Episode 48: Small Operational Improvements With Big Impact

A lot of the work that ultimately affects a patient’s experience happens behind the scenes, but operations can be just as important to a practice’s financial viability as their patient care or marketing. Scott, Michael, and Jared discuss tips for providers to make operational improvements that can have an even greater impact during the pandemic. In this episode, you’ll learn opportunities for healthcare operations to be disrupted and ultimately more profitable in areas such as contracting with insurance plans, interactions with medtech companies, and referral agreements with primary care providers.

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Full Transcript

Announcer: It’s time to think differently about health care, but how do we keep up? The days of yesterday’s medicine are long gone, and we’re left trying to figure out where to go from here. With all the talk about politics and technology, it can be easy to forget that health care is still all about humans, and many of those humans have unbelievable stories to tell. Here, we lead the policy debates to the other guys and focus instead on the people and ideas that are changing the way we address our health. It’s time to navigate the new landscape of health care together and hear some amazing stories along the way. Ready for a breath of fresh air? It’s time for your “Paradigm Shift.”

Michael: Welcome to the “Paradigm Shift of Healthcare,” and thank you for listening. I’m Michael Roberts, here today with my co-hosts, Scott Zeitzer and Jared Johnson. In today’s episode, we’re talking about paradigm shifts in operating specialty practices. Guys, COVID-19 is really magnifying how important it is to get operations right. You know, we really think sometimes about what differentiates one practice from another. It’s just the quality of care. But you know, one of the themes on this show is how operations can be just as important to a practice as financial viability as their patient care or their marketing. 

So you know, a lot of the work that ultimately affects the patient’s experience happens behind the scenes, getting in touch with the insurance plans, figuring out what kind of contract you’re going to have with them, how you’re gonna interact with your med tech companies, and what kind of referral agreements you’re gonna have with your primary care providers. So all of those things in consideration and all of this in consideration during, you know, this time of the coronavirus, what tips do we have for providers on what they should be doing to make operational improvements during this time? Can they make improvements during this time?

Scott: I think I’m being forced to, Michael, and I go back to, like, what you just said about operations management. In the past, if you’re a successful practice, ortho, spine, neuro, cardio, etc., where you’re just so busy, and so most of the time, it’s really more about how quickly and efficiently can we get people in and out, and if people need to wait, they need to wait, we just gotta get them some service, so to speak. That’s changing on a lot of different levels. So number one, there’s a lot more competition out there, and COVID, like you said, it’s bringing out the competition. 

Not as many people want to go out of their houses now for care. The other part is, “Hey, I can’t have a waiting room stuffed with a ton of people anymore.” It doesn’t work. Not allowed. Not even legal, right? Not helpful to anyone. So all of a sudden, they’re starting to think about, well, how quickly can we get in in the back? And are we behind? Because if we’re behind, it really makes it more difficult for the people behind the glass door, shall we say. Now, it’s not just about the patient waiting longer, it’s about everybody being pushed harder. And I think it’s making a lot of people think more.

I actually just had to go see a doctor, and one of the conversations was, “Hey, we’re not gonna let you in the waiting room if there’s too many people. We’ll just ask you to go back to your car, and we’ll call you when we’re ready.” Makes sense, nothing wrong there. And I started laughing with my wife, who had driven me over, and I said, “You know, it’s kinda like going to a restaurant now. I’m waiting for my buzzer to go off so I can go in and get my food.” Isn’t that kinda like that? Isn’t COVID kinda bringing out that consumerization of health care?

Michael: It absolutely is. I definitely agree. I think that it’s bringing out that consumerization and it’s highlighting where some of those things haven’t been resolved yet. You know, just for another kind of quick patient story, like, my wife had an appointment that she had to do, just a regular follow-up appointment, and the person that told her to come back for the appointment said, “Hey, we’re just gonna do it online. Don’t worry about it. We’ll do a virtual visit. No big deal.” And so my wife, Becca, takes that information up to the front desk and says, “Hey, you know, this is the next appointment that I need to schedule, and it’s gonna be virtual.” And the person at the front desk was just, beside herself, that appointment could be done virtually. And so, you know, my wife’s catching some of the overflow of frustration inside the practice because somebody hasn’t communicated. Whichever direction that was, somebody didn’t communicate, and they were unhappy.

Scott: Yeah. It’s one of those things where there’s so much about telehealth that we talked about in a lot of these different conversations where…there’s a lot of telehealth conversations that could certainly make it easier on everybody. I was just talking to somebody who might need surgery, and they were talking about, “Man, it’s a lot easier now.” They just basically had a virtual conversation with a person who just takes their information. Like, we’ve all been there, you know, where you gotta go get surgery at a hospital, like, well, you’re gonna come in, and then you’re gonna wait an hour to just say your name and age. Right? “Okay, I really need to be doing that? Do I need to be in there for that? Can’t I give that to you over the phone?” These are the kind of things that I think, whether you’re a hospital or a practice, that they’re gonna have to focus on.

Jared: Yeah. And, Scott, I really think when we look at the reasons why, like you said, they’ve kind of been forced to, there’s no choice anymore. And instead of just saying, “Well, that’s something we could do,” it’s gotta be at the forefront of everything a practice does now, and there really isn’t a choice anymore. And so the implication of that is to prioritize everything to do with the experiences happening and to spend some time and realize that there’s a return on the investment of time of any time spent on things that you’ve hammered a lot on this program about calling the back, not calling the backline rather, but calling the frontline, the line that the patient has to call to schedule and see how clunky that process is. It doesn’t take much. I mean, I think that’s the irony of it, and I’m sure that’s one of the main reasons why you recommend this so often. It doesn’t take much once that actually happens for them to say, “Wait, this is screwed up. We have to change this. We have to fix this.”

Scott: You guys gotta be crazy. Right. What do you make our patients do? You know, I gave a talk at TOBI, The Orthobiologic Institute. It was a virtual meeting, which was interesting in itself, because we’re normally in Las Vegas for that, but I did it virtually. We had Dr. Scott Sigman, who’s been on our show, Dr. Jay Bowen, myself, and some folks at Doctor.com, and we were just talking about what to do to get your practice up and running again in a COVID environment. 

And part of what came out of that was everything that you kinda were bugged about from a workflow perspective or from a patient experience perspective that you didn’t have time to think about, because you were so busy just seeing patients. You really had to take a deep breath and stop and go, “What are we doing here?” Because you’re not gonna see as many patients. A lot of patients may not stay with you. If you’re not taking good care of them and they’re worried about getting sick, you may lose some of those patients. So you better get on your game, and that’s what I mean about COVID bringing out a lot of those fault lines are now, like, major. They’re not just like these little cracks on the wall. You’re looking up at the wall and go, “Whoa, I gotta do something about this.”

Michael: Yeah. Thinking through how that…you know, because a lot of what you talked through in that particular meeting, Scott, you were looking a lot at the marketing aspects of it too. And you know, marketing just has to look different, you know. Quick aside, like, we’re going through a process right now of working on our main company’s website, and I had, guys, I had like this wonderful photo collection, already picked out the stock photo vendor that we use, I had all the whole board set up, and this is gonna go on this page, the whole deal. 

And then it all felt so inconsiderate of what the world’s going through right now. Not a single person was in a mask, you know. Everybody was like gathered around, you know, doing that kind of cheesy, like, handshake thing, and it’s like, “Oh, no. No, don’t do a handshake right now. That’s terrible.” And so even if you just think of something as simple as the imagery that you’re using, how easy that is to overlook and have that on your website or whatever materials, but there’s a lot of different components that have to be, from the ground up, you gotta come up with a new plan for.

Scott: Yeah, no doubt it. And there’s a lot of stuff that you either could avoid or just didn’t want to deal with, etc. that you really do need to deal with. You’ve got to rebuild your pipeline. Every practice has a pipeline of some sort. Say, an orthopedic surgical practice is more procedural, “Well, I fell down and I broke something,” or “Jeez, I can’t take it anymore. My knee really hurts, and I gotta do something about it,” kind of a thing. And you gotta keep looking for new patients and you gotta keep rebuilding that pipeline. And part of that’s just, do a good job, take good care of the patient. But now we’re starting to see and say, “Hey, what’s the patient experience like?” So that when they mention it to other people, same thing goes with the people who are more pathology, long term.

We deal with a lot of pain management people, we deal with…there are a lot of people out there say, “We’re diabetic,” and you’re going over and over. Can you imagine going to a doctor’s office and constantly and consistently having to wait an extra 20 minutes just because, right? I mean, it’s like, “Why?” And now, I’m in a waiting room, say, with somebody, I don’t know, coughing, and it could be nothing more than an allergy, but I’m freaking out. Do you know what I mean? Someone’s coughing six feet away from me in a mask. Like, calm down. That’s why we’re all wearing masks, I hope. But all of those things are getting exacerbated again, because it’s not about, like, “Oh, just show some patience.” It’s like, “Well, show me some love too, practice. Why am I here? Why am I here for an extra half hour all the time? What’s going on?”

Michael: Yeah. And looking back through some of the recent episodes that…and I was off of a few of them, you know, looking back through, you had a lot of conversations about cutting out the middlemen, trying to reduce costs, trying to make a bunch of different changes within sort of the health care environment, so things like direct contracting, better benefit plans, reducing operational errors, all of those kinds of things that came up with some really wonderful guests that we’ve had over the past several episodes. So you know, along those lines, like, what are the other opportunities, you know, or what are the biggest opportunities really for change and disruption going forward?

Jared: You know, Michael, I feel like it’s just acknowledging, to start off with, that some of those things have little to do with the actual in-clinic experience of the patient, what we were just talking about. A lot of these things, when we talk about operationally, these things happen long before a patient ever sets foot in or before they call to even set up an appointment, right. I mean, contracting with health plans, with insurance, setting your rates, what type of referral patterns you have with other primary care providers or other community providers, those are all operational things. They all happen without a patient even knowing. It’s long before that. 

And there’s only so much you can optimize that experience. I mean, it’s worth all the time to do so to optimize what happens when the patient interacts with your practice, but there’s a lot that happens before that. And I think that’s the point that we were getting to over the last few weeks of interviews, because each of these guests were sharing things about operational errors that just nobody was identifying. Everyone just assumed things happen smoothly after a point. Jessica Walker, with Care Sherpa, was talking about how you just assume that you run an ad campaign and somebody’s gonna answer the phone quickly, and her data showed very much the opposite.

Scott: Her data was like, what was it, Jared? Something like three days to a week later, you get a callback.

Jared: Yes. And it wasn’t 100%. It was like maybe two-thirds of people even answered at all. I mean, there was like a 20% to 30% that didn’t even get a callback period.

Scott: Correct.

Jared: And you wonder why instead of asking the question of, like, how can we optimize our ad campaigns more, no, that didn’t have anything to do with the campaign. That was fully operational. That was an operational issue. And I think that relationship between marketing and operations just…it isn’t talked about enough. That’s come to light a lot with some of these last few guests, and I really enjoyed that, because if you can shore that up or reduce those operational errors, a lot of the other parts are just gonna take care of themselves.

Scott: No doubt about it. I remember when I first started, it was like, “Hey, I’m gonna build your website. I’m done.” Then it became, “I’m gonna build your website, and I’m gonna get people to call you,” but I’m done at that point. You know, I got them to call you. And I remember having conversations where we’re coaching people like…it’s one of my favorite stories. There was a friend of mine who I knew since med school, orthopedic surgeon, he went to go get a sports medicine fellowship. And you know, when you’re a young orthopedic surgeon, you spend a lot of time building up your reputation, you see a lot more people on a first-time basis, you might be working in an ER a lot. 

You’re just trying to build positive trust about yourself and your ability. And he told me like, “Man, I’m constantly running out, going to the ER, doing all the right things, I’m meeting with everyone, but I just don’t seem to be getting a lot of, you know, sports medicine type of patients, arthroscopic needs, that kind of thing.” And then as he was walking out the door, the person answering the phone said, “Sir, how many times do I need to tell you, we do orthopedic surgery, not sports medicine.” And his heart just went kerplunk.

And so it’s one of those things where it’s like you gotta train your staff better or that hand-off with, you know the Care Sherpa conversation, it’s just gotta fail. That’s what her company does. And then we had conversations with other people where they were just talking about like, “Hey, man, the whole middleman thing about Blue Cross Blue Shield, it works really well…for the insurance company, not for anybody else.” Remember that? That was…it’s like, “They’re making a lot of money, insurance companies. Don’t worry, they’re fine.” And then you go like, “Yeah, I get that.”

Michael: You know, going back to sort of that operations, like after that phone call, we worked with a client that we worked with them on a HIPAA-compliant kind of call tracking system. And so, you know, the primary thing that I came into the conversation with was like, “Yeah, look at how many calls we got.” And so we just had all this kinda call data available. As we kept digging into that data more and more, we started talking about things like, “Oh, wait, all of your people are having 30-minute phone calls.” And that’s because they’re on hold for 25 minutes. 

And like, things like this that you start kind of pulling out of what those systems make available. This average of maybe 30 minutes on the phone and then this was the percentage of calls that were just straight-up missed, you know, on a regular basis, it’s like, “Oh, no.” And this was something where, you know, it was very specific, like specifically related to a campaign. So it wasn’t just, “I had your number in my phone already and I just remembered to call you,” or something like that. It was a lot of, like, new patient opportunities that just fell through. So I mean, long before COVID, this was very definitely a problem, and like everybody’s saying here, it just gets more and more pronounced as everything’s going on.

Taking that in a different direction around opportunities, I definitely think a lot about…there’s been so many changes about sort of like the way that care is delivered. You know, we’ve talked something about virtual, but even recently, seeing some more decisions that various boards are making about whether you should have treatments and the hospital reimbursed more than they are, something like an ASC or some other sort of facility. And like, even that, you know, that standard is changing to where they’re coming back and saying, “No, like, the service is what the service is worth, not whether you do it in this building or whether you do it in this building.” So I think that that’s a really positive change for the patient. I think the hospitals are kind of stressed about that to try to, you know, really make that work out. But that continual push towards other facilities where the overhead is lower, you know, getting a Tylenol doesn’t cost $500, you know, because I’m at this kind of facility instead of the hospital.

Scott: Yeah, jumping on that, Michael, there’s no doubt that there are some very positive things that are coming out of this. I think telehealth, hopefully, is here to stay, for anybody who just had to go back to the doctor to do a quick follow-up and wondered why three hours of their day was destroyed. And I don’t mean they’re in the waiting room for three hours, I mean, like, look, they had to drive somewhere, they had to be seen, they had to go drive back. Plans had to be altered, and what was it for? Yep, you’re not coughing anymore. Glad to see it. Well, that’s terrific. And a big part of that, everybody, from a connect-the-dots perspective, is, “Hey, the doctor just wants to be paid for their time.” And telehealth was something that was not reimbursed prior to COVID at the same way. So what’s in it for anyone to do telehealth? Come on in if you’re not gonna pay me.

Hospitals spend significant amounts of money with their lobbyists trying to prevent what you just mentioned, Michael, of a procedure getting done not at the hospital, but say at the ASC or the doctor’s office, getting reimbursed at the same level as like if it was done at a hospital. Like, what’s the difference? If I’m getting an injection, I’m getting an injection. Why does it have to be at a hospital? And again, I go back to, like, people just wanna get paid. So if you’re not gonna get paid or you’re gonna lose money, which can happen, everybody, because of the way that insurance companies reimburse, etc., then why would you do it in the office? Well, as a patient, I don’t wanna go to the hospital. In COVID, you darn tootin’, I don’t wanna go to a hospital. How many people could have COVID? How many people don’t have COVID? Why can’t I go to an ASC? Why do I need…? And so on. And that’s…there’s nothing really positive to say really from COVID. I’m just saying like, it is allowing people to take a step back.

And we talked to a lot of people who are behind the scenes, like Jared’s saying, before even a patient walks in the door, about how people are reimbursed, how insurance plans are setting up, removing the middlemen. All of those things are critical because you go back to Michael that patient who had to wait a half-hour, like we set up an ad campaign, and they were on hold for 25 minutes. One, think about it, if they were on hold for 25 minutes, they would hang up the phone. They really need help. Two, I don’t think that the practices we work with are stupid, they’re just like, “Man, I don’t have enough people to pay for this.” Well, why not? Well, I guess the cut that the middlemen are taking is pretty high, because there’s not a lot left over for a lot of people to be taking better care of you. The walk-through isn’t as good. So there’s so many things that need to be attacked on so many different fronts.

Jared: Right, exactly. At one point or another, those costs and keeping them down is an imperative not just for the bottom line, but because it does affect other things. It does affect, yeah, the experience. It all just seems to come back to that. And another theme from recent guests about keeping costs down is that it not only makes the practice more profitable, but some providers actually consider it their responsibility to their patients.

Scott: Absolutely.

Jared: You know, if we dive into that a little bit, then that just adds another dimension about why it’s worth exploring options and making time for the operational behind the scenes strategies. And you know, some of those examples are things about like Carl Schuessler when we had him on and Doug Aldeen, a couple of recent guests, were both talking about specifically cutting out the middleman with health plans. And we got into speaking with both of them about whose responsibility is it to keep the costs down for the patient and why does that affect. And if you go into things with that kind of a mindset, if you’re even concerned about it at all, then you’re going to have a different response and you’re going to operate your practice differently. And for me, I don’t know if there’s a right or wrong answer to that about “Does the practice have a responsibility to the patient to keep down their costs?”

I do think it’s aligned very much with all of their incentives, right. Their incentives are to make the practice profitable, more profitable each month, each year, and they do have that responsibility to their patients. Absolutely. Do no harm. And I think it was Carl who brought up the fact of, that’s not just clinically or medically. It’s, do no harm financially, whenever possible. And so you could make the argument that it’s actually part of the Hippocratic Oath. Do no harm, including financially, whatever is within your control, whatever it’s possible for you to affect. And that really does just have you look at managing your practice in a whole different light.

Scott: Yeah, it really does. And what you just said, under your control. You know, I’ve talked to a lot. Like, we’ve talked to some primary care doctors, us as a group, where they’re just going, “You know, this doesn’t work. Like, patients are paying too much money. I’m not taking good care of them. Because I’m not making that much money either. So I’ve got to see them like a factory. I’m overcharging them.” And I’m putting that in air quotes if you’re listening. And because I’m not giving the care they need or the time that they need, so I need to think of a new paradigm. So we’ve talked to some people from that perspective, you know, the people on the frontlines. Then the people behind the scenes, like you just mentioned, like Carl, and they’re like, “You know, the insurance companies are doing great, but they really have no desire or interest to lower costs, per se, except how to get more profit.” They’re not really worried about, “How do we take better care of patients?” Like, yeah, they kinda do, but it’s more lip service. It’s more about, “Our job is to make more money for our stockholders.” And of course, you wanna take good care of patients, but do you see how that conversation went? “Our job is to make more money, but of course…” And I do think that some of…again, COVID, going back to COVID, it is bringing out like, “Hey, this is unacceptable.” This was unacceptable before COVID. It’s even more unacceptable now.

Michael: You know, one of the things that I think really makes an impact when we’re talking about costs and then all of the different operational issues that we’re talking about, there’s a level of efficiency that I really think it helps the patient out, it helps just with timeliness and all of those sorts of things, but also better care. And I used to be somebody that just really disliked dealing with systems, dealing with having to construct those plans, that you kind of follow as often as you possibly can, right. But that level of efficiency is definitely been missing from health care for quite some time, and I think that that’s one of the things that, you know, you talk about, like, what the obligation of the practice may be to the patient. 

If they’re more efficient, I think you’re keeping the costs down for the patient and you’re likely getting better profit on that too. And I’m saying that as like not the person that has to go through and figure out how to implement all that efficiency. But that is like a big factor in all of this, you know, and it’s hard to set up new efficiencies when everything’s radically changing. But I do think that, you know, one of the things, again, that we’ve touched on several times here is we now have the chance to rethink things and that we don’t have to be locked into “This is the way we’ve always done it.” And so if we can really keep focusing on “Well, what’s the most efficient way for everybody to benefit from this,” it just really changes how that whole interaction can happen.

Scott: Yeah. And I think you throw into that mix, and I agree with you 150%, but you throw into that mix the fact that a lot of rules were relaxed. Yes, you can get reimbursed, I’m talking telehealth now, the same way as if somebody walked in the door. And of course, why wouldn’t you? I mean, what’s the problem, man? I just need a follow-up. You talk also about the craziness in terms of, if you do have a medical degree in the United States and you’re state-certified in the state of New York, you gotta go get state-certified in New Jersey. Now, I don’t think there’s much happening differently in the area of, I’ll make it up, orthopedics, between New Jersey and New York. And I do get that worst in only 50 states and X number of territories. Sorry, guys, I don’t remember. But some of that stuff is just “Well, that’s the way it always was.” And then when COVID hit, it was like, “Hey, if we need New York docs to take care of our patients, New Jersey, so be it.”

Those rules are now rescinded. That’s how telehealth rules were, you know, for reimbursement. It’s like, “No, they don’t need to come in. You could see them at home. Don’t worry, we’ll pay you.” And then, all of a sudden, we started talking to a lot of doctors where they’re like, “Hey, there’s still some stuff where I don’t feel comfortable with telehealth. I get it. In COVID, I’ll do what I need to do and adapt so I don’t hurt anybody. But here are some things that I could definitely do from a telehealth perspective that there’s no reason I shouldn’t do. Here are some procedures that I used to be doing only at the hospital because I had to to just get paid.” That maybe those rules are getting relaxed where it’s like, “No, just do the injection in the office. What’s the problem?” Those kinds of things. So I hope that some of those positive things come out as well.

Michael: In the midst of COVID-19, I really hope that, on a lot of different levels, we get to hit the reset button.

Scott: Me too.

Michael: And set up a new…what is the new paradigm? The paradigm shift, you know, that’s beyond anything that we had expected when we started this show. That’s for sure.

Scott: You got that right, yeah.

Michael: Guys, thanks so much. I think there’s a ton of other things that we could talk about just from this one point of operations and how that affects health care in general. We’re gonna wrap for today. But again, I think that that’s kind of our main theme of the show, like, where’s the reset button on how care is going now, and what can we expect from care going forward? Thanks, guys.

Scott: Take care, everybody.

Announcer: Thanks again for tuning in to the “Paradigm Shift of Healthcare.” This program is brought to you by P3 Inbound, marketing for ortho, spine, and neuro practices. Subscribe on iTunes, Google Play, or anywhere you listen to podcasts.