Review Your Fees to Keep Your Practice Afloat!

Every practice should track and support their financial status frequently.

Income must exceed expenses.

Ultimately the physician-owner is responsible to make this happen.  (See – How to Keep Your Practice afloat, May 31, 2016.)


Yes you need to check:

  • the cost of supplies and materials.
  • Is payroll correct
  • Are operations costs –rent, utilities, insurance- correct
  • Are the number of patients remaining the same or increasing?


But what about fees? Are you charging what your peers are charging?

Are you receiving the amount that your peers are receiving for:

  • Office Visits
  • Special Services
  • Payment from third party payers
  • Managed Care contracts?


These need constant review. Income must exceed expenses.

You need to make it happen – or you will not remain in business.



Rules Can be Broken

Regulations and rules can take much time from providers and staff in healthcare and keep providers and staff from direct patient care and cause burnout.

Last year the Institute for Healthcare Improvement hosted a “Breaking the Rules for Better Care Week” where providers could circumvent rules they felt prevented them from offering the best care.  The result was that they found that many policies and rules were not legally required. Throughout the week providers found 342 rules had little or no clinical value to patients.  They grouped these into 3 groups:*

  1. Habits formed by organizational behaviors which had no legal requirement such as –preventing staff from keeping bottled water at nursing stations.
  2. Organizational rules such as charging for parking or having restricted visiting hours.
  3. Rules required by regulations & statutes – the most frequent mentioned was the three-day rule for access to skilled nursing facilities.


Thus they realized that many of their rules were fully within their control and could be eliminated.  That left the small amount of rules required by regulations and statutes and these could then be handled by joining together with other providers to discuss at local, state or national levels.




  • Minemeyer, Paige, For Better Patient Care, Providers must Break the Rules, Fierce Healthcare, Jun 8, 2017.


Why is Healthcare such a Complex Problem?

Why can’t we do healthcare insurance like we do all insurances – fire, wind, auto insurances, etc., – Let the individual buy and pay for the insurance they want?

Yes, we’d have to keep Medicare and Medicaid. It would also probably be good if employers quit funding health insurance and put the money into the employee’s paycheck.  (However knowing people as we do, there would probably have to be some type of Health-savings account or people would not have the money when they needed it.)

People buy auto insurance, life insurance and wind and fire insurance and we get along. People figure it out.  They know how much these things cost and choose what they want and pay for it.

Costs for health care have gotten out-of-hand and possibly if people were paying for it with their own dollars, costs would come down.  As long as some “unknown” is paying- pharmacies, hospitals, etc., can run the charges up anywhere they want. Costs have “sky-rocketed” because pharmaceutical companies, insurance companies, device companies can charge anything they want and there is much money to be made!

We say it can’t work without government – that healthcare is too complicated and too expensive. But we’ve made it complicated and expensive. We haven’t always had health insurance. Before World War II people paid for their medical costs. It is not a “right”.   Of course we do not want people to go back to losing their farm or their savings, but we do need some “common sense” in health care. When a “pill” can cause several hundred dollars and a procedure can cost many thousand dollars – more than the cost of my house – that may be a clue that something is not correct.

Physicians should not have to be an expert on every insurance cost and every pharmaceutical cost available.  Let physicians practice medicine and let the citizen pay for what he/she wants.

You say the costs are too high – but maybe they wouldn’t be, if the consumer was in charge.

You say the consequences are too serious – some people have the unfortunate circumstance to have an expensive illness.  Yes, and in that case, there would have to be some type of help – such as Medicare and Medicaid.  But for the majority of people 18 – 50 or 60, insurance companies could work out plans to cover their needs, within their financial circumstances. Get the government out of healthcare and eliminate 98% of the problems. And probably best to get employers out of financing healthcare too. People rely on their employer to finance their healthcare.  People choose their job by the healthcare benefit offered!   Bet insurance companies could simplify their policies and drastically reduce their costs if they negotiated directly with the individual.

I’m sure we would see a rapid and accelerated reduction in costs almost immediately, if we got federal and state governments out of healthcare.  There are way too many people, companies, and organizations in healthcare and too much money to be made. Get the governments and big corporations out and return to common sense – where the individual pays for what he/she gets.



Some Skills Doctors learn after Medical School

Some say doctors are left to learn some skills, at on-the-job training. After Medical School,they say, many physicians lack knowledge in areas of:*

  • Disease-preventive lifestyles – An example given is nutrition. Doctors get little knowledge in nutrition – often reciting info in popular commercials as fact.  Possibly best not to say anything, if not sure. (Popular commercials are not often correct.) Other examples are cleanliness. Some doctors may not think to ask a patient if they wash their hands after going to the bathroom or after they sneeze– some people don’t and germs can spread. Obstacles – doctors need to be aware of obstacles that could cause injury – such as clutter in the house or an untied shoestring. On-the-job, doctors soon learn the lifestyles of their patients and can determine if there is a need to educate them.

  • Personal finance – Some Doctors haven’t a clue how to invest their earnings or have lost money in investments. Maybe best to seek professional financial advisors.


  • Management and leadership – Some doctors are not good at motivating others or managing projects and some say they could use formal leadership training courses. (Would a course on motivation teach them how to motivate a staff of nurses?)


Some of this is just plain “common sense”.  Most doctors will “catch on”, with on-the-job training, in a few months or a year or two.  And if not, then perhaps they do not have the aptitude for the skill and best to let someone who ‘knows how’ do the task. Should precious time in medical school be used for “common sense” education?



*Beaulieu-Volk, Debra, 3 Skills Docs Learn on the Job, FiercePractice Management,  September 27, 2015.


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?


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.**


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.****


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.




*Beaulieu-Volk, Debra, Fierce Practice, April 14, 2015

**  Small, Leslie,, January 22, 2015

*** MacDonald, Ilene,, May 21, 2015

**** Beaulieu-Volk, Debra, December 31, 2014








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.






*                *                *                 *                    *                  *                      *                    *

  •     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,, 2015/08/07

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








Considerations on Healthcare Delivery