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In the first part of this two part blog I addressed the patient visit, looking at the amount of time spent with patients and how it can be affected by the visit reimbursement. The more money for the visit, the more opportunity to break from the 15 minutes per patient model (I am still unable to find how the 15 minute visit time limit was devised, and if doctors had any input.).
In this second part, I’ll discuss how scheduling affects this, as well as the impact of both on patient engagement and satisfaction. There’s a non-ending amount of information that has emerged about patient relationships, and the entire patient experience has been parsed into a range of specific topics. “Patient engagement” seems to be the umbrella over these, incorporating all or some depending on the approach. From my perspective, patient engagement starts with the first contact a patient makes with a physician office and ends after the visit(and/or follow-up visits) and patient issue solved. Scheduling can be extremely problematic. When you consider the time it can take to adequately diagnose a patient’s condition, along with regular problems like late arrivals, more than the allotted time needed for a diagnosis, regular interruptions like unpredicted hospital visits, medical emergencies, procedures or surgeries that run long, etc., it’s easy to see why practices often struggle to minimize or eliminate all of the problems that arise when patients stack up in the waiting room. Obviously, if you are looking at an average reimbursement per patient visit, easily converted into a revenue/day amount, you are also, de facto, arriving at a revenue per day based on a total time you spend on visits. But there’s more to consider: If, for example, you’re an FP doc, seeing patients all day, you will have some non-reimbursed time spent during the day—the goal should be to minimize this by tracking it, analyzing it, and seeing how to compress it through making it part of your overall daily schedule. What you’re looking for here is doctor satisfaction: Predictability of how your day will flow! Maximized revenue for the total time you spend working. How can a practice/employer help you improve workflow and still get you out of the office and home to your family? When and how is this reviewed? Who oversees this issue within the practice? And how are they looking at ways to minimize the physical and emotional drain of extensive non-reimbursed time, a major contributor to fatigue and burnout? This kind of information can be built back into your patient schedule to minimize wait times. There is nothing more detrimental to patient engagement than long wait times. Patients have expectations and have frequently had to schedule much further in advance of their appointment date than they would have liked. Given the importance of social media in your reputation, and your total lack of control over it, you have to address all of this, and keep it on the radar. Although most patient satisfaction studies ask generic questions about wait and visit times, it’s worthwhile to do more focused analysis with a small patient group. Large studies often don’t really address all of the questions necessary for a practice to get the granular data needed to help. To solve these kinds of problems a ranking system of one to five stars will usually need a higher level of explanation and specificity. But don’t forget that all of this should be driven by the desire to improve both—patient and doctor satisfaction, with emphasis on efficient utilization of your time. The latter will have a concurrent impact on patient satisfaction (and revenue). Telemedicine, in it’s infancy, will certainly serve as a balm and possibly a cure to this situation, especially by involving mid-levels in the review of patient records (submitted by the patient) and their interaction by phone to deal with frequent ailments like colds, flu, etc. But it is going to require more clarity from payers and, in my opinion, more definition of the medical protocols. Regardless, you should look for practices that are engaging in telemedicine. And if they are not, ask why. I recently saw an advertisement from a large healthcare system pushing telemedicine of late; the ad read, “You can now eliminate the hassle of visiting the doctor’s office.” This was the first time I’ve seen this kind of diminution from a big player. But it certainly charts the future (oddly, while deriding the value an office visit!). Of course, there are other important factors in the patient engagement and satisfaction equation. More on those in a future blog entry. ---TOM ELLIS Tom is the Founder of www.FirstMEDPractice.com, a platform for resident and fellows entering the job market, that addresses key business of medicine issues related to vetting job offers and structuring a first practice. Over the past year or two I’ve spoken to a number of physicians who have left their current jobs, transitioning away in variety of directions. Some have moved into the “business” of medicine or joined med-tech firms. Others, complaining about the “corporatization” of medicine have moved to smaller, private practices. And, of course, everyone is aware of the growth of concierge medicine, as well as the steady flow of doctors to Functional Medicine or it’s more wholistic relatives.
Most have come from primary care, IM, or OB/Gyn. All have complaints and issues that led to their decisions. But one reason that has been echoing through medicine for over a decade now (and I always hear from them) is the inability to spend more time with patients. They chafe at the current formula that visits not exceed 15 minutes or less and are worn out by the way this plays havoc on their desire to have real patient relationships and the emotional and physical demands of seeing an average of 30-40 patients a day. I have tried to find out just who established the 15 minute rule, but there seems to be no evidence or study that supports it (and where did new patient visits and annuals fit in?). More likely it’s one of the holdovers from the HMO days, when employed doctors came under the control of bean counters. If I’m right, you can be assured there was little or no physician input. For physicians finalizing residency or a fellowship there may not be many options to make significant changes. And income is a major factor with medical school debt to deal with. But don’t agree to anything without doing some shopping and comparisons. You’ll probably see as many as 50 offers, and you have real leverage to get ALL the information you need to make a good decision. You need to understand the patient visit formula of a prospective employer and go beyond it to understand how this relates to your revenue stream, the scheduling process and the important issue of patient satisfaction. These key components of any practice need to be discussed and fully understood. Let’s start with the revenue piece. Request the average reimbursement for the top five codes you will use in your practice as well as the payer mix of the potential employer. With this in hand, ask for a history of the average gross reimbursement amount per patient visit over the last 3-5 years. Has it increased? Decreased? Why? What about the payer mix? How has it changed? Has the practice made any attempt to renegotiate pay rates (this would apply to RVUs as well)? Is there a mechanism to do so within the practice? Is there an IPN or other entity that would provide negotiating leverage? These questions will give you an idea about a practice’s attention to income. Now ask about costs. What is the cost for the average patient visit? Has it increased or decreased during that 3-5 year term. If it’s increased, what actions have been taken to minimize the increase? Who chases “costs” and is responsible for this extremely important metric? Your time is the way you generate income. What you want to do, obviously, is to engage with an employer who has a terrific net revenue per patient total. Compare this amount among the offers you receive. What you find may surprise you; for example, it may be that smaller, private practices are competitive and more with the larger employer groups. And if you have more revenue per patient visit, you may be able to adjust the 15 minute rule upward, and get more time in the exam room to develop the kind of doctor/patient relationship you want. An extra five minutes can be extremely rewarding. If all is running smoothly, and net revenue is being realized, try to find out what kind of salary or income a full-time doc in your specialty should expect. Compare this to your offer, or the salary your employer projects you can make when your practice has matured. Scheduling can play a very important role in all of this. And then there’s the issue of how all of this can impact patient satisfaction. In Part 2 of this blog we’ll address these subjects. ---TOM ELLIS Tom is the Founder of wwwFirstMedPractice.com, a platform for residents and fellows entering the job market that address key business of medicine issues related to vetting job offers and structuring a first practice. By Tom Ellis/FirstMEDPractice.com blog
Autonomy is a word that has taken on a life of its own in medical circles. Depending on who you talk to, it seems to be injected into the conversation surrounding many different aspects of medicine, clinical to operational to the business thereof. The generic definition always revolves around issues of “control” starting with the most basic: That a physician can implement their diagnoses and control the way he or she cares for their patients. This matter seems to come up more and more as medicine becomes more corporatized. However, when the desire for control comes up in other areas—especially those related to HR, staff oversight, scheduling, facility usage, payers, marketing, etc.—it seems that physicians may have the cart ahead of the horse. For over twenty years one of the resounding phrases I’ve heard is, “Doctors are terrible at business.” But I don’t agree. Physicians aren’t bad at business. They are just UNDEREDUCATED about it. Physicians are smart people. The rigors of med-school training are intellectually demanding. But there is little or no educational training that provides the basics of how medical practices work as required course work. I believe autonomy, defined as “control,” needs to be based on education commencing as early as possible, best before the final year of training, when the end of residency or fellowship is in sight. Rounding in the final year is a tremendous opportunity to examine, up close, the variety of different business models employed by different specialties and have access to the administrative types that are responsible for the operations of each practice. Almost as valuable, it gives the graduates a chance to discuss practice governance and how it’s deals with long range planning and implementation. Building this knowledge base is necessary preparation for fielding and analyzing the flood of job offers that will soon come. It’s the antidote to the anxiety when literally dozens of employers start making contact (most graduates receive at least 50 offers). Which brings us back to autonomy. True autonomy comes with knowledge. The path to autonomy starts before entering practice, by having the necessary knowledge to make a good first choice or employer and practicing environment, where business education can continue and be offered and continued. A choice that isn’t filled with anxiety due to undereducation on these topics In their busy schedules, residents and fellows, preparing for their first practice, shouldn’t overlook the importance of business education. It’s the building block of autonomy and a successful career.---TOM ELLIS Last week MD Linx published an article entitled “Work-life balance: Will physicians ever find it?” It provided a fascinating comparison between the productive hours of the “average workday” and 40 hour workweek and those of a physician. According to the survey they quoted, the average workday for the average employee equates to only 2.8 hours of “productive tasks.”
Of course those of a physician were huge in comparison, starting with the fact that few physicians I know work a 40 hour week. An interesting comparison was also made about emotional exhaustion and burnout; physicians are affected by this almost twice as much as ordinary workers. One of the expectations of physicians, as quoted, was that they have the expectation they will “successfully run a practice” including seeing patients, rounding, be on-call, deal with EHR documentation and handle CME requirements. And this list doesn’t include everything, of course. A great point is made that many factors can determine whether or not physicians can handle all of this, and be productive, given the constant distractions and change in workflow. If those occur, it will take more work time to get everything done, and that means elongated office hours, eating into personal time. The article stresses that this situation can become endemic and destroy any concept of work-like balance. The article goes onto list 12 “time wasters” that physicians should attempt to corral. This was an interesting list and as I thought about it some of these distractions are the kind of thing new employed residents and fellows should ask about as they evaluate job opportunities that they see in their final year. As it pertains to physicians about to enter practice, regardless of whether it’s as an employee or venturing into private practice, here were the most contentious listed and that I have seen. These will have a direct impact on the success (i.e., effective use of time) of, as the article says, successfully running a new practice:
More importantly, they will impact the attitude of the physician, and work against the excitement and energy young physicians bring to their first practice. And that might be more harmful than anything. ---TOM ELLIS A few years ago I was working with a client on a special project at a nearby hospital. They had been hired to take over a major area of patient activity, and a team had been assembled to handle both the transfer of responsibility from the prior contract holder, but also to address a large number of deficiencies that had caused the change.
My client had talked to a number of physicians in the group and assembled a group based on prior experience in these kind of transfers, people who had a significant history with the group and in handling the touchy issues that always arise when a hospital makes big changes like this. Besides dealing with patient care issues, there were lots of minor political issues too. The five of us assembled had never worked together but some were more familiar with each other than others. Although we had a few meetings that were highly productive, our time together was compressed. The client came up with a great idea—they hired a company that provided personality profiles to let us all get a better idea of how we would function together. What was our intra-personal dynamic going to look at? The results were highly illuminating: Some who I thought would be the best team players had a hidden, highly structured independence streak. Others proved to need a leader to function best. Finally, one of the most vociferous of the bunch showed to be painfully shy with people he didn’t know. The results helped quantify and structure how the personnel would best mix and be assigned to help complete our mission. Throughout all of this I kept thinking how much the definition of being a physician had changed over the last decade. Not one of the tasks we had touched a patient. There was an article recently in the NJEM that took up the need for new docs have more exposure to what they called “business skills”—leadership, teamwork and data analysis. Maybe every physician should take a personality test to see where they fit into all of the many new roles they are being asked to engage in (this excludes all patient activity). Especially since most of this new “business” of medicine is rarely compensated and can be a significant addition to the time spent away from a personal life. Although I’m no psychologist, I was recommended one platform that looked like an excellent way to start with a personal assessment: The Enneagram. This is markedly different from the personality test I took, going much deeper for a complete look that would work well for individuals, teams and organizations. The advantages of the individual analysis examine motivation, functional and dysfunctional behavior, compassion, and is focused on increasing productivity and motivation, among other characteristics. The emphasis is on self-discovery, personal awareness and personal discovery. The value to teams is in Enneagram’s emphasis on integration, re-channeling negative behavior, and establishing new avenues for communication. Impressive. So much so I’d suggest Enneagram as one of the more important aspects of business skills NJEM addressed. It would certainly have relevance to new doctors and old alike, and could be a very valuable part of building strong teams within institutions or practices. Worth checking out.---TOM ELLIS March 2019 For graduating residents and fellows the word is out: There are not enough of you to fill the demand for physicians in this country, and this problem is only going to grow over the next decade. No matter what can be done in attempts to adjust this equation—better use of mid-levels, telehealth, the move from volume to value, new med schools opening—no significant change will alter this trend in the foreseeable future. I recently received an interesting data sheet from the venerable recruiting firm Merritt Hawkins that plotted hospital inpatient/outpatient revenue generated by certain specialties. Not surprisingly, cardiovascular surgery led with $3.6Million, followed closely by invasive cardiology ($3.5M), neurosurgery (same). At the tail end of this list of ten were pulmonology ($2.4M) and non-invasive cardiology ($2.3M). That’s a lot of downstream income. Short story: Years ago I worked with two surgeons who had built a strong private practice augmented by an integrative platform that really captured all of their patients’ clinical needs (this was years before integrative had become the buzz word it is today). It was a huge success, almost pioneering for its time. Patient volume shot up. The hospital really noticed. Soon, in an effort to insure this explosion of revenue, the hospital approached my docs about coming on board as employed physicians, we demurred and started to gather information. Soon we got a good estimate of the downstream net revenue these surgical procedures generated. The hospital was clearly surprised when we presented this data, and we used this number to negotiate salaries far greater than the MGMA income figures presented to us. In effect, we got a little piece of the bigger pie. So how does all of this come together? There are some obvious touch points. First, in this world of diminishing hospital revenues, physicians with specialties that generate in-patient revenues are going to be absolute necessities for hospital success. Heads and hearts, ortho and gastro will continue to rule. And these types of doctors will be in great demand. Second, with the shortage of physicians growing annually, highly trained specialists will be in great demand. But it won’t just be them. All physicians will be in great demand. So it this a forecast for the perfect storm, the moment when all these forces combine to give physicians, graduating residents and fellows a new strength and leverage in negotiating relationships with hospitals, ASCS, ACOs and even insurance companies? When doctors finally take back some of the power they’ve given up? Some larger employers are already addressing this, creating multi-specialty groups where revenues are not just based on the old standard “eat what you kill.” They understand the value of recognizing and reimbursing physicians for their contribution to the total patient revenue picture. For graduating residents and fellows, I believe the time is now. There is no need to act like a deer in the headlights when negotiating employment agreements. As the number of job offers they field grows from 50 to 100, they have the leverage to really examine potential employers and how they reimburse their physicians and negotiate with hospitals for a piece of the downstream dollars and see how they fit into all of this. It’s an intriguing time, with many changes on the horizon. All docs should be watching developments, but especially graduates.---TOM ELLIS III A few years ago I was called in to work with an OB having trouble with her landlord. A ruptured pipe in the suite above had caused extensive damage to her offices (they were flooded most of an entire weekend), and the damage—which included the typical wall/flooring soaking—had caused cabinets to begin to delaminate and done extensive damage to her wiring and IT systems. It was an insurance mess, complicated by her busy practice, and one other thing that I hadn’t known about in our early meetings.
Her often extremely hostile attitude. She was great with me, cordial, funny, smart. I had known her a bit socially, and we always had good conversation. I had been told she “could be difficult”, but marked that up to a very typical complaint I often head about doctors. Was I surprised. Dr. Jane (pseudonym) ran her office with little “emotional consistency.” Hot, cold, angry, happy, nice, mean, reasonable, unreasonable: She could cover all that ground, often in the same day. The staff was paralyzed. The simple issue of coordinating a complex insurance situation, involving her carrier, the hospital, and the tenant above morphed into a first, tense meeting. At the very start she lashed out at everyone and demanded not only “immediate” repairs, but restitution for downtime including payment for her staff who were unable to see patients, on top of her business interruption insurance. After the first 20 minutes I asked her to join me outside her office where I told her we needed to stop this meeting; to my surprise she said OK, we walked back into her office, where I asked for a postponement and she, much to everyone’s surprise, very cordially thanked the others for coming. As I walked down the hall in her office I stopped to look at a wall of photos of her holding newborns in the delivery room. There was an almost angelic glow that surrounded her in those pictures, and when you could see her full face the smile thereon radiated joy. Clearly this was what she relished about her practice—the interaction with patients. Everything else was just a chore for her. So over the next few weeks, as the repairs to her space began and patient flow got back to normal (she and I agreed this was something I best dealt with and I just provided verbal reports to her on most of the work being done) I was able to work with staff to try to build both bridges and barriers that would minimize the “emotional inconsistencies” and improve reporting and other processes to provide her with better ways to see what was going on in her practice, both financially and from an operations viewpoint. I beefed up the direct communication processes with her clinical staff so she got reports in advance on patient issues (especially post-partum). We looked at restructuring her patient flow with “OB days” and “Gyn days”, which smoothed out the schedule, increased her productivity, and almost eliminated patient wait times. This also opened up more time to chart, within the day, so she got home earlier. The big challenge was the back office. The administrator, who wore a “deer in the headlights” expression on her face most of the time, was the place to start. We developed reports that provided a better snapshot of the practice billing and operations costs, revenues, and drew out a chart that detailed who did what, answered to whom, and protected the staff from her outbreaks. We also began to escrow cash (she always complained of being broke). It took a few months, and consistent pep talks with the staff to buy in, but they did. And, of course, she began to change too. Her peace of mind was more evident. She smiled more. Slowly the relationship with her staff, and especially her administrator, became more based on the idea that everyone in the practice tried to support her real love—patient care—while minimizing stress that might be caused by operational issues. Best, she started to develop empathy as she better understood how things worked, and the dedication of her staff. Yes, there were still days when she went off, when her “emotional inconsistency” reared its head. But they were fewer and farther between, and the staff changed from being paralyzed to helping keep things on course. The flood from above would require extensive repairs, and the after all the damage was dealt with she had what looked like a brand new office, which the patients loved. Simultaneously the repairs we made to her daily operations and overall practice management were smoothed out, improved, and resulted in a happier, more productive staff. To this day I’m still surprised at the way a bit of water damage could cause such a profound change in the way her medical practice worked.--TOM ELLIS III A few years back I was running a healthcare company that was growing rapidly. Finding good physicians and nurses to handle the growth was a challenge—much of the market was dominated by a few big players who were also growing—but we had a great employment package and a new, state of the art hospital as our primary client/work environment. These among other things made us attractive. We also had high standards and a required work history that eliminated new grads or providers with less than 2-3 years of experience.
But over the growth years, in a tough seller’s market, we did find good people. Really good people. And we developed a streamlined on-boarding system that ran like clockwork under the direction of our practice administrator. Then, it all fell apart. And not due to anything we did. The large health system that owned our hospital client decided to consolidate credentialing, taking it away from its hospital members. The suits “downtown” decided it would be more efficient, and they would have more control over who was allowed to work at their facilities if everything was overseen in one office. The years we had spent building a great relationship with our hospital credentialing office were over. The people we had worked with for years had been replaced by faceless names who worked out of an office 35 miles away. And they were overwhelmed. Most of the individual hospitals had 3-4 people engaged in credentialing for the facility. The new office, with not many more people, now had over 30 facilities to credential. And to make matters slow down even more, the background checks became much more comprehensive, meaning now you were also at the mercy of medical institutions that were being asked to locate and send information they had to pull from their files. And they didn’t have someone just standing around doing this job. More slow down. What had been taking us a matter of weeks, now took months. Sometimes as much as 7 months. It was almost impossible for us to give prospective new hires real start dates, because we couldn’t get them from the main office. And to make matters worse, they mandated minimal use of temporary privileges which took away one of our options to get people working. And this was just hospital credentialing. Onboarding fell into disarray, and we started to lose a lot of good candidates because we had no control of this critical piece of the hiring process. Frustration levels were off the charts. Credentialing may be one of the most overlooked headaches in the process of finding good hires. It’s not just obtaining credentials to work at a hospital or ASC. Medicare can take up to 60 days, and only when you have Medicare in place can you apply for Medicaid, which can take another 60 days. Most of the private payers require you have your Medicare credentialing in place before they will credential you; the big players—Blue Cross, United, Aetna, Cigna, etc.—take time too, sometimes 60 days. Smaller payers can be better or worse. And there’s little you can do to move the process along, other than be a VERY squeaky wheel. Without becoming obnoxious. If you are part of a growing practice, looking to bring on new docs, NPs, APNs, etc., it would be wise to appoint someone within your practice to bone up on all things credentialing, developing a realistic timeline between start and finish of the process—Medicare, Medicaid, facilities, large payers and smaller ones as well. It may be the most critical piece of the onboarding process, and it’s surprising how few offices have a handle on it all. It can have a significant impact on cash-flow, of course, but also an impact on new hire satisfaction and confidence in practice operations, not to mention the overall operations of your practice if your new hire is coming to replace a provider or take on a new line of business or patient growth opportunity. Credentialing: You can’t live without it. Get control of this critical piece of growing your medical business.—TOM ELLIS III I’ve worked with a lot of practice administrators (often in a job called “office manager”). What has always surprised me is the variety of roles they play in their practices. Some are highly focused on a few tasks. Others have tended to play a catch all role, with the physicians and providers constantly throwing new responsibilities at them, often with problematic results. I’ve seen great relationship, well grounded, and others where administrator frustration and burn out was almost guaranteed. It’s too important a job to be part of employee turnover.
Here, for example, is a list of the myriad of jobs expected to be covered by the administrator at one practice I’m familiar with: Oversee IT—billing and EHR
Wow. All of this covered by one person??? And, of course, the doctors only want to pay $65,000/year for this position. With no benefits. I won’t even address the salary issue here. Suffice it to say as practice operational demands become more complex it’s time to reframe the hiring process for this key position. Focus on definition. IF you want to empower an administrator they have to know what’s expected and how the fabric of your practice fits together. My first suggestion would be to make a list of tasks that you need covered. You could start with the list above—there may be more that are specific to your operation. For example you may have multiple locations, constantly need locum coverage, credential in-house, or retail products as part of your practice. This kind of operational overview and breakdown will be invaluable in many ways. Treat each as a separate silo. Define what the administrator’s involvement will be in each. If you outsource billing, then just list what kind of reporting relationship the administrator will have with the physicians, as well as the role any physician might have with the billing company. Be sure to tie the administrator to each silo, with as much detail as possible. This is the kind of clarification that’s important to good communication from the outset. For the tasks that are 100% owned by the administrator, take the time to go over each job requirement with the other physicians, your partner, and even the mid-level clinical staff members who will be interfacing with the administrator. Make sure everyone is on board with the job description and how the administrator will interface with them. It’s important who needs to know what he/she is doing, how much they need to know, and when they need to know. I’ve seen a lot of confusion generated because this wasn’t spelled out. If you have existing relationships you want to leave as is, make this part of the job description, but clarify the administrator’s role, if any. And don’t forget the future—how you want the practice to grow, change and evolve over the next 2-3 years. Growth requires planning; planning takes time away from other tasks. And usually the administrator is a critical part of coordinating growth. Thinking through each silo will help you focus your own vision and awareness of your practice, possibly in greater detail than ever before. (A note on Compliance: Outsource the set-up, working with a HIPPA consultant among others. This is an area where the complexity and requirements are varied and changing. Don’t expect your administrator to be able to handle this extremely important area without help from an expert.) Now you’ve put together a comprehensive job description. When you interview address each silo. You may find a candidate who can’t personally handle every task within every silo, but has had experience outsourcing and knows how to work with vendors to accomplish what you need done. You’ll be hard pressed to find someone who can do everything, and you need to make a reality check as to what’s available on the job market, adjusting your want list around the best candidate you can find, and making adjustments to fill gaps. Just be sure to figure out who will be handling these tasks among your partners BEFORE you make the hire. You want a new hire to understand what’s expected of them, but also feel empowered to be involved in operational issues and decisions. Fuel their self-starter attitude. Empower them through a clear outline of where they fit. Pay a good, living wage. Good people, who you can trust and build strong relationships with aren’t cheap. If you look to your peers to provide salary comps, make sure you understand the scope of work their admin person is handling, then compare it to what yours is. And incentivize your new hire to do better, setting goals for them to achieve and be rewarded for. And remember that there are literally dozens of training programs that can help improve and increase any administrator’s job skills. Given the constantly changing face of healthcare, the ROI on these is very high. ---TOM ELLIS Managing clinical risks has always been a hot topic in traditional medicine. There is nothing that scares a physician or hospital like the smell of a malpractice action, and over the years the legal profession has fine-tuned the art of keeping providers out of the courtroom. A good healthcare lawyer can often be invaluable in monitoring the legal landscape to make sure that a practice is up to date in conforming with recent court rulings that might apply directly to the way providers interface with patients, hospitals and even their peers.
This form of risk management is highly sophisticated in traditional medicine. But that’s not the case in functional medicine. Most healthcare lawyers are unfamiliar with it. It seems every state has a different set of rules governing acupuncturists, chiropractors, nutritionists, nurse practitioners and many of the clinicians engaging in functional medicine. When it comes to NDs and MDs working in the field there is little legal case law that address their role and even less oversight from the states addressing them as functional medicine providers. This kind of risk management is critical to your practice and its future. But with no guidelines, what can you do? Here’s a quick overview of some of the basics. Research the state laws that apply directly to your specialty. Most chiropractors are already regulated, for example. Acupuncturists, too. But laws vary from state to state. Make sure you are in total compliance. Look to national organizations for advice and direction in this area. And if you are working with insurance companies and making claims for payment for your services, make sure that you are in compliance with everything they require so there will be no denials; make sure you see if the insurance companies require any particular limits of malpractice coverage, too. Luckily there seem to be ample sources of professional liability insurance for chiropractors, acupuncturists and nutritionists. Even nurse practitioners and nurses. If you are an ND, contact a malpractice company and see how and if you can secure coverage; there are more and more showing up. However, be sure to see what your state law requires, if any, and what the requirements are for insurance companies (if you are going to file claims). Did you graduate from a licensed school? That may have an impact on things. Check with the IFM. I would strongly recommend you insure yourself in a way that an MD would, with a policy with a “per claim” amount, a “total claims” amount, and secure one that has tail coverage. Monitoring the type of traditional coverage an MD has is a smart move. If you are working with an MD, look at the coverage they have. In terms of the coverage, match it, so there’s consistency among the doctors in the practice. If you’re an MD, you’ve already dealt with malpractice and probably know all you need to about coverage requirements. Regardless, talk with your professional liability insurer and make sure they understand the scope of your practice and that you aren’t paying for coverage you no longer need. There are some more pieces of the professional liability situation that you need to make sure you address, too. Functional Medicine is built around collaboration between various providers and physicians. Make sure that everyone you refer to has professional liability insurance (have them send you the “face sheet” from their policy), and make sure it’s current and active. At least annually contact your governing body (IFM, American Association of Nurse Practitioners, American Chiropractic Association, etc.) and see if there have been any court cases that might want you to change reconsider the limits of your coverage; your liability carrier should have this kind of information, too. Finally, document, document, document. Make sure your patient records are thorough and current. If you refer to other doctors or providers, make sure it’s part of the patient record, and for what reason. Make sure the patient clearly understands why you are making the referral, and if your role with them will change. Talk directly to the physician you have recommended about the patient and document the conversation. Then send a referring letter to the physician you’ve suggested and make sure to request an update on the patient after their visit. Follow up and document if the patient did or did not follow your recommendation. This can be a bit of work. Risk management is a big subject, but extremely important to your future. Remember that although functional medicine is still working through many of these issues, if you follow the safeguards traditional medicine has developed you’re on the right path to protection.--TOM ELLIS |
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