William Baker, D.O., is a family medicine physician in Las Cruces, New Mexico, and a cowboy action shooter. Baker sat down for an interview with Medical World News® (MWN) to talk about cowboy action shooting and the value of hobbies for physicians. The transcript below was edited for length and clarity. Visit Medical World News® for the full video interview.

 Well, in cowboy action shooting, there are two versions. There is mounted shooting, which is on a horse, and then what I do is shoot on the ground. We’re shooting steel targets. It’s a variety of things. We shoot two pistols, a rifle and a shotgun.


MWN: How many different targets are there and how far away are they?

 Pistol targets may be as close as 2 yards or they may be as far as 10 to 15 yards and our rifle targets go out to as far as 15 to 17 yards, and shotgun targets are about the same distance. Typically,you’ll have five rounds in each pistol. So that’s 10 rounds, and rifle will typically have nine to 10 rounds. And then shotgun you may shoot anywhere from two shotgun shells to 10 shotgun shells; it depends on who sets the target array up and how they want you to shoot it.

MWN: Is there a time limit? Is this a speed
and accuracy contest? Or just accuracy?

 It is speed and accuracy. Accuracy is to just hit the steel target. You don’t have to hit it in the bull’s-eye. You just have to hit it.

 I took care of a patient a long time ago — this was in the mid-’90s — who had a spinal cord malignancy, and unfortunately he passed away from that. And about six months after his death, his brother called me and asked if I was going to be in the office at the end of the day. I said I would be, and he said, “Well, my brother, I was finishing up his estate and he asked me to bring you something.” I told the brother that I took care of the other brother basically for free because he was destitute at the time that he was in trouble and I said I don’t require any repayment. He said, “No, my brother really wanted you to have this.” So his brother brought me a single-action Colt revolver. And his brother had made the pistol grips for that revolver himself for the person who had expired. So that has quite a bit of meaning to me. But in the meantime, I was reading a magazine at that time, which would have been about 1999 or so, and I saw an article about cowboy action shooting. I looked into it, and there was a small club north of us about an hour. I went up and watched and I thought that was fun. I actually had most of the clothing because I had shown horses and I still show horses at this time. I had some of the firearms; I just had to buy a few extras. I got interested in it and it turns out to be a lot of fun.

MWN: You said you have horses but you don’t do the mounted shooting at all?

 Part of the reason is, you need to have a horse you can shoot off of. And what I was told a long time ago, you can shoot off any horse once, but it’s the second time that provides the entertainment.

MWN: How long have you been doing this competitively?

 I’ve been doing this competitively since about 2002. And I’ve enjoyed doing it, though last year with the COVID-19 issues, matches have been real limited and rare. Nationals were canceled in 2021, and world championships were canceled in 2020. They did hold them last year in Indiana but for me, that’s quite a lot of travel, so I did not make nationals or world championships last year. But I’ve gone to the world championships pretty frequently over the last probably 15 years.

MWN: We tend to think cowboys are just American, but it sounds like there are people from everywhere that are enjoying this.

 There are. I’ve met people from New Zealand, Australia, France, Italy, Slovakia, Norway, Canada, Japan and then from all over the United States.

MWN: Is there any country that’s really good at producing really good cowboys?

 You know, every one of them has very good cowboys that are very tough shooters. And we do compete in different categories. My category I shoot is classic cowboy, which means that I dress up like a cowboy, with the chaps, with the roping cuffs, with the spurs, with the felt hat, I wear the vest, all that stuff. And it’s not age based, so I have to shoot against people who are anywhere from 18 to 100 if they’re in the class. There are categories that are age based, and categories where you can dress up Western so you look like Roy Rogers with the fringe and all the shirts and belts and all that stuff. Or it can just be as simple as wearing a pair of blue jeans, boots, long-sleeved shirt and a hat.

MWN: How does this help you relax after a busy day at the practice?

 It just takes my mind away from all the stressors that I have in the office because I have a fairly busy office practice, and not only dealing with patients — dealing with administration, dealing with finances, all that stuff. This just allows me to decompress a little bit and I think about something completely different.

MWN: What else would you tell people about cowboy action shooting?

 Well, the thing that’s fun about this activity is that everybody that shoots it has a good time. We laugh, we smile. There are people from all walks of life. I’m a physician, but I’ve met people who do everything, and we all have a good time. There’s nobody winning a Cadillac with this. We’re not making a putt that’s going to pay us a million dollars. It’s just fun.

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When he's not treating patients, you might find him dressed like a cowboy demonstrating his target-shooting prowess.

After hours: Meet William Baker, DO, family physician and cowboy action shooter

Sometimes a long-term loan, such as from a bank or an SBA 7(a) Guaranteed Loan, simply does not make sense for a small medical practice. With term lengths typically shorter than five years, short-term loans are ideal for meeting the immediate needs of a medical practice, such as upgrading office equipment, restocking inventory, covering delayed bill payments or increasing cash flow without spending restrictions. There are three common short-term funding options for doctors and medical professionals:

P Merchant cash advances	P Lines of credit	P Invoice factoring

A merchant cash advance (MCA) is not actually a loan. Offered by alternative online lenders, an MCA is technically a form of financing known as an asset purchase. In exchange for a cash advance, your lender will automatically deduct a portion of your practice’s future earnings until the advance is repaid.

Payment amounts are based on your revenue, which means when revenue is lower, your payments will be reduced — and vice versa. As opposed to traditional interest rates, MCAs use what is known as a factor rate based on the financial history of your business. The stronger your history, the lower your rate should be.

It is often easier to get an MCA than other forms of funding because approval requirements tend to be less strict than those for traditional medical practice loans. MCAs also typically do not require collateral. However, MCA regulations vary by state and not all providers are reputable, so do research before signing a contract.

MCAs are best for medical practices that:

Need immediate funding or fast access to working capital.

Seek smaller loan amounts and shorter terms.

Would not be approved by traditional lenders; for instance, businesses with low credit scores.

A line of credit gives you access to working capital without the obligations of a fixed-term loan. Lines of credit give you the flexibility to withdraw as much or as little as you need provided you do not exceed the credit limit, and if your business is performing as well or better than when the line of credit was approved. You can withdraw and repay as many times as needed, and only pay interest on the portion of money borrowed against the line of credit.

Business lines of credit are available from traditional and alternative lenders. Traditional lenders typically have stricter approval requirements such as high minimum credit scores, whereas alternative lenders are more flexible and will consider other factors. When you apply for a business line of credit from an alternative lender, your approval will be based on the revenue and cash flow of your medical practice as well as these factors:

Lines of credit are best for medical practices:

With a strong credit history that want a cushion to fill cash flow shortages

That need flexible access to
working capital

Also known as accounts receivable financing, invoice factoring allows doctors to sell their outstanding invoices to a lender in exchange for the net amount in cash. Typically, the lender will advance the medical practice 70% to 90% of the invoice’s value, often up to a maximum of $100,000 per common ownership. Once your client pays their bill, the lender will remit the remaining 10% to 30% of the invoice — minus the lending fee.

Invoice factoring offers shorter repayment terms than other short-term financing options, typically aligning with your accounts receivable period — generally between 60 and 120 days. There is no standard factoring agreement, so be prepared to negotiate the terms.

When you apply, your lender (called a “factor”) will:

Review and determine your client’s (or client base’s) creditworthiness.

Review previous invoices and assess how successful you have been in collecting payment.

Negotiate with you based on the results of their risk assessment.

When you choose invoice factoring, the factor oversees collecting payment from your clients. That is why it is important to choose a lender you can trust to treat your clients tactfully during the collection process. The last thing you want to do is compromise your business relationship with your clients.

Invoice factoring is best for medical practices:

That need to fill in the gaps between sending invoices and receiving payment.

With invoices valued over $15,000 with extended credit terms, and that are not more than 90 days past due.

Alfredo Rosing is vice president of marketing at Greenbox Capital. Send your financial questions to medec@mjhlifesciences.com.

3 options for short-term medical practice loans

Physicians with an interest in adding real estate investments to their portfolio may wonder how they can possibly make the time to manage properties and do their jobs. But real estate experts offer several ways to earn passive or semi-passive income from real estate that don’t require becoming a landlord in the traditional sense. For physicians, who tend to be high earners, real estate investments can also have tax breaks.

To figure out the right real estate investment strategy, it’s useful to first outline your financial goals, according to Harry Nima Zegarra, MD, a pulmonary and critical care physician at Baylor University Medical Center in Dallas, Texas, and owner of Nima Equity. “A return on investment is important, but as important is how much time do you want to devote to doing certain types of activities?” he asked.

Real estate has multiple advantages, he said, including “cash flow, appreciation, leverage, the equity that keeps building when paying your mortgage, and tax benefits.”

Nima Zegarra, who has an active real estate portfolio, first became excited about real estate’s wealth building possibilities after selling a home he and his wife had bought in 2011 that had appreciated significantly in the years they owned it. They did not want to spend the time and effort that goes into property management and soon found out about real estate syndication.

Real estate syndication is where a group of investors come together to purchase a property at a price that none of them could afford individually. After the property appreciates over time, they sell it and share the profits, according to Eli Goodman, a licensed real estate agent with Illinois Real Estate Buyers in Chicago, Illinois.

In this method, a $2 million to $3 million investment is raised by the investor group, which can include any individuals who decide to invest together, Goodman said. Once the capital is raised, the real estate syndicator oversees all the hard work. “The promoter of this would find the assets, raise the capital, buy the property, raise the value, stabilize it, and manage it,” Goodman said.

Nima Zegarra and his investment group prefer to purchase apartment complexes. So not only do the investors receive passive rental cash flow during the year, which he estimates at a 7% to 10% return each year, but they also gain appreciation as the building increases in value. In four to six years, the syndicate sells the building and splits the equity.

While the returns on syndication can be very good, Nima Zegarra warns that this is not a liquid investment. “If I change my mind in two months in stocks, I can sell my stocks and get my money. In syndication it’s usually an investment for four to six years,” he explained.

Additionally, most of these types of investing require a significant upfront layout, from $50,000 to considerably more. And every investor has to pay the syndicator an entrance fee and an exit fee, typically in the form of a percentage on the return.

The benefit is that it’s a passive form of income building once one has done the legwork to find the right syndication group, which, Nima Zegarra says, takes time and research. And returns can be quite good, as much as 10% to 15% return annually, according to rental investor and broker Donnie McGriff, owner of Echo Properties in Dothan, Alabama.

Nima Zegarra said his group aims for 50% to 60% percent gains on the amount of investment, selling at year 5.

Another real estate method that doesn’t require becoming a landlord is to, essentially, “flip” houses by buying at a low price then investing in renovations and selling it at a higher purchase price, McGriff said. “There are a lot of opportunities in California and nationwide for physicians to buy low and do renovations. California in particular has sub-markets where there’s an opportunity to get into assets that have not been serviced or maintained.”

While this method is still passive over time, it requires a lot more work up front, and a physician should ask some important questions, McGriff said. “Do they want to hold it for a duration, or do they want to renovate and then sell the assets and take advantage of increased value in equity and repairs?”

It’s also possible to pay a broker to do the flipping process, according to Brian LeBow, a licensed real estate broker and owner of Bell Properties in Arcadia, California. “They trust me with their money and we do an equity split,” Bell said. He engages all the parties necessary to renovate and reappraise the property before selling it.

Another angle in flipping properties is to use the appreciation value of a new home, and its higher appraisal value, to take out a loan to purchase another property, McGriff said. “Then you can rinse and repeat. You don’t have to keep your money tied up in a property forever,” he said.

While becoming a landlord may not appeal, cash flow from rental properties can be a great form of passive income, LeBow said. But physicians don’t have to manage the properties themselves; they can outsource that work to a property management company. In LeBow’s experience, “A lot of clients will go six or seven months without any communication [with their property managers]. Many physicians will give property managers a financial authorization to take care of any repairs or issues that crop up. “It can be really hands off for them,” he said. “We have one doctor with a 30-unit apartment complex in Glendale, California. We talk to him maybe once a year around tax time.”

There are property management software programs that simplify and automate the daily tasks of being a landlord, according to Chris Lee, owner of Landlord Gurus, a website that offers advice to independent landlords and rental owners.

“Property management software simplifies and automates the daily responsibilities of landlords, from advertising, tenant screening, bookkeeping and rent collection.” Tenants can even pay their rent directly through the software’s portal.

Perhaps the most passive form of return in the realm of real estate is to simply lend money to those who need loans to buy properties, McGriff said. Not only do you get a good return on your money, but in the worst-case scenario, when someone defaults on the property, you acquire it. “You can be extremely passive.” Goodman says an investor can make as much as an 18% return annually on lending money.

Physicians who have the opportunity to buy the building they work in can take advantage of generous tax benefits, LeBow said. “You can write off big chunks of depreciation over time,” he pointed out, as well as management fees and other costs related to the upkeep of the building.

However a physician begins to build a real estate portfolio, Nima Zegarra urged, “The first thing I would do is get educated. Do some research, start reading, network. You should do your due diligence before investing a good amount of your hard-earned money.”

Physicians with an interest in adding real estate investments to their portfolio may wonder how they can possibly make the time to manage properties and do their jobs. But real estate experts offer several ways to earn passive or semi-passive income from real estate that don’t require becoming a landlord.

How to invest in real estate (without being a landlord)

For 15 years, I unquestioningly followed my organization’s standard process for patient flow. After all, I had been “flow mapped” and “cycle time measured” by a team of managers with Toyota-lean precision, so I assumed this must be the most efficient way to run a practice.

You know the routine I’m talking about. The patient arrives at the check-in window to register and sits down to wait. A medical assistant (MA) shows up holding a chart, calls the patient’s name, and walks them into the clinical area. First stop: the dreaded scale for a weight. Next, into the exam room for vital signs: blood pressure, pulse and temperature. Now, the MA barrages the patient with questions, typing furiously into an electronic system for the next five to 10 minutes or more, depending on the historian. Many of these questions will turn out to be completely irrelevant, already in the chart, or repeated by the physician. Finally, the MA leaves the patient alone in the exam room to wait — and sometimes wait, and wait — until the doctor finally rushes in.

Ah! This is the big moment, and in my opinion, where the magic happens. Doctor and patient sit together and have what seems to the casual observer to be a simple conversation. As the patient talks about their concerns, the doctor probes deeper, asking the relevant questions that have been honed by years of practice in history-taking. During this interview process, the physician will use open-ended questions, work to establish patient trust and apply advanced techniques like motivational interviewing to help guide the patient toward optimal health. The physician not only asks about physical complaints but also addresses wellness issues such as ensuring that appropriate screening tests have been ordered. After a medical plan has been determined, the physician leaves the exam room to rush to the next patient, leaving the MA to complete orders and accompany the patient to the checkout area.

If this orchestrated ballet works perfectly, the patient is out of the office in about an hour, perhaps 15 minutes of which was spent with the physician. Administrators and workflow experts assure doctors that this type of streamlining leads to the most efficient visit and “patient experience.” After all, it takes a team to care for patients these days! Or does it?

Imagine a different scenario. The patient arrives at the office, checks in, and takes a seat. Their own doctor arrives at the door of the waiting room, recognizes their long-term patient by sight, smiles and beckons them into the office. Wait, what?

The doctor then walks the patient down the hall into the exam room, making small talk and building rapport. Both enter the exam room, take a seat, and continue to chat for a few moments. The patient has gotten over their surprise at seeing the doctor so quickly and is now relaxed and comfortable, entering into the history portion of the visit without the usual irritation or even anger at waiting or repeating answers to the same questions over and over. Empathy and trust now sufficiently established, the doctor opens the patient’s chart, and moves right into obtaining the patient’s history.

Now I’m about to get even more radical on you.

Imagine that, once the history has been taken, the doctor obtains their own vital signs.

It’s shocking, I know, and counterintuitive to everything the Toyota people have told us about delegation of duties. But doesn’t it make so much more sense?

First, the patient has been sitting for about 10 minutes, ensuring a more accurate blood pressure reading than one taken immediately after the patient walks into the office. It also helps patients avoid anxiety and stigma over being weighed. While obtaining weight as a health indicator is critical, we know that the scale can be emotionally distressing to some patients. Explaining to a scale-averse patient the rationale for obtaining their weight or allowing them to stand on the scale backwards to avoid seeing the number (a technique some patients with eating disorders employ) may improve their willingness. In many cases, patients who entered the office dreading being weighed will jump on the scale when they realize that their doctor is supportive.

Second, obtaining vitals after the history is consistent with the way physicians are trained to think. In a “SOAP” (subjective, objective, assessment, plan) note format, the physical exam supplements the history in medical decision-making, unless, of course, the patient appears immediately unstable when they walk in the door. It allows the doctor to decide whether additional vital signs like temperature or pulse oximetry are indicated, perhaps not if the patient is presenting to follow up on depression, for example. Most importantly, taking your own vitals ensures that the physician does not miss abnormal readings that are easy to gloss over when looking at a piece of paper or a computer screen. We know that vital signs truly are “vital,” and yet I cannot be the only doctor to admit that I have found myself distracted by a patient’s multiple concerns and noticed an abnormal vital sign reading only as I was doing my notes later in the day, necessitating an urgent recall of the patient.

Probably the most important aspect of taking your own vitals is that it allows the physician to have a truly hands-on experience with the patient. In a traditional busy office setting, patients may feel rushed and that “the doctor never even touched me.”Sometimes there is a good reason for that; maybe the doctor didn’t have the chance to examine them because so much time was spent in discussion, or because an exam wasn’t medically necessary for that particular complaint. Perhaps the doctor did do an abbreviated exam while talking to the patient, but the patient was too distracted to even realize it. Taking your own vital signs allows the patient to truly feel a physical connection with their physician, even if it was only the minute or two that you took to apply a blood pressure cuff.

Another way to achieve a truly hands-on experience is to consider performing your own phlebotomy. Although many physicians haven’t drawn blood since medical school or residency days, consider that phlebotomy is far less invasive than many other procedures we do for our patients, and skills can be quickly refreshed after a few hours watching and practicing with an experienced phlebotomist (most labs are happy to offer this service). Drawing blood is also a satisfying way to wrap up your patient visit, drawing the visit to a natural conclusion.

Physicians may also find that they enjoy other clinical tasks usually relegated to assistants, like administering immunizations or performing EKGs, or may choose to bring in an assistant to complete those tasks. After the clinical work is complete, the final step is to perform clerical duties like scheduling tests, procedures, and referrals; tracking down medical records and setting up a follow-up visit, which can be assigned to a nonclinical assistant.

I know that the idea of doing more hands-on clinical duties as a physician completely contradicts the past 20 years of practice management advice, which has urged us to practice assembly line medicine to “see more patients.”But patients are not machines and medical offices are not manufacturing plants. In fact,patients report the most satisfaction with their office visit when the time they spend with the physician “meets or exceeds their expectations” and get better outcomes when they feel a true connection with their doctor based on trust and mutual understanding. By cutting out intermediaries, patients get exactly what they want and need: time with their doctor.

Physicians also benefit from this strategy. Happier patients are more adherent to medical regimens, show improved disease self-management skills and are less likely to sue for malpractice. Having fewer staff members may reduce the risk of data entry errors and increase team accountability. Believe it or not, taking your own history and vital signs may save you time, as one of the biggest bottlenecks in a practice is time it takes to “room” patients.

But can this strategy actually save a practice money?

It depends. If the physician’s labor must subsidize a C-suite of managers — the kind that pay hefty consulting fees to those office flow “experts” — probably not. But for a small practice where support staff salaries and benefits make up the largest portion of overhead, a reduction in staff members may balance a decrease in total number of office visits per day. Adding a scribe to take notes during each visit can allow a physician to see more patients.

While implementing all these measures may not be possible in your office, consider what small changes you could make to allow you to spend more time with your patients.

Rebekah Bernard, MD, is a family physician in Fort Myers, Florida, and the author of How to Be a Rock Star Doctor and Physician Wellness: The Rock Star Doctor’s Guide.

For 15 years, I unquestioningly followed my organization’s standard process for patient flow.  Not anymore.

Revitalize your practice with this innovative patient flow

A physician’s goal is to care for patients, but a key part of being able to provide that care is the eternal quest for payment. One way to ensure that a practice maximizes its coding regimen is to make sure each session can be efficiently billed. Adhering to the following expert coding tips can help practices supercharge their revenue.

Bill Dacey, M.H.A./MBA, president and CEO of The Dacey Group in Palm Harbor, Florida, says that when some people consider supercharging their coding practices, they think of including smaller things for which they are not already billing. He warns that this approach may not be as effective as expected.

“My approach to this has always been to stop working the corners and the little $3 codes and counting all that little stuff,” he says. “Why don’t you just make sure you’re doing the stuff that you do 99% of the time? That will probably get your revenue where it’s supposed to be.”

Dacey says mastering the new outpatient coding guidelines, released last year, can help shore up revenues by enabling practices to bill for what the new guidance allows. He gives the example of code 99213 for an evaluation and management visit.

“It’s the most commonly reported code in the country, and it’s been a 99213 for 30-odd years, but with the changes that came in 2021, it makes it a whole lot easier to call that a 99214,” he says. Dacey says this feels off to longtime physicians because it has been an evaluation and management level three for so long, but now it is a level four.

“If (a practice) wanted to supercharge their coding, I would do it with the codes that had the real money,” Dacey says. “You’re doing the exact same thing you did two years ago, but now it’s worth 50% more.”

This change can be uncomfortable to implement, but Dacey says it is lucrative. “There (are) only five established patient codes … and the 99213, which has been the workhorse code forever, has now kind of slipped down a notch,” he explains. “Family medicine alone did $3 billion in 99214s last year and internal medicine another $3 billion. And that’s where the money is … most all of the money.”

Nancy Enos, FACMPE, CPC-I, coding consultant with Enos Medical Coding in Warwick, Rhode Island, says the key to getting the most revenue through coding is proper documentation of time spent. “It’s all about the documentation,” she says.

A focus on extensive documentation allows practices to keep track of all time spent on a patient session, enabling efficient billing. She recommends that physicians receive brief internal or external training on documentation.

“(This) will pay off in spades, because if they write certain elements, certain parts of their note, they will translate to the higher codes,” she says. Enos says this documentation becomes very important when billing for nonpatient-facing activities.

Enos also recommends that practices understand which nonpatient-facing activities still count for time. “There are several different things that count as reportable time as long as they’re performed by a billing provider on the same date as the billable visit,” she says. “It can’t be the day before, it can’t be the medical assistant — it has to be a billing provider and it has to be the same date.”

“There are so many things that they can just confirm, like the patient history and labs that were collected by their support staff,” she says. “Then when they review it on the day of the service before they see the patient, that could be another 20 minutes that is billable time toward the level of service, as well as after the patient leaves — any calls to physicians to put in place any coordination of care, (and) documenting and updating the medical record itself is now billable time that never was counted before 2021.”

Enos also recommends ensuring a practice keeps track of time when it comes to telehealth appointments. “There are instances where a telemedicine visit results in advice to come into the office because the patient does need to be seen,” she says. “You can only bill one visit per patient per day, so it’s just the office visit. The telemedicine visit is separately billed, but you can bill for total time spent on the day of the encounter. If you’re coding based on time, then you could add the time together for the telemedicine visit and the in-office visit.”

She notes that this is also a good reason to get your practice’s documentation in order, because properly documented activities are more likely to withstand scrutiny from insurance companies. Enos says that over the past year of audits she had seen some bullet statements listing only the total time spent on one or more of a list of the activities that count without a specific time accounting of time spent on each task. “I would not want insurance companies to audit that I may have done one of the following,” she says. “That doesn’t seem very provable.”

A physician’s goal is to care for patients, but a key part of being able to provide that care is the eternal quest for payment. One way to ensure that a practice maximizes its coding regimen is to make sure each session can be efficiently billed.

Proper coding gets  practices what they are owed

I wish I could do more paperwork,” said no doctor, ever.

Tasks such as filling out forms, checking boxes and fighting with insurance companies have long irritated physicians. But several trends have converged in recent years to bring what had been simmering discontent over administrative and regulatory burden to a boil. Chief among these are the spread of electronic health records (EHRs) and their accompanying documentation requirements, and the growing number of procedures and medications requiring prior authorizations.

Then, in 2020, the brew of physician frustration grew even more toxic with the arrival of COVID-19. Suddenly, doctors found themselves confronted with a whole new array of health and safety mandates, along with needing to reconfigure their practices to care for patients remotely rather than in person.

The impact of paperwork, regulatory burden

Given these developments, it’s hardly surprising that “too much paperwork and regulations” was the leading cause of burnout cited in the 2021 

® Physician Burnout and Wellness Survey. Similarly, 91% of those surveyed by the Medical Group Management Association (MGMA) for its 2021 regulatory burden report said their overall regulatory burden had increased during the previous year — up from 86% in 2018 and 2019.

But even if some administrative tasks are unavoidable in fee-for-service medicine, practice consultants and management experts say there is still much doctors can do to reduce their share of the paperwork load and free up more time for seeing patients.

One of the biggest sources of paperwork and administrative tasks is the EHR. Numerous studies have documented EHRs’ impact on the amount of time doctors spend with patients and their overall workloads. For example, a 2016 study of 57 doctors’ daily activities published in 

 found that physicians spent 49% of their total time on EHR and desk work and only 27% on direct clinical face time with patients.

“The EHR has been and continues to be a huge source of added time and frustration for physicians,” says Adrienne Lloyd, MHA, FACHE, founder and CEO of consulting firm Optimize Healthcare and a former MGMA practice consultant. “Most of them understand the need for it from a medical perspective but it’s not a value added from the patient perspective.”

EHRs actually pose three separate, interconnected challenges for physicians in outpatient practices, according to Ron Holder, M.H.A., MGMA’s chief operating officer. First is their lack of user-friendliness, a flaw arising from the fact that they weren’t originally designed for medical purposes.

“A lot of EHRs are really billing systems disguised as a medical record,” Holder explains “So if the technology is designed for simplification of the billing process, that rarely translates into ease of use when working with it clinically.” And while vendors have made some progress in correcting this, many users still find them difficult to navigate and counterintuitive and resent the additional hours of charting they create.

The second problem, says Holder, arises from the frequent mismatch between the needs of outpatient primary care practices and their parent hospital system. “If you’re part of an integrated delivery system it’s likely that the people making the purchasing decisions are buying an EHR that looks good for a hospital, but that often doesn’t translate into being user friendly for an outpatient practice,” he says. “When you take a product that was designed to do X and try and make it do Y it’s going to cause a lot of frustration.”

Finally, when selecting an EHR system many practices don’t consider how it’s going to affect their workflow. “They mistakenly think they can beat the EHR round hole into the square peg of how they’ve always practiced,” Holder says. Ultimately, he adds, most practices find it’s better to tailor their workflows to fit the EHR rather than the other way around.

“You have to be willing to use the tool how it’s supposed to be used,” Holder adds. “It stinks at the beginning, but it gets much easier later on.”

So what can primary care doctors, and the practices that employ them, do to ease some of the administrative burdens caused by EHRs? A good place to start, and one that’s been growing in popularity, is to use scribes to document patient visits. In a 2018 

 study, 69% of PCPs using scribes reported spending an hour per day less on EHR documentation compared with those not using scribes, 94 % reported greater job satisfaction and 89% reported improved clinical interaction with scribes present.

While some practices balk at the cost of hiring scribes, in many cases they pay for themselves through time savings and added efficiency, notes Owen Dahl, MBA, CHBC, principal of Owen Dahl Consulting. “If I can get, say, $70 for a (CPT code) 99213 established patient office visit, and a scribe allows me to see two more patients per day, then I’ve paid for that scribe,” he notes.

Another technique for improving EHR efficiency, according to Lloyd, is to build order sets and templates. The former consist of services the doctor routinely orders for patients when they reach a certain age or have a chronic condition.

“The EHR generates everything that’s needed (for those services) so the doctor doesn’t have to hunt for each one separately, which makes the process a lot easier for them,” she says.

In a related way, templates enable physicians to standardize and customize their notes, with different fields for vital signs and other things the doctor might want to check,again depending on the patient’s age, gender and chronic conditions. The EHR can then be programmed to use that information as the basis for a note. “So there are ways of building in some automation so the doctor doesn’t have to repeat the same step for each patient,” Lloyd explains.

Sometimes the biggest obstacle to implementing such shortcuts is the doctors themselves, Lloyd says. “It’s getting them to take the time to step back and look at what they do most often so you can build those templates and order sets for them. And it doesn’t take a ton of time; it’s just getting the providers to believe it will help them and getting someone to execute on those things from an IT perspective.”

The technical skills needed for configuring the EHR may require an outside consultant but sometimes a tech-savvy person already on staff is enough. “Even in a small practice often there’s at least one person who can help with configuring the system to what the doctors want and serve as a liaison to the EHR vendor,” she says. “If you’ve got that person it’s a nice opportunity for them to be helpful outside their usual role.”

Practices can enlist patients in the effort to reduce administrative burden, says Holder, by encouraging them to submit basic medical information online so it can be seamlessly entered into their electronic medical record.

“I read an article recently that said even motor vehicle departments are better than many practices at getting people to fill out this stuff before they come in,” he says. “When the DMV is being held up as an example you know you’ve got a problem.” Practices buying or switching EHRs can reduce headaches by learning as much as possible about the system in advance, Holder advises. That is best done by talking to other practices who use it. In addition, have vendor representatives spend time at the practice observing how it operates and its patient flow. “Ask them, ‘What would we have to do different in order to efficiently use your system?’” he says.

The time demands of prior authorizations are another source of frustration for many doctors. In MGMA’s regulatory burden report, 88% of respondents called prior authorization requirements “very” or “extremely” burdensome, up from 82% who used those terms in 2018.

But while prior auths may not be avoidable, experts say there are ways to minimize the burden they impose. One of the most effective, says Dahl, is to compile a running list of which procedures and prescription medications require prior auths from which payers, and under what circumstances. Such information usually can be obtained from the payer’s website and by calling them.

Sometimes, he adds, a payer’s prior authorization requirements will vary even from patient to patient, so it’s important to include the practice’s own prior auth requests and their outcomes. “Don’t just say, ‘We got the authorization’ and leave it at that,” Dahl advises. “Audit what happens with the denials and the authorization hassles encountered. Be aware of the documentation required and ask, ‘Are we providing that documentation and doing so in a timely manner?’”

Analyzing this information usually will clarify which procedures routinely need prior auths from which payers and therefore can be obtained without the doctor getting involved. “I suspect most practices would find the doctor is only needed in about 20% of requests,” he says.

But this process doesn’t relieve doctors of all prior auth responsibilities, Dahl adds. “There’s still some burden on the doctor to make sure what they’re ordering is adequately documented and that there’s sufficient information for the staff to take on the responsibility of communicating with the payer,” he says.

Holder says thorough documentation provides useful ammunition for the times when, even after submitting it, the payer requires a physician-to-physician phone call before it will authorize coverage. “That allows you to say to them, ‘The information is all there in my note. Why am I having to call about this?’” he says.

Holder adds that prior authorizations can become part of payer contract negotiations by, for example, specifying the circumstances under which the doctor does and does not have to get involved in the process. “You can make the argument (to the payer) that they’re limiting your ability to care for their patients by having to spend time on the phone with them,” he points out.

In addition to EHRs and prior auths, experts say doctors can reduce their non-clinical workload by delegating tasks that don’t require the doctor’s input — and ensuring staff members are trained to do them. Lloyd cites the example of assigning a staffer to take patients’ medical histories before they see the doctor.

“The staffer will need to know what information the doctor wants to have before walking in the room with that patient,” she says. “It’s all about allowing the provider to focus on the areas where they can have maximum impact.”

The ability to delegate effectively also requires strong bonds between doctors and staff, says Holder. “Then people are acting out of loyalty. They know you’re working to make them successful and happy and when that happens the team wants to take as much off the physician’s plate as they can.”

Is AI the solution to documentation woes?

Since computers—in the form of electronic health records—have caused so much of the paperwork burdening primary care doctors nowadays, could they also provide a way to reduce that burden? A project underway at the American Academy of Family Physicians (AAFP) suggests that they could.

AAFP has partnered with Suki, a manufacturer of software that integrates voice recognition and artificial intelligence, to develop AI Assistant for Documentation, a program that combines machine learning — a technology that mimics the human brain’s neural network — and voice recognition software to generate documentation of patient visits.

In December 2021, the AAFP announced results of the second phase of a study of the program’s effectiveness. It found that primary care practices using the program saw a 72% reduction in the median documentation time per note, resulting in a time savings of 3.3 hours per week per clinician. Participants also reported improved levels of job satisfaction and decreased feelings of burnout.

Steve Waldren, M.D., M.S., vice president and chief medical informatics officer for AAFP, said AI Assistant differs from standard voice recognition software in its greater ability to understand voice commands. “You can tell it things like, ‘Suki, change my abdominal exam note to ‘mildly distended,’ and it understands that it needs to go to the physical exam, then the abdomen section, and replace the text that’s there with what you just said.”

Waldren noted the program also can be synced with smartphones and other mobile devices, allowing users to dictate notes whenever and wherever they choose. “The nice thing about leveraging smartphones is that they’ve been designed to enable voice because of features like Siri and Google Assistant, which also means docs don’t have to purchase additional hardware to attain that flexibility.”

The program is available for purchase starting at $199, Waldren said.

Don’t let administrative burdens wreck your practice

Destroy busy work

Ransomware has never been a more serious threat for health care organizations, even small medical practices. So what should be done about it? Is it possible to defend yourself? Are there insurance products that can help protect your business in the event of a breach? To discuss these issues, 

® sat down with Peter A. Halprin, Esq., a partner in Pasich LLP’s New York office who specializes in complex insurance coverage matters in relation to cybercrime. The transcript below was edited for length and clarity.

 Let’s put the ransomware issue into context. How big of a problem is it in health care?

 It is a massive problem. We’re talking about billions of dollars in impacts. And I think the average cost of a breach tends to be around $2 million, with about 10% of that being ransomware payments, and the rest being recovery. As I said, the numbers are going up and up and up. So any number I’d give you is already stale. Unfortunately, the trend is only going to continue.

I think health care is a particularly risky sector in this regard for two reasons. One is there is lots of personal information. So data-rich target, if you will, and then the flip side being you’ve got a lot of proprietary systems, you’ve got a lot of older systems that haven’t been updated, don’t get regularly updated. I think in some ways, doctors, like lawyers — they’re focused on their craft. And they’re not necessarily focused on these other things, assuming, Why would anyone do this? Why would anyone target a medical facility or doctor’s office or anything else? And the answer is you’re a target-rich environment and (cybersecurity is) not a priority. So I think health care has continued to be a particularly fertile source for ransomware actors.

ME: How has the COVID-19 pandemic affected cybersecurity?

: Negatively, for sure. I think that the bad guys have taken advantage of people working from home, people being distracted. It’s very hard to stay focused on your tasks. All of a sudden, you get an email that comes in and it looks very convincing. And I’m telling you, the bad guys are bad. For example, people were getting emails in March of 2020 talking about the cure for COVID-19, or the email looked like it was coming from the World Health Organization or the CDC. So they took advantage of that. Cyber hygiene was definitely down.

I think the other side of it is that the bad actors are targeting specifically vulnerable institutions and organizations. So we saw attacks on vaccine research centers, hospitals, doctor’s offices. For those vulnerable sectors, part of their vulnerability is that it is a matter of life and death. The bad actors take advantage of that vulnerability.

ME: Is being targeted by hackers inevitable?

: I’m hesitant to say that it’s inevitable because I don’t want people to just throw their hands up, so I don’t love the word. But it is highly, highly probable that there will be an attack or there will be some form of cyber incident or cybercrime involving a health care institution.

So the question is, knowing that there’s that high probability, how do you address that? You really want to beef up your security, what I call cyber hygiene. It’s protecting your business, it’s making sure that people don’t click those bad links, it’s making sure that you clearly identify when an email comes from an outside source, it’s making sure that sensitive areas in a business are closed off so that people can’t penetrate security.

The second instance can come in the form of limiting access. If someone’s able to access your account, then they can get no further than what you can access. It’s that kind of internal security.

ME: What about cyber liability insurance?

Halprin: Yes, the third layer is cyber insurance. So you get insurance for when things go wrong. This is the same kind of product. Once you have that in place, remember, it’s not a fail-safe; it’s not a defensive system. That’s why I say it’s the third and final resort. But it offers two things. It offers bottom-line protection: Let’s say you have $10 million worth of coverage, and then the bad thing happens. You know that you can be restored up to the $10 million that hit your bottom line.

The other thing that cyber insurance often entails is breach response services. So they can help you build out a program to protect yourself when something happens. They can provide you with vendors, they can provide you with legal counsel, they can provide you with public relations experts, and so they can help build that suite of services around you and your business that are needed to deal with an incident.

Now, most businesses have their own cybersecurity plans and their own incident response plans. One of the biggest flaws that I see in incident response planning is that a company will have its own incident response plan, and then it will also have these cyber insurance resources, but they won’t be integrated. And so the problem there is if you use your own people, and you don’t get consent to use them, the insurance company might say, Hey, we’re not paying for that. So the best thing that you can do is work to get insurance involved on the front end working to make sure the insurance company signed off on the plan so that seamlessly integrates. So when something bad happens, you can bring all those resources to bear.

ME: Should health care organizations ever pay the ransom?

: This is probably one of the trickiest moral and ethical dilemmas for businesses. As a lawyer, I can’t advise anyone to break the law. And if you speak to law enforcement, the overwhelming suggestion is don’t pay. The reason they don’t want you to pay is they don’t want the criminals to be incentivized to continue doing what they’re doing. There are also sometimes actors that are on the sanctions list, right? They’re people that we as a country do not permit our citizens to engage with. So there are a lot of considerations as to why it’s not a good idea to pay.

One other consideration about not paying is sometimes you pay and the actor stays in your system and continues to extort. So you’re not even promised that you’ll get free and clear access from paying. And then even the worst part is, you could get free and clear access, but everything’s corrupted now that they’ve left. And so you get very little for what you pay. Those are all the reasons not to.

But what I think businesses often do practically, especially those in the health care space, is they just pay. I can’t give you a number or a statistic. But overwhelmingly when clients are hiring me and they’re fighting with their insurer; oftentimes it’s because they want to get the insurer to cover the ransom. And I would say if you have a cyber policy that covers ransomware, insurers are amenable to you making those payments and to reimbursing those payments.

ME: Something we often hear from physicians at small or solo practices is they don’t believe they are really being targeted. How true is that?

: It’s not true at all. It’s more kind of a buckshot and goes in a lot of different directions. I don’t think (hackers) are necessarily saying, I want to hit small practices in the Midwest, but it may necessarily end up being that way. There are targeted attacks, for sure, which do end up hitting the larger organizations, but I think that for the smaller medical practices, it’s not necessarily because they picked you. It was more that you happen to have a vulnerability that’s not patched.

ME: Is there anything else that’s important for physicians to know about the subject that we haven’t discussed?

: Just to take this seriously. Some of the questions that physicians have: If I’m going to get hit with this anyway, what’s the point? Why bother? I think the answer is you still want to be prepared. And you still want to take precautions. Because if you’re too nonchalant about it, it could end your business.

Physicians, are you ready for a ransomware attack?

As 2022 moves along, I think it is time to take stock of where we have been and where we are going. As I reflect on the difficulties of the past two years, I find reason for optimism. First, our health care system has been stretched to the breaking point but was held together by the dedication of an amazing workforce. The struggles of this pandemic have clearly illustrated our weaknesses. As the grip of COVID-19 lessens, I am hopeful we can honestly discuss how to be better prepared next time and fix our health care system flaws.

Such conversations are already beginning at the local level. Maybe these collaborative discussions will trickle up to policymakers. It is often in times of struggle that we find the will to make changes for the better.

I am hopeful that preparation for the next public health emergency involves not just our public health institutions and hospitals but also the rest of the health care workforce, those closest to the patients and their communities. Primary care practices, local pharmacies, nursing homes and emergency medical services, for example, all need to be part of any comprehensive response system. The power and innovation of the grassroots response by physicians and nurses gives me hope.

I am hopeful that the loss of bedside nurses will lead to better pay and staffing for these essential professionals. The flight away from clinical nursing in favor of administrative, nurse practitioner or other roles began long ago. The pandemic only spotlighted the weakness in our system and the lack of support for these vital staff members. I hope we improve staffing ratios, pay and appreciation for our clinical nursing professionals.

I am hopeful that all our trusted physicians and other health care clinicians will rediscover their connection with their patients. We have been sidelined too long and need to be the voice of truth and reason on subjects of health.

I am hopeful that the power of telemedicine will be retained and permanently reimbursed by payers at the same level as in-person visits, so that primary care physicians and other providers can use it to expand access, convenience and continuity for their patients. I am hopeful that we will begin to address our country’s mental health needs and recognize that mental health services are key primary care services and belong integrated in our primary care system.

I am hopeful that we will evaluate any improvements in outcomes promised by value- based contracting and will strive to simplify and standardize the rules and metrics of value-based care. While we’re at it, let’s look at the impact of consolidation and venture capital on our health care system.

I am hopeful that the growing call for increased investment in primary care will be heeded. We need payment improvements to support rural physicians and independent practices because these practices are a vital access point for many underserved populations and communities.

I am hopeful that the call for more investment in primary care will bring a significant increase in primary care residency positions and incentives for medical students to choose primary care as a career. I am hopeful that the need for more primary care will lead to discussion of the ideal mix of primary care physician, physician assistant and nurse practitioner resources needed in this country and that we ensure adequate training and standard certification of all clinicians. There is also a need for transparency surrounding the credentials of each type of primary care clinician seeing patients. The public has the right to know the training and credentials of any professional providing them service.

I am hopeful we will address the needs of our elderly and begin to make improvements that support patients growing old gracefully. Finally, am I hopeful or just wishful? I am hopeful because I see in our new residents and young graduates a passion for service, energy and professionalism that will rise above the politics and business of medicine that often get in the way of true change. Here’s to 2022 being the year that we begin to make significant strides in improving the U.S. health care system.

is a family physician and editor-in-chief of 

It is time to take stock of where we have been and where we are going.

A physician's hopes for 2022

Tim Travis is the CEO/CIO and founder of T&T Capital Management, an investment advisory located in Orange County, California. T&T utilizes a deep value investment approach and offers customized portfolio management for clients across the country. The firm is celebrating its 10th anniversary this year and Travis has been in the investment business for nearly 20 years. Seeking Alpha (SA) sat down with Travis to discuss why he also researches the bearish side for potential long ideas, how/why he uses options and why persistence is an undervalued investing characteristic.

: Walk us through your investment decision making process. What area of the market do you focus on and what strategies do you employ?

: Our investment process is focused on maximizing risk-adjusted returns. We begin by trying to identify securities that trade at large discounts to intrinsic value to ensure an adequate margin of safety and create strong upside potential. When we have narrowed down our favorite opportunities, we look at how best to capitalize on them. This often means buying the equity, or perhaps the debt is the better play. It can also mean a more conservative and income-generating strategy such as cash-secured puts or covered calls. This is where the customization of the portfolio comes into play and taking into consideration client risk tolerances and investment objectives.

We do not focus on any one area of the market, but usually we are attracted to areas that are temporarily out of favor, as we tend to find more attractive investment opportunities in those areas. One of the benefits of having been in the business for a long time now is that we are constantly expanding our circle of competence to other industries and companies. Our knowledge of financial stocks is an advantage, but we have invested and had success across a broad spectrum of industries thankfully.

: Do you think there’s an edge from “time arbitrage” (a longer holding period)? Is this an edge that will never be competed away? Are there any specific lessons you’ve learned from holding (and intensively following) a stock for years?

: I absolutely think there is time arbitrage from holding stocks over a longer period of time. Undervalued stocks are often priced cheaply because of difficult short-term conditions. It is uncomfortable to buy stocks when you know the next few quarters are likely to be disappointing, due to a challenging economic environment or whatever the case may be. I think being a truly long-term investor is tougher sale for Wall Street, and an even harder practice to employ psychologically, so I do think it is a durable competitive advantage.

Following a stock for years is enormously beneficial. You get a good feel for management and how they react to challenges and opportunities. Generally, the warts of the business emerge over the microscope of time. Sometimes, as we saw last year, stock prices will drop to truly nonsensical prices on businesses you know deeply, allowing you to bet big and with conviction. ALLY Financial (NYSE:ALLY) was a great example of that. The stock traded down from the $30’s to less than $10 due to C-19/lockdown fears, which implied losses far greater than seen during the Great Recession. I couldn’t justify the price whatsoever, which meant buying big and taking advantage of that dip. Now the stock trades in the mid $50’s, and I still wouldn’t be shocked to see a big bank buy it if they could clear the regulatory hurdles, but I no longer see the clear and obvious margin of safety and upside potential that it had before.

 How do you use management guidance and investor presentations in your analysis? Can you give an example?

: Rarely does anyone know the business better than management, so I certainly use their guidance and investor presentations in my analysis. I don’t focus on any one quarter, but instead look at how they evolve over time. This includes investor conferences where the investment bank conducting it might target specifics areas of the business such as technology, or drug development etc. Over time the mosaic comes together. Does management deliver on their forecasts? Are they overly promotional? Is there a lot of management turnover? ALLY is a great example of a management team that has regularly beaten its forecasts and delivered on its goals, while not being overly promotional. That gives you a lot of confidence, especially when they are dealing with a recessionary environment. Other companies such as Cleveland-Cliffs (NYSE:CLF) and Assured Guaranty (NYSE:AGO) have also been very solid in how they have publicly communicated with investors. The Cliffs earnings calls are usually my favorite due to the CEO’s style and his ability to deliver on what he says.

 If you own a stock (and/or are thinking about buying it), do you research the bearish side? If so, how do you separate the legitimate from the not so legitimate bearish arguments and determine if it’s already priced in? Have you ever exited a long position (or not bought in the first place) after reading a persuasive bearish thesis?

Everything you need to know about deep value investing for the long-term.

Medical Economics April 2022