Doctors Work to Balance Business of Medicine with Patient Care

Believe it or not, there are some physicians out there who only want to practice medicine, the noble profession to which they've dedicated their entire lives.

For some reason, claims coding updates, haggling with insurance companies, monitoring the new walk-in clinic across the street, recruiting new partners to the practice, and developing relationships with referring physicians don't interest them.

Depending upon who's talking, these medicine-only physicians represent either a dying breed or a growing trend.

David R. Neiblum, MD, says these single-hat physicians are disappearing. "We're probably seeing it less so than in the past, where people used to go into practice and not worry about anything except seeing patients and doing clinical activities," says Neiblum, the managing partner at West Chester Gastrointestinal Group, an eight-physician practice in West Chester, PA.

"Now, if you are an owner or a partner in a practice, the business part of it becomes large depending upon your role in it," he says. "So much has changed in healthcare with reimbursement issues and having to worry about increased costs and decreased reimbursement. There is much more of a focus on what we are allowed to do, how to code properly, how to stay in compliance with Medicare regulations, and so on. There is so much more bureaucracy and governmental intrusion and rules that we have to be cognizant about, not just practicing and winging it. You see a patient and you have to know 'are you coding a three-level office visit or a four, and if you code a four can you prove you did that much work?' "

Kenneth T. Hertz, a senior consultant with Alexandria, LA–based MGMA Health Care Consulting Group, is in the other camp, claiming that younger doctors are more inclined to shirk their business duties.

"One of the things we are finding is that a lot of the young docs coming out of school want to go into practice and do one thing: practice," he says. "They don't want to deal with the business side. They don't want to deal with governance issues. They don't want to deal with any of those issues. So, what is happening in some of the practices we are working with, the senior docs are asking ‘what can we do to get the younger docs to get interested in the business side of the practice, the things that need to be done to keep the practice going?'"

To some extent, Hertz says the negligence starts in medical schools. "The business side is something that is simply not talked about in medical school," he says. "In medical school, you 'learn how to be a doctor.' The issues related to running a practice, to how do you code and document properly, to how do you deal with personnel issues, are not talked about."

Because physicians make money when they're practicing their highly skilled profession, it's understandable if they don't want to waste time on less-profitable distractions. But, Hertz says, physicians in private practice have to accept that they are businessmen as well as healing professionals, and that both the clinical and business sides of the practice come with important responsibilities.

"There is the notion of the more time you spend practicing, the more money you make, sure," he says. "But as a business owner, you have certain responsibilities. In that sense, running and owning a medical practice if you are in private practice is really no different than owning the UPS store."

Understand management vs. governance

Hertz says it's also important to make a distinction between the physicians' roles in the management and the governance of the practice.

"Running the practice is management. Physicians don't run the practice. They provide the governance for the practice," he says. "It is their responsibility to set the vision, set the direction, and set the policies. But they hire people to manage the practice."

Hertz says it's critical to spell out the business- and governance-side obligations to new physicians before they're hired.

"In the interview process, when a practice goes to recruit new docs, it is where they have conversations with them, and they discuss what is going to be involved in being part of the business," Hertz says. "'Dr. Smith, you are going to be expected to serve on the board and attend meetings and help market your practice.' If the candidate says 'I'm not interested in that,' you can decide to hire the doc and run into upset down the road or you make a decision that maybe this doc doesn't mesh with the practice."

But in this age of physician shortages, perhaps your practice can't be that choosy. So, be flexible, but also be clear.

"If we find Dr. Jones is absolutely perfect in every way except that he says 'I just want to be an employed doc, I don't want to be an owner, I don't want to do this, that, and the other thing,' it is incumbent on us to be creative and find a way to make it work if we think that Dr. Jones will add that much to the practice," Hertz says.

"Laying out expectations is appropriate. A lot of practices get into trouble when they don't. But by the same token, the idea that it's business as usual is not what today is," he says. "Today it's 'how can we approach it differently? What can we do to make the situation work for us and the candidate? Now is the time we have to be more creative in how we deal with these issues.'"

Consider compensating business responsibilities

Neiblum says the up-front discussions about business responsibilities during the interview process have helped West Chester Gastrointestinal Group avoid friction down the road. New doctors need to know that it's not all going to be Marcus Welby.

"Talk about the business end and how much they are expected to be involved," he says. "Certainly if they are not going to be actively involved, they still have to know about it and keep things in mind and know how to code properly and how to be in compliance with regulations. You can't escape it entirely. Even if you are not going to be a big decision-maker, you have to be aware of them."

Neiblum says West Chester Gastrointestinal Group compensates him for taking extra time to address business issues beyond his normal practice schedule.

"We have a good staff who do most of the things, and that is 90% of the battle, and I keep an eye on things globally, doing some things on my own but often delegating," he says.

He warns, however, that sometimes it's possible for practice partners to be too involved in business operations.

"We have a good structure, but maybe a little too much of the too-many-cooks-spoil-the-brew mentality," he says. "On some things, it's best where I would just make a decision and let's move on. Sometimes we sit down and say this is what we want to do and all of a sudden you start getting dissenting opinions and it becomes a big issue when before it wasn't. But besides that, the structure is pretty good."