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

• Nbaum@dialogmedical.com

• 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