Doctors Comment on Why They Practice Medicine

While some doctors retire early and regret their career choice, many doctors keep showing up and curing people.

Sagging physician morale, frustrations, explosion of bureaucracy in medicine, paperwork, and insurance have increased early retirements.

One 86-year-old doctor comments on his 60-years in Practice, having seen many changes in the practice of medicine, says “his job and passion has stayed fundamentally the same: to care for patients.” He says he may have more love for his fellow man than many other people today and says he is just trying to be a good person.*

Robert Wergin, M.D., President of the American Academy of Family Physicians put it this way: “There are two principal reasons that doctors keep coming back to the office: solving patients’ problems and the value of medicine.” “Once physicians are in a room with a patient I don’t hear any complaints about that,” “the overall fundamentals of providing care one-on-one with patients are still the heart of family medicine.”**

 

An example given was that of a bartender who was asked to make an Old Fashioned for a customer whose Grandmother had just passed away because that was the Grandmother’s favorite drink.  The bartender felt compelled to make the best Old Fashioned he could and he did. The customer acknowledged that the drink was the same as Grandmother liked.  The bartender acknowledged that  was ‘incredibly’ special to him.  He knew he was good at what he did and this was special – he had made something special for someone at a time they needed it most.  The bartender later acknowledged – “for all the crap we put up with, this interaction made everything worth it.  She (the customer) was so happy;  it was awesome.”**

The article’s author says, “I hope that every once in a while, you can reflect on the work you do and say, “That was awesome”.**

That may be how it is with doctors who continue Practice long after retirement age – as they reflect on their work, and say – ‘that was awesome’!

 

 

 

  • Beaulieu-Volk, Debra, Why he hasn’t retired: Doctor comments on as half-century of practice, FiercePractice Management, November 10, 2014.

** Beaulieu-Volk, Debra, What Makes Practicing Medicine worth It, FiercePractice Management, September 9, 2015.

 

Why Are Some Doctors So Arrogant?

  Probably just as we find there are persons in all disciplines of life to     be arrogant.  It’s human nature – it just is.

Physicians do have very specialized skills and understanding and knowledge about a subject  –  medicine, that is of interest to all of us.  And most of us at one time or another, must seek or ask the advice of a physician.  Thus some physicians can begin to believe they are “special”, “better” than other people.  And some physicians just believe they are “superior” to other individuals and definitely “lord” it over the rest of us.  They tell us in no uncertain terms what we should and should not do and the exact way to do it. And at times, some patients need this approach.

Also there are many disciplines or professions (mimicking) or working with and aiding physicians and often a person in one of these professions – whom also tends to be arrogant – can think or pass themselves off as a doctor and so the “real doctor” must, at times, step up and take command.

Are doctors really superior to other individuals?  Well Yes, in knowledge of medicine and that’s it.  They have a few facts and procedures they have learned from another and they have spent many hours and much money to acquire their knowledge and often this special knowledge can help save a life or help a person recover from an illness.

However many persons have special knowledge and expertise in their area of interest and usually it has required much time (and money) to acquire.  And although their knowledge may not save another’s life or cure a disease, it is important in its own way.   It may be building a building, flying an airplane, balancing a group of numbers in accounting, playing a musical instrument, cooking a fine meal – most of these skills many physicians cannot do really well.

This arrogant – condescending attitude, which some physicians have, – what effect does it have on patient care?  Some patients or family may be afraid to ask important questions or relay concerns that only they can understand or know about and that could be vital to treatment.  Being intimidated, a patient may not understand what the doctor is saying but will not say so – and leave the doctor’s office without the understanding.  Thus the doctor may not get the information he needs from the patient to fully understand the patient and the patient’s environment and the patient may not get the information he needs from the doctor to implement the course of treatment required for a successful recovery.  So for maximum success in patient care, it may be best to put arrogant personalities on the shelf.

A physician might best, become an amateur psychologist and evaluate what each patient needs – what tone of voice, mannerism, choice of words, choice of emphasis,  amount of detail. The physician’s duty is to diagnose and treat correctly, and also to relate to the patient correctly so the patient knows and understands what the patient must know and understand.

 

 

 

 

Health Insurance – Affordable?

Private health insurance and the government’s role in shaping it, is a $743 billion high profile industry, dominated by United, Anthem, Aetna and the Blues.  Forecasts are for health spending to increase 5% annually for the next decade.

In the past private insurers, Medicare and Medicaid and large employers negotiated rates paid for services and coordinated care. However with Affordable Care Act (ACA) doctors and hospitals are paid based on their management of cost and quality. Providers are now responsible for insurance risk and total population health management. Providers are increasingly responsible for managing total population health. Once the responsibility of insurers, care coordination, formulary design and medication adherence programs, enrollment and member services, medical management and outcome measurement, claims adjudication, etc., are now necessary to the physician’s practice.

In addition to the financial implications, this presents problems for the individual physician. Patients routinely ask their physicians about what is covered and what is not covered and what things cost. Physicians have no way of knowing without calling the insurer.

So what is affordable? Normally affordability relates to the amount that the consumer can or is willing to pay for the product. However Healthcare is different. Costs are not readily apparent or directly related to prices and charges. Wages have not kept up with health insurance premiums. The average deductible for those with employer sponsored insurance is now $1221.00 and everyone is paying more for drugs. *

So where are we going with Health Insurance? With the new administration in Washington, the topics above will be talked and talked about. As I see the situation at present, Health Insurance costs are too high for most persons and coverage is not adequate for many situations.

 

 

 

  • Keckley, Paul H., The Keckley Report, November 9, 2015, December 5, 2016.

 

 

Doctors and their Patients

How should doctors relate to patients? I don’t want a doctor to be overly sympathetic and hold my hand, but as a patient or family of an ill patient – I don’t want just the cold, hard facts.  I want the facts buried in some compassion.

My reference case is an older lady and her husband who just had a stroke.  The wife hoping and believing that her husband would recover, about Day 3, in an attempt to explain after-hospital treatment, the doctor told the wife – that she could either take her husband home and he would die in 2 weeks or take him to a nursing home and he would die in 4 weeks.

What a shocking thing to say!

What a cruel thing to say!

Isn’t there a better way to inform the wife of the realities? There are such things as kindness, sympathy and empathy! So sandwich the prognosis with a concern for the family.  For a doctor, the situation is just another case – one of many every day.  But for the family when a patient becomes ill, the whole family hurts. Their lives have been turned upside-down.  Schedules have been destroyed. Finances have probably been changed for the worse. There is apprehension and terror and fright as to the prognosis of the loved one.  So be understanding of the patient and family members.

The situation is not a science experiment or an exam question.  These are real people with real concerns and real feelings and they need the truth wrapped in kindness and concern.

 

 

 

 

 

 

Medical Schools – Teach Medicine or Social Graces?

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Today’s practicing doctors were never taught how to collaborate with patients or colleagues, but the approach has emphasized classroom memorization and clinical shadowing.  Today there is too much medical information for anyone to memorize and keep up with, and it is easily accessible by smartphone or tablet, thus schools must alter their priorities and prepare doctors for an ever-changing healthcare environment – make greater emphasis on skills such as teamwork and communication.*

The medical community needs to develop a more scientific approach to evaluate the quality of American Medical Schools. To assess the professional development of each institution’s graduates, the study assigns scores to medical school graduates by tracking their performance in the following categories:  grants, clinical trials, publications and awards/honors. Thus researchers are able to track medical schools’ quality performance over time.  This produces academic physicians who go on to successful biomedical research careers, although it is not well-suited to evaluate institutions that aren’t as research based such as those focusing on producing primary care physicians.**

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Many clinicians need training on how to treat patients based on their overall needs and not solely on their disease or condition.  Today’s doctors and nurses receive training on how to take care of patients’ medical problems, but little education  on psycho-social factors that influence a person’s overall health. Hospitals and health systems must retrain staff so they have the skills to improve patients’ overall health. There are psycho-social dynamics and behaviors that have not been focused on – like the patient who is told to lose weight but doesn’t know how to cook in a less fattening way.  The need for healthcare workers to understand the unique needs of diverse groups of patients, such as Asian and Latino and the aging, lesbian, gay, bisexual and transgender populations and the under-served. ***

Healthcare workers have increasingly pursued patient-centered care to help improve patient experience as well as engagement and outcomes.  Students are taught specific skills that allow them to better partner with patients.  For Patient-centered Care, in simulation-centered encounters, students are evaluated on their interaction with patients, family members and health providers.  It measures their competence in the following areas:

  • Effective communication
  • Active listening
  • Demonstrating empathy
  • Avoiding medical jargon
  • Leading critical conversations

Building better relationships between patients and doctors not only leads to more satisfied patients, but respect between clinicians and their charges.  Needed are strong patient-doctor partnerships.****

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So say the “intellectuals “and “educators” – Don’t teach medical students anything about medicine – how to recognize a medical condition and how to treat the problem, because that is all on the Smart Phone.  Rather teach them to become a “glorified” social worker.

Personally, as a patient, I want my doctor to know MEDICINE – how to diagnose my condition and how to treat the problem.  I don’t care if my doctor isn’t overly polite or comforting. I want the facts – just the facts- that’s why I pay the big bucks.

I don’t care if my doctor gets grants or does clinical trials or how many publications and honors. I just want my doctor to treat my colds, my heart attack, etc.

I don’t want my doctor to go to the Smart Phone and punch in what I tell him/her is wrong with me and then use what the Smart Phone says to do.  The Smart Phone doesn’t know me and cannot evaluate what I don’t even know about me or didn’t think was important to mention. I don’t care if my doctor can get grants or do clinical trials, etc. I just want my doctor to know medicine.

My doctor does not need to know about my cooking ability – I’ll figure that out on my own. If my doctor is rude, he will soon learn with on-the-job training, that doesn’t work real well.  But don’t take the precious medical school time to teach manners and social graces.  PLEASE JUST TEACH MEDICINE.

I want my doctors to be measured by their success with their patients – patients who have been correctly treated and recovered. I don’t want my doctor to be my partner and hold my hand.  I want my doctor to have medical answers and to treat and cure my conditions.

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*Beaulieu-Volk, Debra, Fierce Practice Management.com, April 14, 2015

**  Small, Leslie, www.fiercehealthcare.com, January 22, 2015

*** MacDonald, Ilene, www.fiercehealthcare.com, May 21, 2015

**** Beaulieu-Volk, Debra, www.fiercepracticemamagement.com December 31, 2014

 

 

 

 

 

NONCOMPETES

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Non-compete Agreements or Restrictive Covenants are contracts  that bar a physician from practicing in a specified geographic area for a set amount of time, i.e., working within 20 or 30 miles of their previous office for 1, 2 or 3 years after they leave.

Although they are restricted or illegal in some states, -Alabama, California, Colorado, Delaware, Massachusetts, North Dakota, Tennessee, and Texas- they are generally enforceable as long as the terms are reasonable. It’s the Hospital’s or employer’s insurance which bars doctors from leaving for a competing hospital or clinic and taking patients with them- assuring that the Hospital gets a return on their investment when they hire a doctor.*

When a  physician challenges a signed non-compete, courts often look for a reason to not enforce it.  Some common weaknesses that make the agreement ineffective are:

  • It’s too broad – if it spans more than a year or two or more than 30-50 mile radius of the practice or hospital,
  • The Hospital did’t hold up their end – if the employer promised the doctor a certain level of income or similar benefit and didn’t deliver.
  • Patients may suffer – If there is an inconvenience to patients – if patients will be required to travel a great distance to see a doctor.
  • Hospital fires unfairly – If the hospital determined the doctor to be of such little value that they terminated the doctor – then it is difficult for the hospital to enforce an agreement that presumes the doctor will be a competitive threat.
  • Hospital enforces selectively – if the hospital did not enforce the rule in the past to a doctor, the judge will possibly rule that it can not then apply this time.

New  Mexico  limits restrictive covenants for employed physicians but not for non-solicitation agreements-i.e., physicians who have been employed by an organization  for fewer than three years are allowed to leave and compete – but the organization can require the employee to repay incentives like loans, relocation expenses and signing bonuses.  After three years a doctor can leave with no strings attached.

The three main parts of most restrictive covenants are:

  • Agree not to compete with former employer.
  • Agree to not solicit patients, employees or both,
  • Agree to not use or disclose confidential information.

 

nc-2To prevent theft of a company’s trade secrets these contracts may be closely related to business torts or suits for money damages caused by unfair competitive practices or theft of trade secrets.  Many states have enacted laws modeled after the Uniform Trade Secrets Act to establish standards to protect trade secrets from theft and misappropriation.  These define “trade secrets” to include patient lists and contact information, pricing methods and other similar valuable, non-technical business information.  Even in the absence of a restrictive covenant, the law protects businesses from employees who seek to use their employers trade secrets for their own competitive advantage.  Restrictive covenants allows a business to define its confidential information and the activities it considers off limits.  Like trade secret law, restrictive covenants are regulated by state law, so interpretation and enforceability will vary from state to state.    ***

Again courts in many states will refuse to enforce a restrictive covenant that:

  •  does not protect the employee’s legitimate interest
  • imposes an undue hardship upon the employee
  • contains terms -duration, geographic scope and or breadth of restricted activities- that are broader than necessary to protect the employer’s interests
  • causes harm to the public.

 

However a restrictive covenant will be more likely to be enforced if its description of the employer’s protected business interest is similar to the definition of trade secrets in the home state’s trade secrets act.  Anything broader than that definition will be subject to possible rejection by the court.  Especially if the Agreement is to:

  • last too long
  • cover to wide a geographic scope
  • result in harm to an area of public interest.

 

 

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  •     Beaulieu-Volk, Debra,  Physician Noncompetes stir controversy amid shifts in employment trends, Fierce Practice Management, June 2, 2015.

**     Beaulieu-Volk, Debra, 5 Sign of an Unenforcable Noncompete, Fierce Practice Management, October 5, 2011

***Kirchner, Philip, https://physiciansnews.com, 2015/08/07

**** Caramenico, Alicia, Fierce Healthcare, Hospital’s nocompete agreement inconveniences  patients, judge rules, September 7, 2011.

 

 

 

 

 

 

 

Is Technology Replacing the Physical Exam as the Diagnosis Tool?

fat pt3Is Technology Replacing the Physical Exam as the Diagnosis Tool?

Older doctors are saying that doctors today are spending more time with their computers than at the bedside. Doctor-patient conversations are infrequent and brief. Technological tests are becoming the primary source of information on a patient and the basis for diagnosis.

Today the ability of a doctor to use a physical exam to make an accurate diagnosis is fast disappearing. Today a physician’s exam skills are considered obsolete and are being replaced by technological findings, which are considered to be more objective and accurate.

Insurance, that pays for the tests, accelerated the trend, plus the growing paperwork burden, that doctors have, and many of the generation of mentors who taught physical diagnosis have retired.  Today physicians migrate from the patient’s hospital bed to a conference room down the hall where test results –not the actual patient- are examined.

However there are still some physicians who firmly believe that the physical exam should remain and be the starting point for treatment of all patients.  They say information gleamed from inspecting blood vessels at the back of the eye, observing a patient’s walk, feeling the liver or checking fingernails can provide valuable clues to underlying diseases or incipient problems.  The doctors interviewed said for a surprising number of diseases, diagnosis is based on observation and examination, not a test – Parkinson’s disease, shingles, drug rashes and constructive pericarditis. They say heart murmurs in children – distinguishing “innocent” murmurs from serious ones is an essential, but necessary skill for physicians and can best be done with the physical exam.

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Medical Clipart

These skills, they say, are an essential adjunct to technology and can boost diagnostic accuracy, curb unnecessary and expensive testing and foster a greater connection between patients and doctors. With the physical exam, practitioners can assess enlarged lymph nodes, measure ankle reflexes and perform a knee exam.

With the physical exam the doctor can often find the “obvious” before putting the patient through grueling and expensive tests.  Studies have shown that the physical exam can be as accurate or more so, then the technological counterpart.

One physician said the first thing he always does is the fundamental clinical skill – he listens to the heart – because there is information to be learned. These physicians are saying, reviving the bedside medicine and ordering tests, based on the results of a careful physical exam and history will improve the quality of care for the patient and reduce costs.*

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  • Boodman, Sandra, Emphasis OnTech Has Eroded The Old-Fashioned Physical Exam Diagnosis, Kaiser Health News, Physician News – Spring 2014,

 

 

 

H.R. 2513 – Promoting Access, Competition, and Equity Act of 2015

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H.R. 2513

Promoting Access, Competition and Equity Act of 2015 (H.R. 2513), the PACE Act of 2015.

Some are For and some Against.

 

In 2010, the Patient Protection and Affordable Care Act, (ACA) banned building new or expanding existing physician-owned hospitals. Large General Hospitals and Medical Centers cited that private hospitals were “cherry picking” the healthiest and wealthiest patients, excessive utilization of care and patient safety concerns.

The law when enacted recognized that more than 200 physician owned hospitals were already operating and rather than force them to close, these hospitals were grandfathered in. The law did recognize that these hospitals were operating counter to the spirit of the new law and it thus prevented the opening of any new or expansion of any existing physician owned hospital unless the facility could show need in the community for greater access to care.

Forty plus major building and expansion projects underway at Physician Owned Hospitals, at the time,  were immediately stopped and any physician owned hospital that violated the ban was prohibited from participating in Medicare or Medicaid.

The current law, it is said, is to prevent harm to community hospitals, patients, taxpayers and employers that may be possible when physicians self-refer to hospitals in which they have an ownership interest. Changing the law now would allow broad repercussions for patients, taxpayers and the sustainability of full service community hospitals that provide services 24/7, including trauma care and other high-cost services that are critical to all communities and patients. They say changing the law will weaken full service community hospitals, increase patient safety concerns and increase the excess growth in health care costs that self-referral manifests. *

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On the other hand, private physician-owned hospitals say they do not “cherry-pick” the most profitable patients.  A recent study found that patients at physician-owned hospitals and non-physician owned hospitals were equally likely to have Medicaid insurance and to be from racial or ethnic minority groups. Other studies have found that seven of the top 10 hospitals receiving quality bonuses in the new Hospital Value-based Purchasing Program in 2015 were physician-owned hospitals. This despite the fact that physician owned hospitals represent only 5% of the 5,700 hospitals nationwide.  Also the Centers for Medicare and Medicaid Services released Star Ratings in 2015 based on consumer assessment surveys and it was found that 40% of physician-owned hospitals received the top 5-star rating compared to only 5% of general hospitals.  In addition the Department of Health and Human Services found that patients are three to five times more likely to experience complications at general hospitals than at physician-owned specialty hospitals.  Further the study showed that physician-owned hospitals performed equally to non-physician-owned hospitals on many measures of quality of care, costs and payments for care. Often these hospitals charge less for the same procedures as the non-physician hospitals.  One example said that physician-owned hospitals are saving Medicare $3.2 billion dollars over 10 years.

Physician-owned hospitals also provide more charity care than their counterparts which receive  subsidies and tax exemptions.  One report states that physician-owned hospitals spend nearly 6% of their total revenue on community benefits compared to less than 1% for other hospitals.  Physician-owned hospitals are in both rural and urban areas including full-service hospitals and specialty hospitals focusing on orthopedic  surgery, cardiac care, rehabilitation, psychiatry, etc.  They explain that these are not hospitals where the physician owners expect to get rich. A majority of the physician owners have less than a 2% interest in the hospital.  These physicians, they explain, just want to practice in an environment where their medical expertise counts for something and they can put patient care first.

Physician-owned hospitals want Congress to allow their hospitals to be able to expand and grow in programs and services to the community. Since growth is currently prohibited, they say this poses a serious risk to their patients who look to them for high quality health care in a safe and personalized setting.

Physician-owned hospitals say that the big community hospitals see them as competition.  The big hospitals often are a major employer and thus they have more clout with local, state and federal politicians . **

Currently there are approximately 250 hospitals operating in 34 states, where physicians have an ownership stake.

The new legislation (H.R. 2513) –Promoting Access, Competition, and Equity Act of 2015, will suspend the moratorium on physician –owned hospital expansion for three years so that current physician-owned hospitals can expand their facilities and allow those facilities that were under development at the time the law was passed to be grandfathered in.

It may be of interest to read more about the bill and to contact your Congress person for more insight.

 

 

 

 

  • “Oppose Legislation (H.R. 2513) that would Allow for the Proliferation of Self-referral to Physician Owned Hospitals”, Federation of American Hospitals.

** Turner, Grace-Marie, “Lift the Ban on Physician-Owned Hospitals”,  www.Forbes.com, Nov 6, 2015.

 

 

 

 

 

 

 

 

 

Anti-Kickback Statue

 

antiKB6When signing a new employment contract, fee agreement or other financial arrangement for services, review it carefully to ensure that you will be reimbursed or paid for services that you actually perform and that the pay reflects the fair market value for the work done.  One can be found to violate the AKS (Anti-Kickback Statue). A recent case in the Midwest found 4 hospital executives and 4 physicians guilty of offering and receiving illegal bribes and kickbacks to induce patient referrals to the hospital and to increase the patient census, which then will increase hospital revenue. These persons received prison sentences of several months.   Another example described compensation arrangements where physicians received additional compensation for advance job titles, such as “Director” when the title was not appropriate or compensation arrangements where a physician’s compensation included payment of the salaries for his office staff.

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The Federal anti-kickback statue prohibits individuals and entities from knowingly and willfully offering, paying, soliciting or receiving remuneration to induce or reward referrals or business, reimbursable under any Federal health care program (FHCP). The types of remuneration covered include kickbacks, bribes and rebates, whether made directly or indirectly, overtly or covertly, in cash or in kind. The statue covers not only referrals of patients, but also the purchasing, leasing, or ordering of, or arranging for or recommending the purchasing, leasing, or ordering of, anything paid for by any FHCP.  There are, exceptions known as “safe harbors”.  Hospitals, suppliers and others may seek to comply with a safe harbor to ensure that their payment or business practice does not violate the statue.*

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A Hospital or Health Care facility may furnish software or information technology to a physician practice. This may imply a kickback as it is potential remuneration for the Hospital.  This can be significant especially with electronic health records (EHR) – involving interoperable EHR software, information technology and training services. If the goal is to promote technology that will benefit patient care then safe harbor can protect these arrangements. There are conditions that exist in the use of safe harbor.  It is best to consult with legal counsel.

Physicians should take care that all compensation agreements reflect fair market value for services they actually provide. Also be certain that services included are not covered in other agreements. Keeping records of tasks done and time involved may be a good method to provide evidence should it be needed.

 

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  • Office of Inspector General, U.S. Health & Human Services, OIG Alert, October 6, 2015.

 

 

How To Keep Your Practice Afloat.

 

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Dr-1Managing a private practice or any private business today is challenging and balancing revenue and expenses can become a struggle to stay afloat.  Physicians say that payer reimbursements are barely keeping pace with practice expenses. Today’s medical practices contend with many new demands including high-deductible health plans, the new ICD- 10 coding system and new federal quality-care mandates.

The one answer to financial business problems is accurate and timely financial reports and then proper action on those reports. You must know where every cent comes from and where every cent goes and you must end-up with a positive final balance.acct tape-2

If expenses exceed income, you must decrease expenses or increase income and make these columns balance or income exceed expenses. If not, you will not remain in business. No matter how valid the expense is or how important you think the expense is, if you can’t afford it – you can’t afford it!  You have to do without or find a way to increase income to cover the cost.

Fountain Pen and Sign --- Image by © Royalty-Free/Corbis

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And you must do the review YOURSELF!  You must see the numbers.  You do not turn this over to an office manager or an accountant to write up reports that you never look at. Such assignments are to note all transactions and to categorize and organize the information.  It is your job to review and know the numbers and make decisions accordingly.

Depending on the size of your organization, you must have regular (bi-weekly or monthly meetings) to go over the numbers related to the areas of responsibility of staff members. For the front office staff- are patients complaining or are fewer patients coming in?  For the purchasing person – are products costing more? Ask and know what is going on.  Are new patient visits growing or declining, is the practice doing more or fewer procedures than last year, are established patients remaining stable? Are referrals increasing or decreasing? Ask staff – they will have opinions – they are the front line.

Do not say that your responsibility is the medical care of the patient and the financial area is not yours. And do not say you are trained for the medical expertise and that you do not like business and thus you let someone else do the business. Do not say that you delegate the financial work. If you are in private practice, financial is part of your work. If you do not like the business, then get an “employed” position.

You are not too busy! It is part of the job of a private business.  If you want the advantages of a private practice, then you must assume all the responsibilities of the job.  Finances and the bottom line cannot be delegated.

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So look at those numbers.  Know those numbers.  Have regularly scheduled meetings to discuss financial with staff.  Then act and correct the problem. Do not wait, problems usually do not go away and a smaller problem may be easier to correct. Some decisions will be difficult. Having to reduce staff or services – but if it must be done, do it and go on. And what’s more – you may actually like your new “financially growing” business!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Considerations on Healthcare Delivery