'Do not hesitate to seek help’: Balancing business, patient care in private practice
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Private practice rheumatologists face an increasing array of challenges as large, corporate and academic health systems become the norm for medical care, threatening to bump smaller entities aside.
In response, the American College of Rheumatology has established the Community Practice Council (CPC), a group of private practice providers tasked with defining this array of challenges and providing solutions where possible.
To build on these efforts and connect with private practice rheumatologists one-on-one, Tien-I Karleen Su, MD, FACR, first chairperson of the CPC, formed the Rheumatology Private Practice Alliance Summit, which brought together a diverse panel of experts to address the unique issues plaguing private practice management in the specialty.
Two experts on the panel include Aaron Broadwell, MD, of Rheumatology and Osteoporosis Specialists, in Shreveport, Louisiana — also an assistant professor at the Louisiana State University Health Sciences Center — and Adrienne Hollander, MD, a practicing rheumatologist and president of Trabecular Medical Group/Arthritis Rheumatic and Bone Disease Associates, in Vorhees, N.J.
At the Rheumatology Private Practice Alliance Summit, Broadwell moderated a panel session about the use of advanced practice providers (APPs) and other such practitioners in rheumatology care, while Hollander addressed general topics regarding operations of a private practice.
Healio sat down with Broadwell and Hollander to discuss these and other ancillary issues critical to preserving physician autonomy and delivering high-quality care to patients.
Healio: What are the two or three of the biggest challenges you face as the owner of a small rheumatology practice?
Hollander: Running a small rheumatology practice in the current health care landscape presents several challenges. First, the issue of declining reimbursement adds a layer of complexity to sustaining the financial health of the practice. As a business owner, navigating the intricacies of insurance reimbursement, negotiating contracts with payors, and ensuring a steady cash flow demands a strategic approach. It can be difficult to focus on providing quality patient care while grappling with the administrative aspects of managing contracts.
As physicians, our training primarily focuses on patient care, so stepping back to work on the business requires a conscious effort and strategic planning.
Healio: How do consolidation and the increasing corporatization of medicine impact these challenges?
Hollander: The consolidation trend in the health care industry poses a significant threat to small rheumatology businesses. The emergence of larger health systems and the potential exclusion from insurance company panels due to the size of the practice further complicates matters. Many payors, particularly larger insurance companies, may prefer to engage with larger health care entities, leaving smaller practices on the sidelines.
This exclusion can stem from various factors, including the perceived administrative complexities of dealing with smaller practices or a preference for negotiating with larger, consolidated health care systems.
In addition, if not excluded from a payor panel, smaller practices find themselves navigating contracts where the reimbursement rates are disproportionately low, making it challenging to sustain the operational costs of providing quality care. These low reimbursement rates can result in financial strain, hinder investments in technology or staff development, and, ultimately, compromise the overall viability of the practice.
Finally, smaller practices are competing with larger health systems for patients and staff. These large entities often have more extensive resources for marketing and patient outreach.
Healio: Your panel at RPPA addressed the topic of whether to grow as a practice. What are the advantages of growing a practice vs. not growing a practice?
Hollander: The decision to grow a medical practice involves careful consideration of various factors. On the advantages side, there are several compelling business reasons, but one of the most significant benefits is the sense of community among physicians. Having a network of colleagues to share clinical insights with and address complex questions enhances our collective knowledge and elevates the level of patient care.
In terms of business advantages, growing the practice can lead to a steadier revenue stream. This growth also translates into increased leverage with payers in the region. The larger the practice, the more negotiating power we have, allowing us to secure better reimbursement rates and favorable contract terms. This includes the potential for larger discounts and higher rebates. Economies of scale play a crucial role in the business aspect of growth. Sharing costs for resources such as billing, marketing, malpractice insurance, and human resources becomes more feasible, contributing to overall operational efficiency.
Importantly, as the practice expands, physicians can regain some of their time. This means less on-call duty and the ability to share patient responsibilities with colleagues. Moreover, growing larger can provide options on how the practice evolves. Although a larger practice may be more attractive for investment from private equity and hospital systems, thus offering new avenues for financial opportunities, it also may serve as protection from acquisition by larger health systems or companies.
This independence allows us to maintain control over the direction of the practice and the quality of care we provide. It is about finding a balance between achieving economies of scale and preserving the personalized, patient-centric approach that smaller practices often excel at.
Healio: And what are the disadvantages of growing?
Hollander: There are several drawbacks to scale up a practice. First and foremost, scaling takes dedicated work and time. It is not an instantaneous process — it requires strategic planning and a commitment to navigating the challenges that come with growth.
Investing in resources is a critical aspect of effective scaling. Systems need to be implemented and continuously monitored to ensure seamless operations. As a practice expands, the organizational culture may undergo changes, and preserving a positive and cohesive culture becomes a conscious effort.
It is important to invest in maintaining the values that make the practice unique and patient focused. With multiple locations, staffing and monitoring becomes more challenging compared to a single-location practice. Ensuring consistent quality of care and adherence to established standards across all locations demands robust monitoring and management systems.
The growth of a practice also introduces new legal considerations. Compliance with additional regulations becomes necessary, and staying abreast of these legal requirements is crucial to avoid potential legal issues.
Moreover, venturing into new areas, such as offering infusion services, can be risky. Inadequate planning or improper execution can result in financial losses. Shared decision responsibility, especially in a larger group, can pose governance challenges. Factors like corporate governance become more critical and require attention, which may not be as pressing in a smaller group.
Healio: What are some of the most common mistakes small private practice rheumatology providers make?
Hollander: One significant mistake is the tendency to run the practice more as a clinical entity rather than a business. Although we excel at using data and outcome measures for patient care, we sometimes fall short in applying the same principles to the business side.
Relying on gestalt rather than following the data of the practice can lead to missed opportunities for operational improvements, strategic planning, and financial management. Furthermore, doctors, being highly intelligent individuals, may sometimes hesitate to ask for help or work with others in the realm of business management. It is critical to assemble the right team for the business tasks and seek guidance and consultation from mentors and experts in business management.
Asking for help does not diminish our intelligence. Rather, it enhances our ability to make informed decisions and drives the success of the practice.
Healio: What are some of the solutions to those mistakes?
Hollander: We have implemented several strategies to ensure a more effective and sustainable operation. We have adopted a philosophy of continuous measurement for various aspects, including revenue cycle, provider productivity, and appointment scheduling. This approach mirrors our commitment to patient care, where we understand the importance of continuous monitoring, even when things appear controlled. This proactive approach helps us identify and address issues before they escalate.
Additionally, hiring the right team is of paramount importance. We have learned that assembling a team with diverse skills and expertise in areas such as finance, operations, and marketing is crucial for the success of the practice. Recognizing that not all aspects of business management align with our clinical expertise, we are not afraid to seek external help when needed. This could involve consulting with experts who bring specialized knowledge to the table, just as we would consult with specialists in patient care.
We are actively working to cultivate a workplace where physicians and staff genuinely want to come to work. This involves recognizing and appreciating the unique contributions of each team member and promoting a collaborative atmosphere.
In terms of growth, we have adopted a strategic approach beyond organic growth. For instance, we have expanded our capacity to support other practices that prefer maintaining their independent operations. By working collaboratively, these practices would benefit from economies of scale, streamlined billing processes, and more favorable contract negotiations. This approach will allow us to integrate practices without compromising their autonomy, fostering a network that benefits all involved.
In essence, our approach revolves around continuous measurement, fostering a positive workplace culture, assembling the right team, and strategically growing in ways that support both our practice and those we collaborate with in the health care ecosystem.
Healio: How do you staff a small rheumatology practice? What are some of the pitfalls to avoid?
Hollander: We prioritize a strategic approach that considers both the cost of running the business and the invaluable contribution of our staff. Although maintaining efficiency and lean operations is crucial, we understand that our staff is one of the best investments we can make. The right team, utilized in the correct way, not only makes the provider’s workflow smoother but also enhances patient care and improves the overall efficiency of the business side of the practice.
When hiring, we prioritize cultural fit over skill set initially. We believe that we can teach the right people how to perform tasks effectively, but it is much more challenging to teach the wrong people the values and culture integral to our practice. A cohesive team with shared values contributes significantly to the success of the practice and the satisfaction of both staff and patients.
Considering staff salary and benefits is another critical aspect of our approach. Although it is essential to be mindful of the budget, we avoid losing sight of the bigger picture. We recognize that a small gesture, such as a staff bonus, might not hold significant value to us, but it could mean a great deal to our staff. Understanding and acknowledging the individual needs and priorities of our team members fosters a positive working environment.
Healio: What were some of the themes you introduced in your RPPA presentation about maximizing the potential of APPs?
Broadwell: Maximizing an APP’s potential in the clinic involves a solid base of training, then allowing them to leverage their knowledge to help the clinic flow better and provide access to excellent care.
Healio: What can individual rheumatologists do to better utilize APPs and other professionals in their region or health system?
Broadwell: Individual rheumatologists can look at their practices and analyze how to incorporate APPs into their overall clinic workflow or modify workflows to assign APPs tasks that are the most clinically appropriate.
Communication is paramount in both setting expectations, education, as well as continuation of the physician/APP/patient dialogue. Patients should be made aware of what the APP’s role in the clinic is, and routine feedback to APPs regarding clinical decision-making is needed.
Healio: What are some of the obstacles to maximizing the potential of APPs?
Broadwell: Some of the obstacles include lack of knowledge and training in rheumatology from PA and NP programs, risk of loss of APPs to other non-rheumatology practices, and the decisions regarding supervision for APPs.
Healio: What are some pearls for helping rheumatologists be better businesspeople?
Hollander: In navigating the transition from a clinical focus to a more business-oriented mindset, we can consider several strategies. Firstly, it is essential to recognize that no one can do everything. Prioritization is key. Identify the aspects of the business that you are passionate about or feel are within your skill set and prioritize those. For the areas where you may lack expertise, do not hesitate to seek help, whether through hiring professionals, consultants, or engaging with organizations that specialize in health care business management.
Data analytics is a powerful tool in enhancing business acumen. By leveraging data, we can gain valuable insights into patient trends, practice efficiency, and financial performance. Implementing data-driven decision-making allows for a more strategic and informed approach to managing the business side of the practice.
Leadership skills play a vital role in business acumen. Developing leadership qualities can positively influence the direction of the practice and the team’s performance. This includes effective communication, strategic thinking, and the ability to motivate and inspire.
Finally, keeping patient care at the forefront is non-negotiable. Excellent patient care is not only ethically imperative but also contributes to the overall success of the practice. Prioritizing patient satisfaction and focusing on delivering high-quality health care services will inherently support the business side of the practice through positive patient reviews, referrals, and sustained growth.
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