Jennifer A. O’Brien, MSOD
When a physician gives an order to a nurse, technician, physical therapist, or pharmacist, the standard, appropriate response, albeit unspoken most of the time, is “Yes, doctor.” With practice managers, however, it’s different.
In an orthopaedic group, the purpose and success of the whole comes first. The orthopaedic surgeons who are partners in the group make the practice manager the keeper of that mission. So the practice manager may deny a surgeon’s request to add a clinic, if doing so will affect other partners and everyone’s patients because the number of exam rooms and other resources are insufficient to support it.
In today’s healthcare environment, it is essential to understand and optimize the role of the group practice manager. This series looks at what orthopaedic surgeons should expect from a practice manager.
Information and analysis
When partners are faced with a business decision, they should expect the practice manager to gather pertinent information and present the material in a way that helps the physicians have a meaningful discussion and make an informed decision. Some obvious examples include a pro forma for a new service line or additional physician, expenses for renovations, and a cost-benefit analysis for new technology. It also helps to have qualitative comparisons for some projects. Table 1 shows a qualitative analysis for four possible ambulatory surgery center sites.
In the operations of a practice, power outages, down servers, tornado warnings, mentally unstable drug seekers, temper tantrums, mishaps, and risk management breaches may occur. Although it may be a bit of an oversimplification, a practice manager needs to have the procedures and protocols in place to address all these possibilities—and more. The manager should also apply them consistently, as well as demonstrate sound judgment, communicate effectively and, of course, keep calm and carry on.
The manager must apply the same stability and consistency of policies and protocols in the ordinary, day-to-day operations of the practice. For example, in group practices, differences of opinion may be voiced among the partners on issues such as hardship write-offs for shared revenue streams (physical therapy) or the collections of copayments for patients who are also employees of the practice.
The practice should also have documented policies on issues that represent shared revenue or risk, and the surgeons can expect the manager to adhere to the policies consistently. In some instances, an individual physician may be displeased when the response to, “Why should my medical assistant have to pay a copay on her visit to my partner?” is “Writing off copayments for our employees and their dependents puts the entire practice’s health insurance coverage at risk, and we cannot do that.” The partners should expect the managers to give the same response each time.
The following data points are those that an orthopaedic surgeon should expect to receive, as an individual, every month from the management staff:
- top 25 physician referral sources
- top 10 workers’ compensation referral sources
- next available new patient appointment
- next available established patient appointment
- operational overhead
- net collections rate
- days in accounts receivable (A/R)
- percentage of A/R more than 90 days
- summary of noncontractual adjustments
- payer mix
- insurance A/R more than 60 days and more than $250
- patient responsibility A/R more than 60 days and more than $250 with no activity
All of the physicians may not look at this information every month, but it should still be provided for every physician, every month. See “Dashboard Gives You Big Picture” (AAOS Now, December 2009) for formatting, summaries, and definitions.
Healthy, steady practice growth is essential to serving the community into the future. The manager needs to help the physicians identify the needed rate of growth and participate in the recruitment as appropriate for the practice.
In some practices, the manager helps identify candidates. In all practices, the manager plays a facilitative role, presenting the practice in a positive light, educating candidates on relevant aspects of the practice, and getting a feel for whether the candidate will be a good fit for the practice. On behalf of the partners, the manager should communicate frequently with candidates and respond promptly to candidate questions and emails.
The manager creates introduction, assessment, partnership decision, and onboarding processes and ensures that these are applied with little variation to every candidate. That is, there is timing, protocol, and process for interviews, tours, CV review, subsequent visits, reference checking, partner discussions and decision, offers, contracting, and onboarding. Although every candidate will not go through the entire process, the manager needs to be sure every hire does.
Whether it is located in a small town, an academic medical center, or an urban environment, a healthcare practice is an essential community service, and the practice manager must represent the practice with professionalism, intelligence, and friendliness. Having the manager participate in community events, committees, work groups, and philanthropic organizations helps build the practice and enhances the practice’s reputation.
Vetting and comparisons
When a practice is considering a new vendor, service, advisor, or consultant or periodically evaluating an existing one, the manager should research several providers of the same services (billing, banking, clearing house), request proposals from each, and provide a comprehensive comparison so that the physicians or board can make an informed choice.
The manager finds the service providers, makes the inquiries, requests the proposals, checks references, and provides a comparison and recommendation. Comparing vendors using the table format shown in Table 1 will facilitate this process.
Organizational structure and accessibility
Recent survey results show that the average group practice has five orthopaedic surgeons and a 1:6 orthopaedic surgeon:employee ratio. Even if the practice defines itself simply as “orthopaedic surgeons who want to help patients,” the reality is that practices are healthcare organizations with many employees, each with roles and responsibilities essential to the overall mission.
Managing people is a huge component of the group practice manager’s job. The practice manager must establish and maintain an organizational structure that supports operational functions and achieves accountability. For example, he or she must ensure that the practice meets regulations and collects payment. At the same time, the practice manager must keep the accessibility and connections among employees, physicians, and patients close and friendly.
Orthopaedic surgeons and group practice managers also have the unique challenge of the matrix management of clinical support staff. The surgeon and the practice manager must comanage nurses, medical assistants, radiology technicians, cast technicians, and other clinical support staff. The working relationship between the physician and the clinical support staff must be both seamless and effective to support the patient experience, provide and document the diagnostics and care, and hold the clinical support staff accountable to the organization as a whole, as other employees are.
Jennifer A. O’Brien, MSOD, is a consultant with KarenZupko & Associates, where she is involved in helping orthopaedic surgeons recruit and select managerial staff.