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Practice Management for the Millennium
How to Improve the Efficiency of Your Practice and Enhance
Referrals From PCPs
Dr. Neil Baum
New Orleans, Louisiana
Goals and Objectives
• Identify the needs and wants of the American urologist
• Techniques to market and promote incontinence to potential patients
• How to attract physician referrals for urinary incontinence
• Use of new technology-Electronic Medical Records
Needs and Wants of Physicians
• Maintain existing patients
• Attract new patients
• Improve reimbursements
• Decrease overhead
• Decrease litigation
• Improve morale of the staff
• Improve the efficiency of the practice
• Put the “manage” into managed care
• Add new technology to your office practice
Patients already in your practice
Attracting newpatients
Your relationship withreferring physicians
A highly motivated staff
The Four Pillars of aSuccessful Practice
The Two Secrets of Success
1. Find out what the patient wants and give him/her more of it
2. Find out what the patient doesn’t want and avoid it
Secret #1. Find out what the patient wants and give
him/her more of it.
“Ask and you shall receive!”
Patient surveys
Give your practice a check-up
How do patients perceive your practice?
• Conduct personal interviews
• Create a focus group
• Use a suggestion box
• Commission a mystery shopper
• Conduct patient surveys
Secret #2. Find out what the patient doesn’t want and avoid it
Patients do not want to wait to be seen by the doctor
Effective Scheduling““Languishing in the waiting Languishing in the waiting
rooms causes more patient rooms causes more patient dissatisfaction than any other dissatisfaction than any other aspect of medical care aspect of medical care including feesincluding fees.”.”
Study by AMAStudy by AMA
Time and Motion Study
____ Time patient arrive in the office
____Time patient taken to the exam room
____ Time spent with the provider
____ Time patient left the office
____
Total time in office / total time with MD
Effective Management of Delays
• Anticipate delays
• Apologize
• See patient at end of day-coffee coupons and beeper
Effective Management of Delays
• Call patient at home
• Apology letter
• (Don’t charge the patient)
Second Take Home Message...
• FEW of us can change health care policy
• ALL of us can be more sensitive to the patient’s time
Who Are the Key Patients?
• Patients receiving out-patient Patients receiving out-patient studies or proceduresstudies or procedures
• OtherOther
• Recently discharged patientsRecently discharged patients
Advantages of Calling Your Key Patients
• Fewer calls from your Fewer calls from your patientspatients
• Efficient use of your timeEfficient use of your time
• Very appreciatedVery appreciated
Response From a Key Patient
“This is the first time a member of your profession has taken the time to call me at home and check on my condition. Undoubtedly it will foster a better relationship between you and me.”
Attracting New Patients
Public Speaking
• Seminars
• Lectures– AARP– Junior League– Church groups– Service organizations
Writing to attract new patients
• Local magazine
• Newspaper
• Health publications
Using the Internet
• 33 million patients are willing to switch to a physician who has practice Web site and offers E-mail access to the practice*
*Cyber Dialog, 2004
Internet
• Must be more than an electronic version of your brochure
• Looking for outstanding clinical content– Credentialed by a legitimate medical
sources– Academic sites– National organizations and societies
Provide value-added services
• Secure messaging
• Appointment scheduling
• Insurance verification
• Prescription refills
• Access to patient’s medical record
• Procedure-specific information
Notify Current Patients of Your Web Presence
• Stationary
• Brochures
• Calling cards
What will the Internet do for your practice?
• Increase revenue
• Decrease expenses
• Improve office efficiency
• Improve the quality of care
• Can communicate with most patients in your practice
Final Advice On Attracting New Patients
• Make certain that they have easy access to your practice
• Do not allow a new patient to wait 4-6 weeks for an appointment
Enhance your relationship with referring physicians
The 3rd Pillar of aSuccessful Practice
Some Eye-Opening Opportunities
• Each urologist has approximately 10 loyal referring PCPs
• Average PCP sees 30 patients\day
• Approximately 15 are women, and 10 have risk factors for UI
• Bottom Line: 100 women could be screened each day!
How to Screen 100 Women\Day?
• Need to educate PCPs to ask questions about UI
• Need to educate PCPs to treat mild to moderate UI and when to make appropriate referrals to a urologist
Potential income from 100 screened women\day
• IOVs• FU visits• UA, urine C & S• Urodynamic studies• Cystoscopies, BUS, Flow Rates• Surgery (Needle Suspensions, Slings)• Other urologic conditions (UTI, Stones,
Cancer, IC)• Opportunity to treat family and friends
(vasectomies, BPH, CaP, ED)
Marketing To Referring Physicians and Their Staffs
Educating Referring Physicians
Lunch and Learn Programs
Meet with PCPs and their office staffs to discuss evaluation and treatment of UI
“UI-When to Treat and When to Refer”
10-12 minute informal presentation
Follow-up letter
Suggestions for “Lunch and Learn”
• No slides or computer
• Informal
• Leave a handout with your name and contact information
• Ask pharmaceutical companies to sponsor the lunch
Enhancing Communication With Referring Physicians
Why Do Physicians Refer?• Returns patients 38%
• Reports back promptly 33%• Availability 13%• Friendliness 11%• Scientific talks 7%• Give RPs an active role 5%• Teaching in hospitals and schools 7%• Entertaining 1%• Publish professional articles 1%
• Gifts 1%
Traditional Referral Letter
•Long•Arrives in 10-14 days
•Expensive
Key Ingredients of a Referral Letter
•Diagnosis•Medications•Treatment plan
Computerized “Boiler Plate” Referral Letter Example
Dear <Name of Doctor>
<Name of Patient> was seen for a problem of <diagnosis>.
I recommended <medications and treatment plan>. I anticipate <number of additional visits> additional visits and appreciate your authorizing the continued care in my office.
I will keep in touch with you regarding his progress.
Sincerely,
Neil Baum
Advantages of boiler plate letter:
• Reduces the cost ($15-$1)• Increases the efficiency of your
practice• Keeps the referring doctor as
the captain of the patient’s health care ship
The 4th Pillar of aSuccessful Practice
Motivating your staff
Highly motivated staffs follow a mission
statement
What is a mission statement?
A truth told in advance that tells where you and your practice are going
Our Mission Our Mission StatementStatement
• Commitment to providing the best health care for our patients
• Commitment to exceeding patients’ expectations regarding their health care
• Commitment to the attention to the LITTLE details because they make a BIG difference
Where to display the mission statement
• Reception area
• Exam room
• Employee lounge
• Brochures
• Newsletters
• Stationary
• Web site
“I could conquer the world if I had enough red ribbon.”
Napoleon
ABCD Awards
• Above and
• Beyond the
• Call of
• Duty
Second Take Home Message
• If you take outstanding care of the staff, they will take outstanding care of your patients!
Performance Review• Can’t be done once a year at salary
review
• Suggest every 3-4 months
• Complete worksheet before the review– What do you like the most about this job?– What would you like to improve?– Where do you want to be professionally in
the next 3,6, 12 months?– What can I do to help you reach your goals?
Surprise the Staff
Surprise is the spice of life
• Office closes for lunch
• Limo picks up staff
• Box lunch provided on the way to the mall
• Each staff member receives $100 which must be spent during one hour at the mall on gifts for themselves
Improve the Efficiency of the Practice
• In the past, we enjoyed the luxury of low volumes of patients and high profit margins
• Today, we can expect large volumes of patients with narrow profit margins
• Therefore, we will need to see more patients in the same amount of time without sacrificing quality and patient satisfaction
Improve the Efficiency-Office Videos
• Topics-medical discussions that are done one or more times a day or several times\wk– Annual exam– Evaluation of ED– Use of Viagra– Vasectomy– Treatment of localized prostate cancer– Evaluation of incontinence
Equipment for Office Videos
• Video camera
• Tripod
• Script
Getting Started
Gather information
• Tape record a conversation with a pt.
• Review pamphlets and educational materials from pharmaceutical and medical manufacturing companies
• Review other videos
Prepare the Script• Describe the topic• Why is it important to your health?• What are the risks and complications?• What are the alternatives?• “I will return to the room after you
have completed the video to answer any questions that you may have and provide you with a summary of the video.”
Advantages of Do-It-Yourself Videos
• Improves efficiency• Medical-legal protection• Nice take-home value• Can use to demonstrate
patient understood the material
Examples of My Office Videos
Please check my website:www.neilbaum.com
Do our colleagues appear a little sullen and sad?
Lost LHRH Agonist Income2003 2004 2005
Reimbursement/
Injection$1784 $1504 $697
Cost/Injection $658 $658 $658
Net /Injection $1126 $846 $39
Injections/Patient/Year
4 4 4
# of Patients 200 200 200Income per Year
$900,800 $676,800 $31,200
Income Reduction from Prior
Year
$224,000 $869600
Income By Size of Group
2003 2004 2005
4 man group/200
$900,800 $676,800 $31,200
2 man/100 $450,400 $338,400 $15,600
1 man/50 $225,200 $169,200 $7,800
x
Identify what it takes to make your practice financially
successful
Gross Collections of $1m\year
Projected expenses + M.D. Salaries
• How much is required month\week\day\hr?Assume $1million\yr\phy to run
practice
• Need to collect $83,333\month
• $20,833\week
• $4166\dayor…..
• $416\hr (based on 10 hour day)
Average amount collected\patient encounter
• $83,333\month collections\physician
• 500 patients seen each month\physician
• $106? collected for each pt encounter
• Need to see only 4-6 patients\hr to generate $416\hr or $1m\yr
EMR
• Doctors must document normal findings in Hx and PEx in order to receive E & M credit for their codes
EMR
• Doctors must document normal findings in Hx and PEx in order to receive E & M credit for their codes
EMR-Fact!
• 85% of all E & M records contain normal values
• If you don’t document what you did, you didn’t do it!
• With EMR, documentation is a click away
ROI-Return on Investment
• Can easily, ethically, and honestly move from level 2-3 E & M to level 4-5…and be able to sleep at night!
Before and After EMR-NP
0
10
20
30
40
50
Level 1 Level 2 Level 3 Level 4 Level 5
Before EMR
After EMR
Before and After EMR-EP
0
10
20
30
40
50
60
Level 1 Level 2 Level 3 Level 4 Level 5
Before EMR
After EMR
Take Home Message
• There are a lot of opportunities, i.e., a “big pie,” for urologists
• We just need to “grow the pie”
SummarySummary
The Chinese symbol for crisis is the
same as the symbol for opportunity
Do we see the glass of milk as half
full or half empty?
The Chinese symbol for crisis is the
same as the symbol for opportunity
Do we see the glass of milk as half
full or half empty?
Let Me Hear From You
• www.neilbaum.com
• FAX: 504 891-8505
• Office Phone: 504 891-8454
Suggested “Lunch and Learn” Talk to PCPs
Urinary Incontinence
When To Treat and When To Refer
Goals and Objectives
• Discuss the incidence and pathophysiology of UI
• Review the evaluation of the patient with UI
• Describe the medical management of UI
• Provide indications for urologic referral
Urinary Incontinence
• Affects 14 million Americans
• Affects 50% of all patients in nursing homes
• More common in women and the elderly
• Not a normal part of the aging process
• Less than 5% seek help from the medical profession
Common Causes of Incontinence
• UTI
• Childbirth injuries to the pelvic floor
• Surgical injuries to the urinary tract
• Hormonal deficiencies
• Medications
• Birth defects
• Diabetes
• Neurologic disorders
• Physical Capabilities-lack of mobility
Risk Factors for UI
• Immobility
• Impaired cognition
• Morbid obesity
• Smoking
• Environmental barriers
• Diabetes, stroke, estrogen deficiency, pelvic muscle weakness
• Medications
Medications Causing UI
• Diuretics
• Caffeine
• Anticholinergics
• Psychotropics
• Narcotics
• Alpha adrenergic blockers and agonists
• Alcohol
Types of Incontinence
• Stress incontinence-outlet fails to remain closed
• Urge incontinence-detrusor over activity
• Mixed-stress and urge incontinence
• Overflow incontinence-failure to empty
• Functional incontinence-factors outside of the urinary tract
Evaluation of UI
• History-drug history
• Physical examination-abdomen, pelvic, DRE
• Measurement of PVR
• UA, C & S if there is pyuria or bacteruria
Medical Management of UI
• Anticholinergics
• Smooth muscle relaxants
• Alpha adrenergic agonists
• Estrogens
• Exercises
• Mechanical compression
Indications for Urologic\Gynecologic Referral
• Failed pharmacologic management
• Hematuria
• Recurrent UTIs
• Overflow incontinence
• Large post-void residual
• Urinary retention
• Incontinence associated with anatomic abnormalities
Summary• UI is a common conditions that affect
millions of American men and women
• UI can be evaluated in the primary care setting
• Most patients with UI can be medically managed by PCP
• Urologic\gynecologic is referral is indicated in appropriate circumstances