. While Southwest gives employees a percentage in the company (employees own 13-14% of company stock and share in profits), there are other ways to encourage staff ”ownership” of their jobs.

Other things you can do is to listen to staff members and implement ideas they have that would work. For example, the person at your front desk is going to know more about the flow up there than you will. She/he will know where the breakdowns are, and how to best meet patient/client needs. The same thing with your back office person. While you are in the room seeing the patients, she/he is juggling what is happening in the back office, and may have some excellent idea how things might work a bit smoother.

At the very least, just like you listen to your patients; pay special attention and listen to your staff.

3. “We’re very, very disciplined about hiring and we’re very, very disciplined about mentoring and coaching. We’re a very forgiving company in terms of good honest mistakes, but we’re not at all forgiving about attitude and behavior and demeanor.”

This is so important, and so difficult. Hiring the right person is an art as much as it is a skill. It is important that you follow some best practices and bring on the person who you feel is best, and then work with them to become the best they can be. On the other hand, if you find they have an attitude or exhibit behavior that is not consistent with your office culture; then it is best they move on.

Southwest Airlines is known for being a very different kind of airline to fly with and to work for. These three key ideas shared by Ms. Barrett give us a glimpse into why. How can you take this information and use it in your business?

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How Doctors Respond When Patients Choose Prayer Over Treatment

9/15/2009

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How do doctors interpret and respond to conflicts between their best medical advice and a patient’s religious concerns?

A study in the Archives of Internal Medicine suggests that such conflicts are not uncommon, that most physicians strive to accommodate the demands of a patient’s faith, but that certain types of conflict tend to push doctors over a threshold toward negotiation, persuasion and appeal to other authorities.

“There is often a tension between respecting the patient’s religious beliefs and pursuing the patient’s best interests,” said study director Farr Curlin, Assistant Professor in Medicine. “We explored the ways doctors negotiate that tension, how they balance respect for a patient’s beliefs against their own commitment to promote and protect a patient’s health.”

Although most physicians try to remain neutral regarding the religious beliefs and values of their patients, the authors have suggested this is not always possible. “Science tells patients what they can do,” the authors noted, “but physicians tell patients what they should do, and the latter is always a moral exercise.”

Curlin and colleagues conducted 21 one-on-one, in-depth interviews, centered on “open-ended grand tour” questions, with physicians representing diverse religious backgrounds. They kept doing interviews, he said, until they reached the point of “thematic saturation.”

Almost all of the 21 physicians had encountered cases where religion and medicine came into conflict, and these conflicts fell into three categories.

Physicians were least frustrated by cases of stark disagreement, in which the lines between medical and religious reasoning were clear, such as a Jehovah’s Witness who needed but refused blood transfusions. “As long as somebody understands the situation,” noted one physician, “then that’s his or her choice.”

Physicians were more disturbed by cases where the conflict was not between science and religion but rather between “different worldviews.” For example, some patients or families insisted “life in any form was better than death,” and demanded aggressive treatment even when the doctors considered it medically futile.

Doctors seemed most aggravated by patients who had no moral objection to a particular therapy but simply chose faith over medicine. Several physicians mentioned patients who decided to rely purely on prayer despite having a disease for which effective treatment is available.

“That’s really tragic,” said one physician, citing the case of a woman with a small breast cancer who chose prayer over treatment. The doctor recalled telling this patient, “We can do something for you now, but six months from now it will be a lot harder.”

Cases like that challenge a physician’s desire to remain open-minded and flexible, or at least to accommodate patients’ religious ideas. Curlin’s team noted that doctors described three strategies they use to persuade patients to accept their recommendations.

First, physicians may encourage patients to think of prayer as an adjunct to medicine, not as a substitute. If that fails, they often try to convince the patient that medical care can be part of a religious worldview, that therapy is “something provided by God,” or that “God is bringing you here for us to try to help you.” If that fails, the doctor may appeal to the patient’s religious community, such as family members or clergy.

When advising patients, “rather than striving for illusory neutrality,” the authors concluded, “physicians should practice an ethic of candid, respectful dialogue in which they negotiate accommodations that allow them to respectfully work together with patients, despite their different ways of understanding the world.”

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Are You Practicing Defensive Medicine?

9/11/2009

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What is defensive medicine?

Defensive medicine is the deviation from sound medical practice to avoid the threat of malpractice litigation.

According to a study in JAMA, over 90 percent of physicians surveyed admitted to practicing defensive medicine. This can range from “positive” defensive medicine, like ordering unnecessary tests, referring to consultants, or performing unneeded procedures; to “negative” defensive medicine, like avoiding high-risk patients or procedures.

Why practice defensive medicine?

Physicians practice defensive medicine to avoid malpractice litigation. A malpractice lawsuit is the most scarring ordeal that a physician can undergo, both emotionally and financially. There is an expectation that doctors have to be 100% accurate with their diagnoses. A missed diagnosis, whether it’s a 1 in a 100, or 1 in a million case, makes a physician vulnerable to a malpractice lawsuit. However, medicine by nature is an imperfect science, and the expectation of perfection is not realistic, nor possible. There is no test that is 100 percent accurate - an unfortunate outcome can occur even if a doctor practices textbook medicine. A recent study in the NEJM showed that almost 40 percent of malpractice cases were found to be without medical error.

Due to this uncertainty regarding unfortunate outcomes, physicians err on the side of caution and practice defensive medicine. It is much easier to defend the fact that a doctor ordered a test, as opposed to not ordering the test at all.

What are the downsides to defensive medicine?

Defensive medicine is expensive, has no basis in evidence-based study, and exposes the patient to a host of complications. Contrary to popular opinion, more medicine does not equal better medicine.

If a physician is 99 percent sure of a diagnosis, how much more will a patient be willing to pay for that added 0.5 percent certainty? A CT scan costing hundreds of dollars? An MRI costing thousands? Now, there may be some patients who are willing to spend that money for the most thorough workup possible. However, it is not feasible to routinely spend that kind of money to achieve minimal improvements in diagnostic certainty which may not benefit the patient at all.

Defensive medicine is one of the most important drivers in rising health care costs today. There are few reliable studies to back this up. This is because defensive medicine is impossible to quantify. There is a fine, and largely undefined, line separating thorough care and defensive medicine. What one doctor may interpret as a “being cautious”, another may say is defensive. Because defensive medicine cannot be quantified and is so subjective, its impact on the cost of health care has been minimized and under-publicized.

The practice of ordering extra tests is also bereft of evidence. There are no studies suggesting that ordering PSA screening tests saves lives from prostate cancer, or ordering routine abdominal CT scans saves lives from appendicitis. Is relying on the evidence good enough? The answer is no. The standard of care used in medicine cannot be applied to the courts. Standard of care varies from jury to jury.

Take the case of Dr. M. Major clinical guidelines, including the American Cancer Society and the American College of Physicians, suggests that the physician discuss the pros and cons of PSA screening tests with the patient. Since there is no evidence that this test saves lives, and may in fact cause damage by leading to unnecessary prostate biopsies, it is recommended that the decision of whether the test is ordered be shared between the doctor and patient. Dr. M did just that, and documented the discussion appropriately. Unfortunately, the patient later went on to develop late-stage prostate cancer, and sued Dr. M and the hospital for not ordering the PSA test. Citing the clinical guidelines of the ACS and ACP did not help - the hospital was found to be at fault. Again, it is much easier to defend the fact that a physician ordered the test, as opposed to not ordering the test at all.

Many would think that “the more tests, the better”. Nothing could be further from the truth. Tests themselves have their own risks: ranging from radiation exposure from CT scans to serious complications like bleeding and infection from needle biopsies.

Since no test is 100% accurate, unnecessary testing can lead to “false positives”. This is defined as having a positive test result in the absence of disease. False positives lead to progressively more invasive tests, which may eventually lead to a non-dangerous diagnoses or even nothing at all. As the tests become more invasive - like a needle biopsy or cardiac catheterization - the complications become more dangerous. Exposing patients to these unnecessary complications, for the sake of avoiding malpractice litigation, is bad medicine.

What can a patient do to help curb defensive medicine?

A patient should understand why a test is being ordered. Ask questions. How necessary is the test? What diagnosis are you looking for? What are the risks of not doing the test? What are the risks of the test itself? Understand that the goal of perfection in medicine is impossible, and that simply ordering more tests is not necessarily better medicine.

How can defensive medicine be reduced?

Obviously a difficult question, since it is a difficult entity to even quantify. The focus of the question is, “What does the physician want to avoid?” The answer of course, is the ordeal of malpractice litigation. Even if physicians do win the majority of malpractice cases that make it to trial, the mere process of a malpractice suit is tremendously scarring. Remember, the vast number of cases are settled, never reaching a jury. And the solution is not simply, “practice better medicine” or “make less mistakes”. Keep in mind that almost 40 percent of malpractice cases do not involve medical error. Unfortunate outcomes despite textbook medicine are a fact of life - that is a hard truth that one has to accept.

Some have suggested that capping malpractice awards, no-fault insurance, arbitration, or health courts as approaches to curb defensive medicine. Although I suspect that these options will help curb defensive medicine, the probability of such sweeping reforms happening in the near future appear minimal.

A simpler way would be to have clinical, evidence-based, guidelines globally applied to malpractice cases. That way, standard of care would be more consistent, and not vary from jury to jury. It will lessen the impact of “hired gun” experts, who can support whatever standard of care is convenient to the lawyers. Doctors can then focus on practicing evidence-based medicine, confident that the standards they are held to in the community, will be the same in the legal world. Only when that confidence is gained, will defensive medicine start to decline.

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