Between ever-changing regulatory requirements, more time spent interacting with electronic health records systems than with patients, and a lack of work/life balance, physicians are burning out at an unprecedented rate. Yet there is hope that the next generation of women physicians can address many of the systemic issues that currently plague the field of medicine.  
	
	But the question remains: will they be given the opportunity to do so?
	
	When Diane Birnbaumer, MD, FACEP, emeritus professor in the department of emergency medicine at Harbor-UCLA Medical Center, was training to be a physician more than 30 years ago, she did a clinical rotation in otolaryngology with an older, well-established male surgeon. When she finished the rotation, the surgeon complimented Birnbaumer on her abilities, but also told her he wasn’t going to give her a good evaluation.
	
	“I immediately asked, ‘Why?’” she says. “He told me, ‘Women will ruin medicine. All you want to do is come into medicine and make it part-time. Women want other things. Medicine just isn’t your passion the same way it is for [male physicians].’”
	
	It would be easy to say that such a conversation is a relic of a time long gone, when men dominated the field of medicine and women were fighting just for the  opportunity to show what they might bring to the examining room. After all, today  about one-third of practicing physicians are women. And most of those, like Birnbaumer, have worked hard to advance in their careers.
	
	And more and more women are entering the field. Per the Association of American Medical Colleges, women today not only make up the majority of medical school applicants but are enrolling and graduating from medical school at a rate slightly higher than their male counterparts.
	Despite those growing numbers, Roberta Gebhard, DO, president of the American Medical Women’s Association, says that women still face significant challenges as they pursue their careers. While they may not experience discrimination quite as blatant as Birnbaumer did when she was a trainee, there are still significant hurdles they must overcome.
	
	“Even though we are seeing parity in the numbers, and we have for a couple years now, what we are not seeing is parity in pay for women or in the opportunities to advance in their careers,” she explains. “And it’s the kind of stuff that, over the course of a career, can really hold someone back from reaching their true potential.”
	
	With so many women entering the field-and looming fears of physician shortages-many observers hope that women will help to transform medicine for the better. Women today constitute the majority of physicians in countries with highly effective healthcare services. But how can healthcare fulfill the promise of women in medicine when women continue to face the same  systemic obstacles as previous generations?
	
	


	
	There is good reason why so many see women physicians as integral to solving many of  medicine’s problems. Research studies suggest that women physicians spend more time with patients, on average, than men-and focus more on discussions about preventative medicine.
	
	Female physicians are more likely to closely follow evidence-based clinical guidelines for care. And patients who see a female physician are less likely to be re-hospitalized within 30 days or succumb to their illnesses.
	
	While many of these studies are small,  the collective results suggest that, especially as medicine moves to value-based models of care, women doctors are a valuable asset to healthcare, says Susan Hingle, MD, MACP, a professor of medicine at Southern Illinois University School of Medicine and former chair of the American College of Physicians’ Board of Regents.
	
	“These are very targeted studies, but in multiple situations and in multiple specialties, we see that women physicians are showing better outcomes than male physicians,” says Hingle, who co-authored a position paper regarding improving gender pay equity.
	
	But studies also show the challenges women working in medicine commonly face. Timothy Hoff, Ph.D., a professor of management, healthcare systems, and health policy at Northeastern University, has been studying such barriers for decades. And despite the growing number of female physicians, many of those issues have not improved over time.
	
	Hoff noted in a recent Medical Economics blog post that women are more likely to experience work-family conflicts, less likely to be promoted or selected for leadership positions, and still experience high rates of sexual harassment. On the whole, they also make significantly less money than similarly qualified male physicians.
	
	“We have a fairly pervasive situation where physicians who are doing the same job are getting less money just because they happen to be women,” says Hoff. “That’s a problem. And these issues are deep-rooted and long-standing trends in this particular field that need to be addressed.”
	
	


	
	Many physicians, even women physicians, say medicine is close to or has already achieved gender parity, says Gebhard. These physicians refer to their own personal successes, the growing number of female doctors and medical students, and the fact that high-profile leadership positions, including the presidency of the American Medical Association, are now being occupied by women.  At times, Hoff says, it is difficult to see the discrepancies.
	
	“Doctors are some of the most successful people in the country,” says Hoff. “They work and sacrifice an awful lot to get where they are. In some respects it’s difficult for people-once they reach what they think is the pinnacle of what they see as their own hard work and perseverance-to understand they are not being treated the same ways as their peers.”
	
	At times, those very discrepancies can be used to make the case that medicine has become more female-friendly. In a recent New York Times article, three female physicians discuss how they make time for their growing families while continuing to work in medicine. One switched to a less demanding (and less lucrative) specialty where she could better control her hours. Another took a position as a hospitalist where she works predictable shifts. The third is working remotely, doing radiology scans from home.
	
	“The possibility that the establishment might allow these women to stay in competitive, highly successful, and lucrative careers was never mentioned in this piece,” says Gebhard. “Men manage to have families and stay in those kinds of careers without a problem. But here, these women had to make sacrifices. They had to give up potential earnings and leadership positions. Is that really such a big improvement?”
	
	While Birnbaumer acknowledges Gebhard’s point-and notes that these issues are not unique to medicine-she thinks the article shows that things are improving, albeit slowly, for women. And for male physicians, too.
	
	“Thirty years ago, women had to choose between family and career. There was no middle ground,” says Birnbaumer. “But having women in the field has changed how medicine is practiced and just what is possible. Today, there are options so you can have a better work-life balance. Women drove that.
	
	“And the male residents I work with are just as interested in options that allow them to have more time with their families,” she adds. “As more women enter the field, I think we’ll see more changes in the way medicine is practiced that will benefit everyone.”
	
	


	
	Experts agree that the medical profession is at least starting to recognize that it needs to change so that women can achieve greater parity, both in terms of opportunities for advancement as well as remuneration. Hoff suggests that addressing the myriad challenges that women face, including implicit biases about abilities and sexual harassment, as early as medical school will help to change them in the future.
	
	“If medical schools and residency programs start addressing these issues during training-because that’s when they start -and challenge the way that women have historically been viewed and treated, it’s an important start,” he says. “We also need as many strong female role models as we can get going into leadership positions so we can change those implicit biases people have about women.”
	
	LaTasha Seliby Perkins, MD, a family physician in Washington, D.C., and a board member of the American Academy of Family Physicians, agrees. It’s one reason why she decided to take on a leadership position in the organization, even while experiencing a high-risk pregnancy.
	
	“I want every single person in medicine to see women as leaders,” she says. “I want them to see women taking on more demanding roles in more demanding specialties and succeeding, whether they have a family or not. I want more women to apply for challenging jobs, to ask for more money, and know that they have earned their place at the table. That kind of visibility is vital not only to our success as women, but to the success of medicine as a whole.”
	
	Krystal Savice, a third-year medical student at the Touro College of Osteopathic Medicine, has already taken on a leadership position as a student with the Student National Medical Association, and is set on becoming a residency director in the future. She intends to be the change she wants to see in the field.
	
	“Women have made a lot of strides in medicine and are demonstrating just what is possible,” she explains. “We will become the leaders we need.”

Articles

As the number of women doctors grows, many are trying to square that promise with the systemic challenges they face.  

Will women transform medicine?

Small medical practices must perform many information technology (IT) functions-EHR system management, cybersecurity, imaging, billing, and controlling and keeping tabs on infrastructure operations, among others,-to achieve the clinical and financial outcomes necessary for their success.
	
	While most such offices don’t have in-house IT staff, some do, whether they train existing personnel to perform these functions or hire dedicated staff who already have these skills.
	
	This article looks at both approaches, examining the pros and cons of each, and when, or if, it makes sense to combine them.
	
	Before a practice decides who will oversee its IT functions, it must know which functions are essential to clinical and financial success. EHRs are a given, but so is a practice management system that integrates patient data with health records and  creates a workflow that expedites patient appointments.
	
	To accomplish this, the EHR must have an API (Application Programming Interface) that has easy back-and-forth communication with the management system, and both components must be HIPAA-compliant. While not mandatory, it’s certainly desirable to have a patient portal that lets patients access their appointment schedules and records online.
	
	


	
	The tradeoffs of hiring IT staff versus outsourcing the function is that a practice has greater operational control over employed staff, but assumes higher costs and risks, says Graham Caparulo, principal consultant with Diligex, a New York City-based provider of outsourced IT services to small and medium-sized medical practices.
	
	“On the risk side, if you have your own staff and a data breach, there’s no one to point the finger at except yourself,” Caparulo says.  (Under the HIPAA Omnibus Rule, if a contractor has signed a HIPAA Business Associate agreement with the practice to comply with HIPAA privacy, security and breach notification requirements, it is liable for any HIPAA infractions it commits.)
	
	Contracting out IT lets a practice focus on its core business of providing healthcare. Moreover, the practice may get a broad base of contract employees with a wide variety of technical competencies, and it’s not left exposed if the in-house IT staffer gets sick, goes on vacation, or leaves the practice.
	
	“The average tenure of an IT person is about two or three years,” says Caparulo, “so do you want to go through this every couple of years or shift that over to somebody else?”
	
	Before hiring outside contractors, the practice needs to conduct a thorough internal inventory to determine what the staff members and doctors already know about the existing IT system, identify their IT product and service needs, then develop a Request for Proposals based on those precise needs.
	
	


	
	At some point, however, it usually makes sense for a small practice to hire someone for what Caparulo calls “level one or front-end triage issues,” such as if a front-desk staffer can’t log in to the EHR, access e-mail, or print out a medical record. In those instances, it’s better to have a more technically adept practice employee on hand to solve the problem. “They’ll likely get things resolved quicker than if they go through an outsourced provider,” says Caparulo.
	
	A practice that doesn’t outsource its IT functions might train its own employees-even if they have little or no IT experience-instead of hiring someone. While this approach certainly costs less than hiring a full-time, dedicated IT employee, the question becomes: is it worth the time to train a tech neophyte currently on the practice’s staff, and will the growth in size and complexity of an IT structure be too much for that staffer to manage in the future? It might be easier to choose this path if the practice’s IT vendor makes training and system support part of the services it provides.
	
	On the other hand, many people today are increasingly comfortable with sophisticated digital technology, says Ken Hertz, FACMPE, a principal with MGMA Health Care Consulting Group, in Englewood, Colo. These staffers can learn the workings of the EHR and perform certain IT functions in a practice, potentially removing the need for a full-time IT employee.
	
	These “super users” can be and “are highly trained in software, and in understanding and problem-solving with the EHR or practice management software. A vendor can furnish that training.

“Now, they’re not going to solve your network problems and things like that,”  Hertz cautions, while noting that super-users who develop more experience handling software can sometimes help with networking and hardware problems as well.
	
	But the more complex services, such as interoperability and telemedicine, ought to be left to contract experts, Hertz says. “You want somebody who knows all about HIPAA issues, cybersecurity issues, encoding messages and so forth.”
	
	


	
	For some small practices-like that of Karen Smith, MD, a family physician in rural Raeford, N.C.-hiring new or training existing in-house staff isn’t an option. First, the cost is prohibitive-about $30,000 per year, according to practice administrator Michael Hendricks. That would be an operations budget-buster for Smith.
	
	Second, it’s more practical to use a sub-contractor from nearby Ft. Bragg to provide IT support, “Even if we had an IT specialist to come in and train us it’s out of our purview because we would literally have to study that technology and know what the upgrades are,” explains Smith.
	
	Each service the practice installs incurs  training costs. It’s also highly important that the contractor have an industry-specific knowledge base.
	“Subcontract with someone who stays up to date with technology and who understands healthcare,” Smith says. “You really need an IT person who understands the nuances of medicine.”
	
	Practices also should understand how IT pricing works. More labor-intensive functions, such as a help desk, are likely to be costly, Hertz says. But vendors may charge a lower monthly fee for certain standard services, such as security, anti-virus security, back-up, monitoring alerts, and hardware support.
	
	Finally, Hertz says, a vendor contract should address response time for dealing with technical issues or downtime. “They may say, ‘Yeah, we said we’d be onsite, but didn’t you read the part of the contract where we said we’d probably be there within three days?’”

The pros and cons of each approach to handling IT staff

Hiring IT staff vs outsourcing

How physicians behave after learning that they’re being sued for medical malpractice can determine the outcome of the case, regardless of its legal and medical merits.
	
	That’s why it’s important for physicians to know how to act upon being served notice of a lawsuit. Medical Economics spoke to malpractice defense attorneys and insurers to determine the do’s and don’ts to follow. The experts are:

Ericka Adler, a malpractice defense attorney with Roetzel & Andress in Chicago

Richard Cahill, JD, vice president and associate general counsel, The Doctors Company, a medical malpractice insurer

Sam Rosenberg, a malpractice defense attorney with Rosenberg Jacobs Heller & Fleming, P.C. in Morris Plains, N.J.

Notify your insurer as soon as you’re served.


	
	Not only does that get your insurer working on your behalf as soon as possible, it also means you’ll have legal representation faster, and that provides a protective shield for some conversations, says Adler. If doctors learn of a likely lawsuit before it’s filed, they should alert the insurer, she says.
	
	Employed physicians should notify their employers immediately as well.
	
	


	
	This protects conversations between legal counsel and their clients from disclosure in lawsuits. However, it only applies once a client has retained or had counsel appointed, and only in conversations regarding the case. Defendants should talk about the case only when their attorney is present and only with those people who are relevant to the case, says Rosenberg, who adds, “Everything you say can be used against you.”  
	 
	


	
	Doctors should review their malpractice policy to know exactly what is covered, the amount of coverage and what rights and responsibilities they have. Employed physicians should examine their contracts to determine their own and their employer’s responsibilities. While many policies give the physician final say in whether a suit is settled, many employment contracts give the employer that discretion.
	
	


	
	It’s natural upon being sued for physicians to have multiple questions for their attorneys. Physicians should ask their attorney about how long the process will take, the steps involved, and any other questions they have.
	
	

Talk to a mental health professional, if necessary.


	
	Being sued for malpractice is a mental and emotional blow, and not being able to talk to friends and colleagues about it can place enormous stress on the physician. “To have an adverse event is bad enough; when it results in a lawsuit that’s even worse,” Cahill says. Conversations with mental health professionals are, of course, privileged.
	
	


	
	Rosenberg estimates that 10 percent of defendants continue to treat the patients who are suing them. In those cases, they should treat them only for conditions unrelated to the lawsuit. Dropping the patient can be seen as an admission of guilt, he warns.
	
	


	
	Malpractice settlements and adverse judgments are reported to the National Practitioner Data Bank (NPDB) and state medical boards. This information follows physicians throughout their careers. Adler says she tries, when negotiating employment contracts with hospitals, to give doctors the right of approval for the language in the NPDB report. Doctors can appeal notification wording to the NPDB if they feel it’s unfair or inaccurate.
	
	


	
	Being sued is common and the odds are in your favor. A 2012 study published in the Archives of Internal Medicine found that about 55 percent of claims resulted in a lawsuit. Of those litigated claims, more than half were dismissed by the court. Of the rest, most were settled before a verdict; less than 5 percent were decided by a trial verdict. And the verdict was in favor of the doctor 80 percent of the time.
	
	

Don’t talk to anyone other than your attorney.


	
	This is one of the most difficult rules to follow, but also one of the most important, says Cahill. It’s natural to want to discuss the case with colleagues, friends and others, but those conversations can come back to hurt the defense because they’re not privileged.
	
	“Conversations with other providers, including employees, partners, colleagues, hospital administrators and consultants, are generally subject to discovery and may create an adverse inference that the witnesses were somehow colluding to get their story straight and thereby avoid liability,” Cahill says.
	
	


	
	It’s tempting to go back and complete or correct the relevant medical records, but doing so is a big mistake. Plaintiff attorneys will seize upon any alterations and make them look like a doctor’s attempt to conceal or destroy evidence, says Rosenberg.
	
	Any change made to records should be dated, initialed and accompanied by an entry noting who made the change and why. Cahill recommends segregating the relevant original paper records and severely limiting access to them.
	
	“Physicians with electronic health records should exercise similar care,” he says. “Changes to electronic entries should not be made without a clear notation that it is an addendum or a late entry-those should be made only on rare occasion, should be objective and not self-serving and should never attempt to falsely contradict prior entries.”
	
	


	
	The natural impulse upon being sued is to go back and review the case, looking for errors, incomplete records, the involvement or liability of other providers, etc. This could involve talking to colleagues, staff and others involved in the case, which can be seen as an effort to block the investigation or cover up wrongdoing. 
	
	

Don’t talk to the plaintiff’s attorney.


	
	It’s not uncommon for a plaintiff’s attorney to call or email the office of the defendant doctor with a request for records or other information, says Rosenberg. Do not respond to such requests or talk to anyone on the plaintiff’s side, because the conversation can be used against you, he says. Let your attorney handle all records requests. And, of course, don’t offer a settlement.
	
	


	
	Unless a doctor has been sued so often that his or her personal attorney is a malpractice specialist, it’s safer to be represented by an attorney appointed by the insurer or employer. They’re experts in malpractice law and are familiar with the tactics used by plaintiff’s attorneys. “Using your own attorney is like going to a podiatrist to treat your heart disease,” says Rosenberg.
	
	


	
	Most malpractice cases are settled out of court, often with no admission of wrongdoing. These settlements usually are driven by the insurer’s decision that it’s easier and less expensive to settle than to go to trial, Adler says.
	
	“For anyone to have to settle something when they’ve done nothing wrong is hard,” she says. “A lot of it is really about money. It’s a business decision and not about whether the doctor is good or bad.”

What to do if you are sued for malpractice

A recent survey conducted by InstaMed, an online healthcare payments service, revealed that 93 percent of patients were surprised by their medical bill, including 61 percent who received a bill for more than expected and 50 percent who received an unexpected bill.
	
	“This surprise and confusion stems all too often from a lack of communication between medical practices and their patients,” says Deirdre Ruttle, senior vice president of strategy and communications for InstaMed. “Patients are not usually aware of their responsibility until after a visit, which is unlike many other payment experiences where there is a clear price tag and an understanding of how to pay.”
	
	But medical practices can remove the uncertainty in healthcare payments by communicating early with patients, setting expectations, and offering payment convenience. This includes talking about payment responsibility, insurance coverage and cost estimates, offering multiple payment options including online payments and automated payment plans, and enhancing patient convenience through electronic statements, email notifications and text notifications, experts say.
	
	


	
	David Belk, MD, an internist in Alameda, Calif., says there was a time when most discussions about medical costs centered around questions like “Will insurance cover this?” or “How can we get insurance to cover this?”
	
	“As nightmarish as those conversations were thought to be, such questions do seem rather quaint and simplistic by today’s standards,” he says, citing discussions today of questions like, “What does covered even mean?” “Can I afford this test or procedure even if it is covered?” and “Would I be better off not even using my insurance and just paying for the medical test or procedure myself?”
	
	Brian P. Sanders, MD, a family physician at About You Family Medicine in Atlanta, Ga., says he’s finding that fewer people are  shy about discussing cost of care.
	
	“For folks that live paycheck to paycheck, the discussion involves how to save up to afford a more expensive but necessary evaluation or treatment or procedure,” he says. “Without these discussions, many patients would oftentimes not get any medical care or allow the problem to fester until it becomes a more expensive emergency.
	
	Troy Russell, MD, a family doctor in Lynn, Mass., notes that for about half the medications he prescribes, patients will ask whether it is covered by insurance. He’s also asked routinely whether all the medications they take are absolutely necessary.
	
	“Patients are often most concerned about costs of specialty medications like insulin, Remicade, and Xarelto,” he says. “My response is usually that we try to use generic medications first, try to use coupon programs like GoodRx and if that doesn’t work, we pursue prior authorization through insurance.”
	
	Katarina Lindley, DO, FACOFP, a direct primary care family physician in Brock, Texas, says she discusses pricing and affordability with patients almost daily. For example, when she orders labs or imaging for patients, she helps them decide where to have them done.
	
	Some patients prefer to pay directly rather than going through insurance because deductibles are so high.
	
	“An example is, I can get labs for an annual physical for about $20, but with insurance it can be $150-500 if the patient has not reached their deductible,” she says.
	
	The same is true with medications. Before prescribing, Lindley discusses with her patients if they can afford them. Such discussions are important, she says, because patients sometimes are embarrassed to say they cannot pay for meds and won’t get them filled.
	
	“My job as their doctor is not only to help them recover from or control an illness but also to look at their overall health and at times that means financial needs as well,” she says. “All physicians should have these discussions with patients, because they may not be compliant and their blood pressure is still high because they could not pay for that third medication.”
	
	Jeffrey Gold, MD, a pediatrician in Marblehead, Mass., notes that a typical discussion will find him showing a patient what lab test pricing is compared to what a typical hospital charges, using websites such as mymedicalshopper.com and healthcarebluebook.com.
	
	“I once saved a patient $2,000 for a cardiac stress test by sending him to Derry, New Hampshire, versus our local hospital,” he says. “Obviously, this was a low probability test and non-urgent, and it took him two weeks to get a reply from his insurer as to what his out-of-pocket payment would be. But it was something that was greatly appreciated.”
	
	


	
	Russell routinely has his medical assistant screen for financial or social economic barriers to care so he’s prepared for where the conversation will go.
	
	“Some patients are not interested in telling me these issues unless it is really bothering them,” he says. “Since my medical assistant staff are native Spanish speakers and culturally able to connect better with some patients, they are able to elicit this information a little easier.” They do this, he says, simply by asking if the patient has any questions or concerns.
	
	Gold says physicians need to be open and honest, and not just say what the patient wants to hear. “Most people still don’t even understand what coinsurance, deductibles or networks are, and the conversations are still not as prevalent as I would like them to be, but definitely more common,” he says. “If you’re honest with them about their options, it can drive the relationship even further.”
	
	


	
	One of the most common questions patients ask physicians is where they can find help in reducing their out-of-pocket costs. Doctors say prescription drugs often are a good place to start.
	
	“Most people believe that they’re getting a good deal from their insurance if they’re only paying a $5-$10 monthly copay for a generic medication,” Belk says. “They’re usually wrong about that.”

How to discuss care costs with patients

Proactively managing risk and avoiding harm is almost always cheaper and more predictable than managing any actual crisis. 
	
	Asset protection has three layers: a culture of compliance that helps avoid the most common risks; a well-developed insurance program to help cover any mistakes or accidents; and legal tools that separate risks and assets to back up anything not covered by the first two.
	
	In this article we address one of the major risks physicians experience that does not involve patients: Risks from exposures related to your employees.
	
	Employment law exposures are among the most common risks American business owners face and medical practices are no exception. In addition to the traditional claims related to wages and labor law, employers now must manage less tangible, more subjective issues.
	
	Our socially- and politically-charged climate, including the #MeToo movement, requires attention and physician leadership. Businesses are up to five times more likely to be sued over an employment issue than for any other reason. In addition, employees are winning more often and the average sexual harassment lawsuit verdict is roughly $500,000.
	
	Fortunately, this risk can be effectively managed in three simple steps:

Be adequately insured for both employment law related liability with EPLI (employment practices liability coverage) insurance and general liability and other specialty commercial insurance that protects the business from the vicarious liability of being an employer. For doctors, common exposures might include HIPAA employee breaches that reveal confidential patient information including photos or other identifying patient data or social media related liability for making defamatory statements or claims. 
	Having these basics in place will put many medical practices ahead of their peers and not just help defend against such a claim, but ideally avoid ever facing one in the first place.

Create a culture of respect, compliance, and authority. Every workplace has its own “vibe”, some are formal and all business, others are more casual, fun and familiar. Either may be effective, but both need to start with a culture that observes and uniformly enforces good conduct among physicians, executives, and other staff. This means a willingness to be (or delegating someone to be) the adult in the room and address issues and set standards. 

Have an enforced, custom drafted, state-law specific employment manual. Failing to do so means that many rules polices will be open to interpretation by your employees, and worse, the courts. I routinely find that many practices have no manual or have one they got off the internet or cobbled together themselves that may not be up to date or legally compliant.

Ike Devji, JD, has practiced law exclusively in the areas of asset protection, risk management and wealth preservation for the last 16 years. Send your financial questions to medec@mmhgroup.com.

Proactively managing risk and avoiding harm is almost always cheaper and more predictable than managing any actual crisis.

Three tips to avoid legal risks with employees

For many small practices, creating a budget is an annual exercise that culminates in a binder that sits on the shelf and collects dust for the remainder of the year. But experts say practices that don’t develop and regularly review a budget are missing out on a tool that can provide warning signs of financial trouble and fraud, and help make large purchases less disruptive to cash flow.
	
	“If you think of a practice as a living body, the budget is like a vaccine,” says Rick Gundling, CMA, senior vice president for healthcare financial practices for the Healthcare Financial Management Association. “Having one doesn’t mea3n your practice’s health won’t go off track, but the risks are minimized. And when you check in on a periodic basis, that’s like your financial stethoscope.”
	
	A solid, regularly reviewed budget sparks conversations between the physician and staff about potential trouble spots in the practice. “It keeps you informed instead of surprised and lets you take action before something becomes a problem,” Gundling says.
	
	Janet Burns, business manager for University Family Medicine Center, a two-physician primary care practice in Orlando, says the importance of budgeting and watching overhead is not always obvious to physicians, because they don’t understand the value they can get from it.
	
	“By looking at monthly numbers, I am able to find things that are happening that I otherwise would not be aware of,” she says.
	
	


	
	An effective budget does not have to be complicated, but should match the management style of the physician, or else it won’t be effective experts say.
	
	Doctors who prefer high-level overviews with minimal details of the business should work from budgets with those same traits. Doctors who are detail-oriented may be interested in a budget with more line items that show expenses in greater detail, says Cindy Nyberg, CPA, CMPE, chief financial officer and strategic planning consultant for Fulcrum Strategies, a physician consulting firm in Raleigh, North Carolina.
	
	For example, medical supplies could be one broad category, or broken down into specific subcategories for greater detail.
	
	Melissa Lucarelli, MD, a primary care physician in Randolph, Wisconsin, tried a detailed annual budgeting process but didn’t see any return on the time and cost of creating it. “For a small practice like mine, I don’t have the luxury of saying, ‘We’ll go into the red this month and make it up next month.’”
	
	What works for her practice is a simpler accounting review of monthly expenses compared to what the practice has spent in the past. “We are just looking at how much do we have, how much are we getting in and how much do we need to pay each month,” says Lucarelli, a member of the Medical Economics editorial advisory board. “To me, it feels more agile and less stressful.”
	
	“I always caution physicians to keep it as simple as possible,” says Nick Fabrizio, Ph.D., FACMPE, principal at the Medical Group Management Association.
	
	“Come up with a simple process you can use that monitors revenue and expenses. It’s OK to forget things when you start. It’s better to do that than to create an elaborate budget with 50 line items that is too difficult to understand and becomes this big, scary thing that no one wants to touch.” Detail may be great, but keep in mind that more detail also requires more staff time to track, he adds.
	
	Lucarelli’s strategy for budgeting exemplifies the best approach-find what works, experts say. “There’s not one model you must use,” says Nyberg. “The budget has to serve the business.”
	
	The first step in creating a budget is to look at revenue and payer mix, Nyberg says. This will not only establish a starting point, but offer insight into creating growth. “You can’t just say you’re going to increase revenue 10% next year,” she says. “If you are 50% Medicare, revenue is pretty much flat.”
	
	Once revenue is established in the budget, Nyberg suggests organizing and dividing expenses into categories like staff compensation and benefits, occupancy expenses, furniture and equipment, medical expenses, miscellaneous expenses, midlevel provider expense and physicians expense. These broad categories make a budget much easier to understand, and if variances occur, practices can gather information to provide more detail and get a better idea of what is causing the changes.
	
	“If you aren’t making financial decisions off every office and medical supply purchase, then put them together,” says Gundling. “If you need to go deeper, then do it.”
	
	Communicate to the staff which expenses go in each category, because they may not always be obvious, Nyberg says. Some staff members may be involved in the budget-creation process, but who is included is largely a level of job function and physician comfort with sharing financial details.
	
	“Getting input is great, but it depends on how much the owners want to share with the staff,” says Nyberg. “Eventually though, someone will be held responsible for trying to move the needle on budget goals and they should have some input into the creation process.”
	
	


	
	Once the budget is finalized, it must be reviewed at least monthly to be useful, experts say.
	
	Gundling says physicians should look for trends-compare the current month’s numbers to the prior month and  to the same month from the year prior. If a particular category is much higher or lower than it was previously, start asking questions.
	
	“Once you understand the variance, then you can start formulating what to do,” says Gundling. “The budget causes you to ask the ‘what’ and the ‘why’ questions. It gives you more impetus to dig deep.”
	
	If, for example, supplies are costing more than in the past, maybe a contract or supplier review is in order. If nothing can be done about the increase, then maybe money needs to be taken elsewhere from the budget to make up the difference and protect cash flow, says Gundling.
	
	“Work with your staff to be very attuned to those variances to try to understand whether it’s a one-time thing or an ongoing problem,” he adds.
	
	Fabrizio recommends looking at actual dollar amounts and not just percentage increases or decreases when reviewing. “Two percent in one category may be $100 while in others it might be $1,000,” he says. “If that extra $1,000 expense goes on for 10 months, you might have paid out $10,000 before you realize it.”
	
	Burns explains that her practice’s budget functions as a guide on where to focus cost-cutting efforts. It can also be used to forecast returns on larger investments.
	
	For example, Nyberg worked with a practice that was sending patients out for MRIs. The physicians thought getting their own MRI machine would be a good investment so as to keep the money in-house, but a budget analysis showed that with 53% of their payer mix in Medicare and with the correspondingly small reimbursements, the machine would never pay for itself.
	
	When a budget is done correctly and regularly reviewed, it can offer many beneficial insights into the financial health-present and future-of a practice.
	
	“It’s one of those necessary things, but I think physicians look at budgeting like they look at having a tooth pulled,” Gundling says. “But budgeting really does help in having an ongoing conversation about the practice and minimizes surprises and maximizes cash flow. A budget allows you to stay on top of your practice.”

Budgeting for practice excellence

The Illinois Biometric Information Privacy Act (BIPA) of 2008 was the first state law in the country to regulate biometric data use. For physicians, the intersection of laws such as BIPA and the federal HIPAA law cannot be overlooked. 
	
	Let’s begin with the term “biometric.”
	
	Since various components of personally identifiable information (PII) are inherent in the definition of Protected Health Information (PHI), the HIPAA Privacy Rule applies to the de-identification of PHI. The HIPAA Privacy Rule sets forth two acceptable de-identification methods:

expert determination (an expert is utilized to ascertain that an individual could not be identified); and

safe harbor (no actual knowledge that PII, including biometrics, can identify an individual).

Satisfying either method demonstrates that the regulation has been met and that the likelihood of exposure is slim. HIPAA includes certain exceptions, such as for law enforcement purposes and the protections afforded to whistleblowers and workforce member crime victims.
	
	It is important to realize that because a biometric falls under the category of PHI, entities must adhere to the Security Rule to ensure that adequate technical, administrative, and physical safeguards are in place to protect the confidentiality, integrity, and availability of the data. 
	
	BIPA also requires adequate technical, administrative and physical safeguards. And it applies to a variety of industries, ranging from healthcare to retail to hospitality to any employer who uses fingerprint technology for time keeping purposes.
	
	As with PHI in relation to HIPAA, BIPA, in most instances, requires providing notice that the biometric information is being collected and stored; giving written notice of the specific purpose and length of time for which that biometric information will be used and stored; and obtaining written consent.
	
	Healthcare is a bit different than simply using a biometric to log in to record hours worked, because the 6-7-year period of record retention serves another purpose-ensuring the continuity of patient care and treatment. 
	
	One key distinction between BIPA and HIPAA is that BIPA allows a private cause of action to be brought by individuals, without showing that actual harm occurred in order to recover damages.
	
	There is no private cause of action expressly stated in HIPAA; rather, individuals typically sue under a common law negligence theory and use HIPAA as the standard to satisfy the elements of duty and breach. Causation and damages are items that still need to be proven in order to recover under a negligence case. 
	
	Compliance with HIPAA and any state privacy laws has never been more important. I’m still amazed at the number of practices that have not done a risk analysis in years or ever. This one item, a proper annual risk analysis, can prevent significant financial, legal, and reputational damage.

Biometric information is another type of personal health informaion.

Biometric data: Another HIPAA risk to address

Most people struggle to balance a single full-time job, but what if that single job carried the weight of two, three, or even four careers all at once? Would it even be possible?                

Just ask a physician who runs his or her own practice.

Physicians who own their own medical practices not only bear the responsibilities of a doctor, but also simultaneously those of a CEO, business operations manager and entrepreneur. It adds up-some 

 of physicians report feeling burned out or depressed in some way, with 

 of that set attributing the bulk of their troubles to “bureaucratic tasks.”

That’s why finding the time and wherewithal to invest in and grow a practice probably seems like a daunting and near-impossible task for many. But it doesn’t have to be that way-there are many physicians who are able to successfully scale their businesses.

For those looking to grow and diversify their practices but just don’t know where to start, here are five tips to keep in mind:

Make sure you have a firm grasp of the current state of your business. Assess your revenue, costs, budget, and staff productivity on a recurring basis. Celebrate your strengths and current successes, but also make an honest assessment of your biggest weaknesses and needs as a business.  And don’t forget the last step: document the assessment to ensure follow up and execution.

It may seem obvious on the front end, but starting-and maintaining-a routine of self-monitoring and assessment is an essential first step for scaling and fostering long-term success at your practice.

2. Dream, then set realistic expectations by prioritizing.

Are you looking to expand your services? Have you had your eye on some new equipment or exciting technology? Wish you could flex into a larger, sleeker office space? That’s great-as the office entrepreneur, give yourself the permission to be creative and think big.

But chances are you can’t do everything you want in the near-term.

Try to determine what can realistically be done in one, three, and five years given your patient roster, prospective revenue, and responsibilities. By embarking on this exercise, you’ll find that you’re less likely to get overwhelmed trying to achieve all of your goals, which often can lead to being discouraged when it isn’t all completed. Creating a documented plan to manage the change will keep you on track.

3. Find out what kind of financing is best for your needs. 

Expanding your footprint can be exciting-but price barriers can get in the way. Practice startup costs alone run upwards of 

. So, if you’re looking to grow your practice, you’ll need to evaluate what borrowing options will work best for you. Remember that interest rates don’t tell the whole story-there are account fees, premiums, and other closing costs to consider. Always scrutinize the details and the entirety of the lending relationship before landing on a decision. 

A key point to consider is the term of your loan. Cash flow is extremely important, and while you may want to do a quick payoff, that can create a cashflow crunch. Most loans will allow you to pay down the debt quicker if things are going well.

SBA loans can be especially helpful for doctors who are looking to open, acquire, or expand their practices because of a federal guarantee of up to 85%. That means there’s less risk for the lender and easier access for the borrower.

Expert tip: When you’ve figured out what type of financing works best for you, don’t just let the banks interview you-interview the banks themselves. You’ll find that some have expertise and experience dealing with certain types of businesses-including medical practices. Often, the business savvy they bring is every bit as important as the financing itself. Do your research and ask questions.

4. Formalize your thoughts in a business strategy.

Once you’ve arrived at a strategy, put pen to paper. Your bank or lender of choice can assist with developing your business plan, setting financial goals and parameters, and weighing financial gain against your interests and passions as a physician.

From there, it’s time to go shopping – but stick to your plan and your budget. Any smart lender will make sure you do so. It’s mutually beneficial.

5. Thoughtfully and carefully build out your team.

Human capital is your most important growth area, and it’s where you’ll be investing the majority of your capital.

Whether you’re adding a partner, hiring a nonphysician provider, or even bringing on an office manager to help with the administrative load, you’ll want to take extra care to choose team members that will be the right fit for your practice in the long-run. Unlike a big company, each person represents a significant chunk of your business. Resist the temptation to hire quickly because of immediate demands or pressures. This is where the best plans are often ruined. Focus instead on curating a high-quality staff for sustainable growth.

And if you find a new hire just isn’t the right fit, don’t drag out the inevitable. It may seem counter-intuitive, but positioning your business for success and long-term growth may require you cut before you scale again.

” The smaller your business is, the more critical this becomes.

By taking each of these steps in stride, you can start putting together the building blocks of a successful practice and unlock long-term value for yourself and your patients. Navigating the business of medicine can definitely be a challenge, but it doesn't have to be an insurmountable one.

David Burch is the Business Banking Director of Sales and Specialty Banking at Huntington Bank, the nation’s largest SBA lender by volume over the past decade. 

There are concrete steps to take for physicians looking to grow and diversify their practices.

February 25, 2020 edition