Episode 7: The Practice’s Backstage Evolution

It’s helpful to know what goes on behind the scenes at your doctor’s office to understand the right conversations to have. Terry Leidner gives a glimpse into her backstage world as practice administrator for Ridgewood Orthopedic Group and what it takes now to help patients navigate the new landscape. Managed care, mandates, and pre-authorizations are only a few of the challenges, but understanding how hard the practice management team works to make care happen can empower patients to make the right requests and no longer feel helpless.

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Full Transcript

Announcer: It’s time to think differently about healthcare, 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 healthcare is still all about humans, and many of those humans have unbelievable stories to tell. Here, we leave 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 healthcare together, and here’s 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 with my co-host, Scott Zeitzer. On today’s episode, we’re talking to Terry Leidner, the Practice Administrator for Ridgewood Orthopedic Group in New Jersey, and we’re talking about the changes that she’s seen in the process of running a practice.

Hi, Terry. Welcome to the show.

Terry: Hi. Thank you, guys. Happy to be here.

Scott: Yeah. I’ve known Terry for quite some time, probably longer than Terry or I would like to admit. I’ll probably say something like 20 some odd years. Is that right, Terry?

Terry: That is correct. Yes.

Scott: Yes. I knew Terry originally as a young salesperson when I was selling orthopedic implants and I was helping my boss take care of this particular medical practice and I met Terry back then. I think Terry at the time was five or six years old.

Terry: Yes.

Scott: How long has Ridgewood Ortho been in business? How long have they been taking care of patients?

Terry: Well, we’ve been taking care of patients in this location from 1981. We went through a couple different iterations and became a partnership in 1998. So we’ve been doing business as Ridgewood Orthopedic Group LLC since 1998.

Scott: Yeah, that’s quite a while. So quite a bit has changed over the years. From your perspective as an administrator for this group, first of all, just let our, everybody know. Currently how many orthopods are in there? How many PTs do you have? Like, how big is this practice?

Terry: Right now we have seven orthopedic surgeons. We have a pain management of, physiatrist. We have five PAs. We do not have any ancillaries.

Scott: A pretty decently sized group. Ridgewood Orthopedics is in northern New Jersey in a nice area. From your perspective, what are some of the biggest changes you’ve seen over the years?

Terry: Oh my goodness. The changes are tremendous. When I started working here, there was no managed care. Nobody knew what managed care was, nobody was in managed care. Then it sort of burst onto the scene, onto the scenes and we joined everything as everybody else did. And then we realized that managed care is really not all it was chalked up to be and we started going out-of-network with a lot of insurance companies.

That was a big change way back when. And now it’s just an issue of reimbursement and competition, patients not understanding their insurances, not understanding the restrictions, patients becoming more demanding because they don’t understand the restrictions. And as technology changes, like for instance Mako, there’s no reimbursement early on for Mako and you just have to kind of deal with that.

Scott: Mako, for people who are not in the orthopedic business, Mako is a type of robotic system I think by Stryker if I’m not mistaken. And so, here’s this new technology for robotic total joint replacement and a lot of insurances weren’t paying for it originally. A lot of the insurance companies were saying, I’m not sure if it’s worth it for the patient, from patient benefit perspective, from our perspective, etc.

And so initially you guys had to essentially deal with the cost differentials there. That to me, you know, over the years, insurance certainly in terms of compensation and then how patients deal with all those insurance changes I’m sure is a lot. I think everything for me, tell me if you agree with this.

What about referral patterns? Have they changed a lot with the competition too?

Terry: Well, no. Because we’re in Bergen County, New Jersey, and it’s a relatively close-knit area, we don’t really get affected by referrals. We were out-of-network for a long, long time. The last couple of years we went in network with a few companies. We don’t really have to deal with referrals.

Scott: That’s something that’s interesting because when I deal with a lot of practices, when we do their marketing, referrals are a big part of the conversation. So that’s something where you may be a bit of an outlier and lucky for you. That’s great.

Terry: We have a bigger problem with authorizations and pre-cert. That’s where we spend a lot of time and effort and staff trying to get our surgeries pre-certed, our EMGs pre-certed, advanced imaging pre-certed, and that’s something that we didn’t have to deal with years ago.

Scott: Yeah. So precertification has got to be a major thing. About how many staff members do you have just working on that?

Terry: I have two, but all they do is pre-cert and pre-authorizations.

Michael: Incredible.

Terry: And then I have three surgery schedulers and they have to double check that every single surgery has been pre-certed or we’re gonna be stuck holding the bag for that particular surgery. There’s a lot of staff involved just to meet the requirements.

Scott: Yeah. You know, it’s interesting because I was talking to Michael a little bit about, I’m very used to the backend, you know, having worked with a lot of practices, having been back there and seeing a lot of the pressure back there. You have a child who has a chronic condition, you’re in offices a lot. And you see it from the other side where it’s like, “Why can’t I just be seen?”

Terry: Right.

Michael: Right. I’m interested in, like… you guys are going through all this process of trying to work with the insurance companies, get everything lined up the way that that it needs to be. What is the patient experiencing during that time frame? Are they hearing that, “Oh, we’re having trouble with this insurance and we’re not sure exactly when this is going to get lined up?”

Terry: Well, that the patients, I think, unfortunately they experience an awful lot of frustration. They want to have a surgery, they want to have it next week and they can’t because the insurance company is just not gonna get back to us soon enough. If our documentation on some insurances, we found the other day that if we don’t have, say one particular word in the documentation, they will not authorize the surgery, whatever their particular word is for that particular surgery, which is totally ridiculous.

And we will say to the patients, you know, “We’re trying. We will get it, we will try.” As a last resort, we always tell the patients, “Call the insurance company because you are their client, and if you scream and yell, perhaps we’ll get this done.”

Michael: Yeah, we’ve actually… It’s funny you say that because we’ve been the screamers and yellers before to try and get things done. And it’s interesting from, we just were recently in a chat about healthcare not long ago and I was talking about how, you know, the average patient doesn’t necessarily know all the different people that have to work together in order to make a surgery happen, in order to get something, you know, like this actually accomplished.

And so there is this feeling of helplessness that can kind of creep up because you don’t know who to go to. And I think what’s, I’ve been surprised by the further I’ve gotten involved in healthcare and just understanding all the players, is that oftentimes there are many people that can feel helpless in the process and end up kind of banging their heads against the wall just to get the care that the patient needs.

Terry: Yes, yes. And as the government comes down with more and more demands on how we perform our services, it’s more frustrating on everybody’s end.

Scott: Just from the big picture perspective, a patient with what I’ll put in quotes, air quotes of good healthcare coverage, they just expect to go in and say, “Hey, I’m sick. Fix me and of course my insurance will pay for it minus a deductible. Like, what’s the problem?” And then when you go behind the scenes, you’ll find out like, “Well, you didn’t use the right word or all of these things need to be checked off.” And I don’t think insurance companies, so if anybody from the insurance business is listening to this, are evil or anything. I think they’re just trying to make sure that, “Hey, this is an appropriate surgery,” and then there’s all these unintended consequences that occur because of it as well. But it is a lot more complicated than just, “I showed up at 11:00. I don’t understand why I wasn’t seen.”

Terry: That’s exactly right. That’s exactly right.

Scott: Because you’ve got, you said seven orthopods. I forgot the total number, but we’ll say 10-ish, 10 to 12-ish. And then how much support staff back there?

Terry: I have 15 employees.

Scott: That’s a lot.

Terry: That’s a lot. There are MAs on the floor that help the physicians, because now that we’re in a world of EHR and we’ve got to do documentation and we have to meet, it was originally PQRI and then meaningful use and now bundled payments. We have to meet all the criteria and all the documentation. The work that goes in to the patient’s visit, the smallest amount of time is probably when the doctor sees the patient.

Scott: Yeah, I think that’s really a very incredibly insightful thing that that is a very difficult balance. Whether it’s a one or two-person practice or a larger group like your own, and I can only imagine like if you’re over at, you know, say a Kaiser Permanente or something where just how many people are in support staff and how many people are just making sure that the 11:00 patient gets seen at 11:00 and that everybody gets paid and everybody gets taken care of. There’s a lot of moving parts, to put it mildly.

Terry: You’re absolutely right. It was much easier way back when, when I started. The patients came in, we bill the insurance company, they paid us, they paid whatever their co-insurance was and that was it. Now we have to make sure that, one, we can see them, two, we’ll get paid for whatever services they need because we preauthorized it, we’ve done whatever we’ve had to do, we’ve documented exactly what they wanted, we’ve got all the data metrics that the government wants us to collect and then we want to take care of the patient.

Scott: That brings up a really interesting topic just along patient expectations, because so much has changed regarding what needs to get done so you can take care of the patient. Forget about what their healthcare issue is, right? There’s so many cause things. What’s going on with the patient and how you see their expectations?

Terry: I’m not ever sure anyone will agree with this, but I think that the patients have become more demanding, and it’s not necessarily their fault. They don’t understand their insurance plans. I mean, who reads the booklet that’s 300 pages long? They don’t read the booklet. They don’t understand there are things that are not gonna be paid because it’s just not in their plan and they don’t know that and they never figure it out until they really need whatever that service is.

Scott: So when they come in for that service, so a patient comes in and they’re told that, you know, that they’re gonna need a particular type of procedure. Is that something like where you walk them through like this is what’s gonna get paid and this is what’s not gonna get paid or you really don’t know, you can only get so far down the road with what’s paid and what’s not?

Terry: On history of other patients having similar issues, we can generally guess, but the information is not always out there. For instance, we’re not in network with Aetna. That’s the one company we decided not to be in network. Now, if a patient comes in and it’s an out-of-network patient and we’re trying to help them and say, “Okay, this is what your responsibility is going to be.” Because we’re out-of-network, Aetna won’t tell us. So now it’s out of our hands. The patients have to call and try to get an answer out of Aetna. And we had…

Scott: That’s because they don’t know what they’re really doing to be quite honest.

Terry: That’s right. We went through a patient last week who was Aetna who really wanted one of our doctors to do a surgery. He’s got some medical issues, he’s a bright man. He researched this and researched this. He said, “I want your doctor to do my total hip. I don’t want anybody else.” But the poor guy, he’s got a $30,000 deductible. Right.

Scott: Wow. I can’t even fathom a $30,000 deductible.

Terry: That’s right. So he’s gonna be on the hook for a lot. And as much as we want to help him, we’re constrained. I mean, we can’t just…

Scott: Yeah. Totally, you’re right. Sure.

Terry: …we can’t say to him, “Well, we’re gonna write off your deductible.” We don’t do that. We can’t say we’re gonna write off your co-insurance which is 50%. We can’t do that either. But we want to help the guy.

Scott: Sure. And, you know, from that perspective, it is something that, it’s always going to be this balance between, you know, frankly being profitable, I mean, that’s why you’re in business, everybody wants to make a living, while you’re taking good care of patients. Do you ever find yourself on the phone basically saying like, “Look, this guy wants to be here, but we’re gonna refer you out to somebody else because this is what’s best for you from an affordability perspective.” Has that phone call happened quite a bit as well?

Terry: Oh, I had to do it the other day with this gentleman.

Scott: Yeah, I can well imagine.

Terry: The bottom line is this fellow may actually have us do his surgery because there’s nobody around here that he wants surgery by.

Scott: Wow. For this particular condition.

Terry: Mm-hmm.

Scott: Yeah. This is not the first time I’ve heard this conversation occur where I have a very specific need, this particular surgeon is very good at it, has done it quite often. I mean, it’s the kinda, I get questions all the time from relatives, because I’ve been in the business, when anybody has an Ortho or spine issue, you know, magically I’m gonna be able to find them somebody. And I always say like, “Look, I really don’t know your particular area. But that being said, some really good questions are, do you do the procedure a lot and how often do you consider a lot? And how does that compare to other people?” And all those kinds of questions come up because the more you do it, the better you are at it in general.

Terry: And it’s kind of funny because we found one of the things that make frustrates our patients more than anything, it’s such a silly thing, but when we go to make an appointment for them, the first thing we have to ask them is, “What’s your insurance?” And they’re angry. “What do you mean? You only care about my insurance? You don’t care about me.” “No, that’s not true. We’re trying to look out for you.”

Scott: Yeah, it is interesting. I’ve coached a lot of practices about how to ask that question over the years, how to set appropriate expectations, and I will say everybody, I’ve been up there. It’s a very well-run practice and they do a good job of it. It’s why we have Terry on the phone. It is tough, I mean, plainly put.

Terry: Thank you for that.

Scott: My pleasure. Go ahead.

Michael: Terry, we’ve talked about, a lot about how things have changed and how much more difficult it’s gotten. Looking forward from here, what are your expectations around the challenges? Is there a way for the systems to get more streamlined and for things to get better or do you think that running a practice is just going to get harder and harder?

Terry: I think a lot is going to depend on what happens unfortunately politically, which you know, gets in everybody’s face. But right now I feel that unless you continue to grow or join forces with other established groups, that you’re going to be left by the wayside. I don’t think the mom and pop shops that all the patients really love are going to be able to survive. I see the insurance reimbursements going down, going down, where other things coming into play where maybe you can make ends meet, the bundle payments that are out there that are supposed to improve outcomes and supposedly improve efficiency and really just require more documentation, because we’re all good doctors anyway. But the biggest thing is we’re just going to have to get bigger.

Scott: Yeah. Like, become bigger, more efficient. We’re not gonna make as much per procedure, but we’ll have more procedures kind of a conversation and we’ll streamline the process.

Terry: Having more procedures doesn’t really help the bottom line, because the more patients you see and the more procedures you do, there’s an increased cost associated with that. There is really a very fine line. I think that the EHR system, the whole, all of the systems that are out there could be more user friendly, could really help you become more efficient. I don’t believe that that’s the case right now. There’s not a single person I’ve ever talked to that loves their EHR.

Scott: Yeah. It’s funny that you bring that up about electronic health records systems, the EHR. I haven’t either. And I’ve met with a lot of electronic health record companies and they are, you know, really striving to do better. I also think that if you could somehow, and, I mean truly anonymize in a HIPAA compliant manner, a lot of the data points to better treat people, it may not be so much in a type of thing like orthopedics where it’s like, “Hey, I’m broken. Fix me.” But with chronic care, for sure, they talk a lot about it with diabetes and insulin management, etc.

I really do think from a future perspective, tapping into these EHRs somehow in an intelligent way and creating good data platforms, again, I’ll say it over and over, that are anonymized and clean so that we’re not getting into people’s patient histories inappropriately, there might be some help for that from a long term.

Terry: Well, it certainly can’t hurt because I think the way it is now, it’s kind of broken.

Scott: I couldn’t agree more. From my perspective as a patient when I walk in the door, I’ve got some baselines. I set an appointment for 11:00, I expect to be seen at 11:00. I expect for the doctor to talk to me for X number of minutes and I expect my bill to be paid mostly by insurance, and I’ve got good health insurance, and I would say most of the people in your area are like that. What percentage of people do you think are walking out the door where those expectations, I’m talking about from a billing perspective where they were so far off, and no matter what you did or could do, you couldn’t help them. Is it mostly like the out-of-network people that fall into this trap?

Terry: No. Actually, the out-of-network people, they understand. It’s kind of funny. Because we are out-of-network with so many companies for such a long time, we explained it to them as best we could. They knew they were coming out-of-network. This location, our community, they’re very educated. So that wasn’t an issue so much. Sometimes the patients, they don’t like paying their copay. They don’t like, you know, there are always outliers. Most of our patients are very happy. Most of our patients we don’t have any trouble with, with billing. It happens, but it’s rare.

Scott: That’s good to hear. I mean, it honestly is. My perspective on all this is I’d love to get some feedback when we’re talking to some other people. I can’t wait to get ahold of the person like, I know we’re gonna be reaching out to some patient advocate people who help take care of people in complex areas with complex issues like cancer.

I know we’re gonna be talking to some people about that. I know that we’re gonna try to reach out to some people from the insurance side as well because there’s a lot of frustration on this. I think another person we need to talk to, it might be an EHR person, an Electronic Health Records person. What do you think, Michael?

Michael: It surprises me more and more. One of the things that we’ve really been trying to talk about with this show, kind of a through line that we’ve been discussing quite a bit is, what is it that each player in the space can do to make things on people? And there are these limitations that you run up against where there isn’t something that any one person can do to fix all the things, right, like that’s gonna just completely make the patient experience smooth. I’m never gonna have to call my insurance company, I’m never going to have to call the practice back again, any of that kind of stuff.

There’s definitely gonna be that tension that keeps going. But you know, what is it that each person can do in the meantimes? I think, you know, talking to, to each of these different people is interesting. Terry, when you think about the best way to help the patient get through these things, like do you have any tips that you would offer patients as they’re trying to navigate this?

Terry: I think that if they had some sort of a complex something or other, not your everyday orthopedic thing, they’re almost best served calling their insurance company and finding out what their plan allows. That’s not an easy path though, because they, you know, we have had issues where something unusual is going on with the patient and the patient has proactively called the insurance company, but they get, from their card, they’re calling the member services side. So now we call the provider side, and the answer can be as far off as opposite.

Scott: Wow. Jeez. It’s really something. So I think my takeaway for a lot of patients who may be listening to this stuff is, good information is great. You should make those phone calls and be proactive. You should talk to the doctor, the practice, about what was said to you. Keep track of who talked to you as well. I think that’s important. Because when these things happen, it’s not like the practice is battling the patient. It’s the practice is talking to a different person, and I don’t think the insurance agent is certainly trying to poopoo everything, they’re just trying to dot their i’s and cross their t’s and make sure that they make a living because apparently, they’ve got to make money too.

Everybody’s got to make, take part in coming up with this balance in this equation, and my best advice to patients is, hey, get good information from everybody and then when you get all on the same page, you’ll be in a better place because that is really what it comes down to. It’s not that simple. You don’t get to walk in the door anymore and say, “Hey, I’ve got a total hip knee.”

Michael: Terry, thank you so much for joining us today. This was really, it’s really helpful for me as a patient, as a father of a patient, understanding what’s going on behind the scenes. It helps me have the right conversations and make requests that makes sense, you know, of the provider, of the insurance company. I think that so many times, like we kind of mentioned earlier, like people do get to this state of feeling helpless, and understanding the landscape a little bit more really empowers a lot of people. So thank you for that.

Terry: Yeah, you’re both quite welcome. It was a pleasure.

Scott: Oh, it’s always a pleasure to talk you, Terry. You have a great day.

Terry: All righty. Bye-bye.

Michael: The “Paradigm Shift of Healthcare” is brought to you by P3 Inbound. You can find our full archive of episodes at https://www.p3inbound.com/resources/podcast.php, and recommend a guest or topic on Twitter @p3inbound.

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.