® asks our physician readers what challenges they are facing in their practices. And every year, we get the same answer as the top challenge: administrative burdens.

For our first issue of 2023, we decided to take a stab at fleshing out
what some of those administrative burdens are and what physicians
can do about them in their practice. We focused on five
administrative burdens that our readers commonly tell us
are major issues.

The number of prior authorization requests continues to increase — despite promises to the contrary by payers — costing physicians time and money. A Medical Group Management Association (MGMA) poll found that 70% of medical groups indicated that prior authorizations increased in the last year.

Physicians say that their practices continue to struggle with either a lack of response or no response from payers, increased time spent by staff to try to gain approval and a lack of automation in the process.

All these difficulties can lead to delays in patient care. A University of Colorado study found that 93% of physicians reported care delays and that 82% reported cases of treatment abandonment (when the patient does not follow through) because of prior authorization requirements.

“There’s not one standardized way to submit prior authorizations or additional information — maybe clinical information or chart information — to the health plans,” says Anders Gilberg, senior vice president of government affairs for MGMA. “Each health plan thinks they have the best proprietary way to make it really easy.”

But with practices dealing with
20 to 30 payers, that can mean 20 to 30 different websites and passwords.

“The way it works is you have to hire staff to go in there and learn each one of those processes, which is time-consuming and redundant,” says Gilberg. “Ideally, we’re looking for one standard and one way of submitting them, such as pushing a button or maybe having it integrated with an electronic medical record and the clinical record. We could provide the information health plans need but do so in a streamlined way that isn’t just multiplied by 20 and having that staff burden.”

Although that solution doesn’t exist yet and physicians can’t change the prior authorization demands from payers, they can take the following steps to minimize the burden.

Designate a prior authorization champion. 

Having one person run point on prior authorizations will help that person learn what each payer wants and the best ways to get authorizations approved in a timely manner.

All it takes is one piece of information to be missing from a patient’s chart for a payer to deny the authorization. Always keep this in mind when documenting a patient’s condition and what tests have been done. If something is abnormal, document it.

Payers will have different requirements before authorizing tests like an MRI. If the payer requires an X-ray first, make a note of that for future reference and complete as many of the requirements as possible before submitting the prior authorization.

Just because a payer denies the first request doesn’t mean you should give up. Some payers have staff with minimal medical backgrounds who review initial requests and may just be looking for key “trigger” words as a reason to reject a claim. An appeal will most likely go to someone with more medical training.

 Have the patient call the insurance company if necessary. They will be talking to a different department and may either get a different answer or gain clues on what is needed to get the prior authorization approved.

There is little point in arguing with a payer-employed nurse over a complex medical issue that may be well outside their expertise. Ask for a peer-to-peer review or, in extreme cases, to speak with the medical director or chief medical officer. They still may not have experience in the relevant specialty but will at least have a background to better understand the specific challenge being addressed.

Staffing has emerged as a top issue for physicians, and heading into 2023, the situation may be going from bad to worse.

In 2022, lack of staffing was one of the toughest issues identified by 

®’ annual physician report and a MGMA survey. Most physicians reported shortages across all roles, and according to the latest findings from The Physicians Foundation, 73% had significant or moderate shortages of registered nurses.

“What we’re seeing across the board, regardless of whether it’s a physician-owned or hospital-owned practice, is that it’s a challenge to recruit and retain support staff,” says Ron Holder, M.H.A., chief operating officer for MGMA. “And support staff — medical assistants, nurses and office staff — are critically important for physicians’ practices to succeed. And their challenges are compensation and costs keeping with inflation.”

What are the best ways to keep employees and find new ones?

All the strategies recommended for 2022 — increasing pay and perks, having flexible work hours, listening to employees’ suggestions for workplace improvement and more — could still work in 2023. What follows are more tips to take your recruitment and retention to the next level this year.

Get ready to pay, especially for office staff.

 Holder notes that when restaurants, retailers or other businesses pay more than doctors’ practices, clerical workers can take their organizational and customer service skills where they can make more money.

All staff should work at the top of their license.

 “Working on top of licensure is doing the things that they were trained to do and not having to do things that other people in the practice could effectively do at a lower level of licensure,” Holder says. “You have to maximize your licensure at every level.”

If your practice is shorthanded, don’t just pile more work onto everyone else. That can lead to feelings of dissatisfaction that make employees look for new jobs, Holder says. If they leave, that could make the situation worse. In 2022, some MGMA members reported closing practices one additional day a week to spread staff across their locations to avoid cutting hours.

If you’re in a small practice, embrace flexibility. 

Staff crunches in large health systems lead to analyses about pay changes for dozens, perhaps hundreds, of employees. Small practices don’t have that burden, Holder notes. “If you only have two medical assistants in your practice and one of them leaves, you basically can adjust your pay grade on the fly in order to recruit back for that one,” he says.

Although early careerists with one to two years of experience are sparking bidding wars in the hunt for new workers, Holder says they should not start at higher salaries than staff with more experience.

 Recruiting and retaining staff with minimum qualifications and less experience often are more difficult than keeping those with 10 or more years of experience and who may stay with an organization for reasons beyond just a salary.

“Therefore, it’s a contemporary practice to be more dynamic to those who would be lower in the pay grade, moving them toward the midpoint faster, with growth in pay slowing a little in the higher part of the pay grade,” Holder says. “You have to be dynamic for those people who are looking to grow their compensation the fastest because if you don’t, someone else might.”

Look for ways that every worker can reduce the number of clicks to complete tasks and for ways that medical assistants can help with record entry and patient intake.

t wasn’t so long ago, relatively speaking, that doctors and medical practices had only a few ways of communicating with patients (and vice versa): in person, by landline telephone, or via U.S. mail.

Now those days seem as quaint as the era of travel by horse and buggy. Today medical providers and patients have a myriad of new communication tools at their disposal, such as text messaging, telehealth, patient portals and social media platforms — not to mention the widespread use of cell phones.

The explosion in communication technologies brings numerous challenges for doctors and medical practices, starting with patient expectations. Patients, especially younger ones, expect the same ease and convenience in communicating with their doctor that they find when shopping or ordering a meal online. In a recent survey of 2,000 adults, 61% said they wanted health care to mimic the experience provided by a customer service app, and 79% said they wanted the ability to use technology to manage their overall health care experience.

“Patients want the convenience of connecting with your practice however and whenever they want — by phone, website or text, inside or outside office hours,” says Justin Jacobson, vice president of patient engagement solutions for Nuance Communications Inc., a technology company that offers conversational artificial intelligence solutions.

COVID-19’s arrival further highlighted the importance that patients place on communicating with their doctor. In a 2021 survey of patients by health care software company SymphonyRM, now Actium Health, 41% of respondents said they had less confidence in their doctor since the arrival of COVID-19, mainly due to a lack of communication about the disease. Conversely, those who reported more confidence said it was due to their provider’s rapid transition to virtual care, frequency of communication about COVID-19 and use of digital communication tools.

For medical practices, the implications are clear. Their success increasingly depends on their ability to acquire and integrate the communication channels that patients have come to expect in other aspects of their daily lives. Practices that meet those expectations can reap benefits such as higher levels of patient engagement and loyalty, a stronger bottom line and improved patient outcomes.

Among the newer communication tools, texting may offer the most advantages for the least cost and effort. Practices can use automated text messages to remind patients of upcoming appointments (thereby reducing no-shows), share pre-appointment requirements such as fasting, and inform them when they are due to receive preventive services like colonoscopies and vaccinations.

In addition, follow-up text messages are more effective than telephone calls at reducing hospital readmissions or emergency department visits following hospital discharge, according to a 2022 study published in 

A further benefit of texting is its popularity with patients. A 2021 health survey by Healthcare Information and Management Systems Society/Solutionreach Inc. found that 65% of patients want to get appointment confirmation/reminders and pre-visit care instructions via text message. Moreover, more than one-third of those surveyed — including 64% of those age 50 and younger — said they’d be willing to change providers to receive text messages and other modern forms of communication. Nearly 90% cited convenience as the primary reason why they preferred texting versus other means of communicating with their doctor.

Ultimately, the goal of all patient communications should be to create an approach that “empowers patients to become active participants in their care,” says Gary Hamilton, CEO of 

, a developer and provider of patient engagement solutions. “This requires physicians and all other medical staff to develop good communication skills and address patient needs effectively.”

Here are three tips for using new technologies to improve patient communications:

Try to meet patients where they are. Find out what mode of communication each patient prefers and use it as much as possible when communicating with that patient.

Install and use as many different communication forms as your practice budget allows, and let patients know you have them and how to use them.

Assign a staff member responsibility for monitoring the patient portal, including answering patients’ questions about how to use it and what information is available on it and triaging messages and requests that come through it.

Providing care management services, including chronic care management (CCM) and principal care management (PCM), is not easy.

The first overarching challenge is that not enough patients actually participate in care management with a primary care physician. In fact, a recent 

 from the Primary Care Collaborative and the American Academy of Family Physicians’ Robert Graham Center found that more Americans lack a consistent source of health care — most often primary care — despite the COVID-19 pandemic.

 — and particularly more than one — is growing fast,” says Tom Ferry, president and CEO of

, a CCM services provider. “So is the number of people aging into Medicare. One in 4 American adults and 66% of Medicare beneficiaries now have multiple chronic conditions. And the Medicare population increases by 1.5 million people annually.

“At the same time, fewer primary care providers are available to take care of this growing population, an issue compounded by 

 the field. These factors have created a situation that’s overwhelming the health care system.”

The second challenge, germane to the administrative burdens facing medical practices, is that managing care plans involves a good deal of coding and documentation so that physicians and their practices can get compensated for the time they spend on them. New codes, introduced in 2022, can benefit both physicians and patients but require understanding to make sure they are used correctly.

What follows is a brief explainer on using CCM and PCM codes correctly.

New Current Procedural Terminology (CPT) codes were added in early 2022 to describe PCM services. These codes are similar to CCM service codes in that the work involves the establishment, implementation, revision and monitoring of a care plan for a patient. However, PCM focuses on a single condition rather than two or more.

CPT code 99424 describes the first 30 minutes of a PCM service per calendar month provided by a physician or qualified health care professional. To capture each additional 30 minutes of service in addition to 99424, CPT code 99425 would be reported. CPT codes 99426 and 99427 also describe PCM services, but these are for clinical staff time directed by a physician or qualified health care professional.

Medicare now accepts CPT codes 99424, 99425, 99426 and 99427 and discontinued Healthcare Common Procedure Coding System codes G2064 and G2065.

For a detailed explanation for the codes, see PCM Services chart at left.

Reminder: CCM involves monitoring two or more chronic conditions. A new CPT code was created in early 2022 to describe each additional 30 minutes of a CCM service performed by a physician or qualified health care professional. CPT code 99437 may be reported in addition to CPT code 99491.

Quality metric reporting can be a significant challenge to health care administration due to a number of obstacles. First and foremost, you need buy-in from the physicians providing the care to the patients. Without this, it is difficult to make any meaningful changes to the pattern of care provided.

Second, it requires having a very robust quality and data analytics team in your health care system. The startup costs for this can be very high, and it may not always be easy to quantify the direct reimbursement seen from this.

“As medical practitioners, we strive to provide great quality care to our patients,” says Marc Afman, D.O., medical director of Clinical Integrated Network with University of Michigan Health-West in Wyoming, Michigan. “However, improving quality at the expense of increased costs does not lead to improved value to the community and the patients we serve. This has been a major paradigm shift on how we have practiced medicine in the past.”

Previously, he explains, physicians worked only in a fee-for-service environment with less emphasis placed on quality. In today’s health care landscape, physicians are asking providers to find the balance between providing exceptional quality to patients while still being mindful of the costs incurred to obtain this.

“A large focus of our efforts is on quality initiatives and reporting,” Afman says. “We are continually working with various payers on how to improve the quality of care provided from the payer perspective. Sometimes it comes down to making simple changes to the level of specificity of diagnosis coding or including additional appropriate diagnosis codes that explain the medical decision-making process (to determine) whether or not we get credit for some quality measures.”

Researchers have found that consumers are interested in quality measures that convey information about a physician’s technical care and interpersonal skills. Typically, technical quality is measured using clinical information found in administrative databases, electronic health records or medical charts, whereas interpersonal quality is measured using patient surveys.

The patient is always the first and foremost priority, but it’s now also important for physicians to maintain high-quality scores to be able to earn the reimbursement and quality ratings that enable the health system to continue to take care of the patient.

Leah Alexander, M.D., a pediatrician at PediatriCare Associates in Fair Lawn, New Jersey, notes that the quality of health care is important to patients, providers and payers and that in an effort to improve quality and value, many organizations are now focusing on quality metric reporting.

Although this can be a useful tool, it also presents some challenges.

“There is no standard definition of what constitutes a ‘quality’ metric,” she says. “This can make it difficult to compare data across different organizations. Additionally, collecting accurate data can be challenging. For example, electronic health records ... may not always capture all the relevant data points.”

Another challenge is that quality metrics often focus on process measures rather than outcome measures. This can make it difficult to assess whether a particular intervention is actually improving patient care. Also, some quality metrics may be subject to gaming, meaning that providers may focus on meeting the metric rather than on providing high-quality care.

“Despite these challenges, quality metric reporting can be a useful tool for improving quality and value in health care,” Alexander says. “To overcome the challenges, it is important to work with an experienced partner who can help you collect accurate data and interpret (these data) in a way that will improve patient care.”

Additionally, it is important to focus on outcome measures rather than process measures. By doing so, physicians can ensure that quality metrics are actually making a difference in the lives of their patients.

Articles

The five administrative burdens that trouble physicians the most

The top administrative challenges and what to do about them

Effective legal counsel has become a critical aspect of the modern medical practice. As practices grow and become more intimately involved in patients’ complete health care — including regimens of sleep, nutrition, lifestyle, and even wearables — there is more room for lapses, errors or disagreements that pose questions suitable for lawyers.

“Similarly, as the patient population becomes more autonomous and well informed, patients have legal questions for their medical practices,” says Benjamin Caplan, M.D., a family medicine physician and chief medical officer of CED Clinic in Chestnut Hill, Massachusetts. “As important as such queries are, there is precious little time left in their busy schedules for medical providers to distract themselves away from patient care.”

In addition to a doctor’s numerous clinical responsibilities, most medical practices are entering the digital data age, in which patient information holds potential value. As intellectual property, that value must be protected by appropriate legal counsel.

In the post-pandemic era, more than ever, medical practices are overwhelmed. “Inevitably, patient care comes with risks and benefits to both providers and patients,” Caplan says. “Both parties strive toward effective, open communication, and most often everyone hopes to avoid disagreements or offenses that must be resolved in the court system, or with lawyers.”

But all practices need attorneys. Consequently, such lawyers must be able to deftly navigate the complexities of relevant law while wrangling with the many players involved in most modern practices.

“In days long past, a medical provider was a single entity, and there were more simple communication channels,” Caplan says. Now, with nonphysician providers (nurse practitioners, physician assistants), insurance companies, outsourced billing, scheduling, administration, call center staff, and even complex ownership roles, legal entanglements can be increasingly convoluted.

“These intricacies require knowledge and understanding, and its effective navigation demands considerable billable hours,” Caplan says. “All of these point to a huge advantage to lawyers who are experienced, knowledgeable or at least willing to work with ever less lucrative medical practices to support their needs in a financially sustainable manner.”

Attorneys’ Knowledge, Reputation Are Selling Points

When it comes to selecting counsel, a lawyer’s knowledge and reputation are of paramount importance to most physician practices. Often a practice has several attorneys; each has a specialty, be it contracts, audits or handling malpractice complaints.

When searching for a contract lawyer, Jordan Grumet, MD, an internist in Northbrook, Illinois, had a checklist. It included someone adept at explaining and translating legal jargon into medical, who was free of conflict and familiar with the laws of the area in which he worked. For audits or disagreements with insurance companies, Grumet looked for a lawyer with experience with Medicare or the specific company, as well as a risk-mitigation mindset. For malpractice disputes, it was important to find a tenacious, experienced deal-maker or breaker.

Rudolf Probst, M.D., who specializes in internal medicine and surgery and works with Audiology Research, notes that when choosing an attorney, a practice needs to find someone who is trustworthy, has an office nearby, does not waver under pressure and has medical understanding.

Lawyers with affordable rates who provide thoughtful, attentive services beyond assuaging concerns and putting out fires also become invaluable to a medical practice client.

“Having a team of support on the legal team, where costs of research and education can be leveraged across less costly team members, is a valuable offering,” Caplan says. “Knowledge of the law, of course, is priority No. 1, but being able to defuse tension, communicate effectively with clients and patients, and ideally corrected broken or ineffective communication so as to avoid legal entanglements is an invaluable skill set too.”

Most medical practices communicate with and recommend legal teams that have proven effective. There are no free trial periods with lawyers, so an effective track record is important. Because an open, honest relationship is imperative, the practice and individuals dealing with the attorney must feel comfortable reaching out without hesitation.

Christopher Ryan, counsel and health care litigation task force co-chair at Dickinson Wright in Ann Arbor, Michigan, agrees that medical practices should look for lawyers who regularly deal with health care matters and clients.

“Health care clients are required to abide by numerous laws and regulations unique to the health care industry, and therefore need to take into account many issues that other businesses may not need to consider,” he says. “A lawyer with experience in the health care sector can help clients identify issues that other attorneys may miss.”

It is critical for the lawyer to understand the goals of the client. Sometimes the goal may be obvious, but other times it is less so.

“Many legal issues can be addressed in a variety of different ways, and oftentimes there is no ‘one’ right answer,” Ryan says. “Understanding the goals of the client will help the attorney provide relevant and helpful advice designed to meet the client’s objectives.”

Lana Ros, a partner in Pashman Stein Walder Hayden in Purchase, New York, notes that because health care is highly regulated with many complex laws and regulations, it is crucial that the attorney be well versed in health care law in the state in which the medical practice is located. Additionally, because a medical practice is a business with employees, the attorney or their firm should have knowledge and experience in employment and business law.

“Having expertise in these areas would make for a well-versed lawyer who is able to advise on day-to-day operations, as well as handle the majority of the issues and transactions associated with medical practices,” Ros says. “Aside from knowledge and experience, the practice should take into account their comfort level with the attorney. For the relationship to be beneficial to the practice, the practice must feel comfortable to be open and honest with the attorney.”

An attorney familiar with the operations is in a better position to provide advice that is applicable and tailored for the practice. “Each practice has its own personality, and one of the benefits of having an attorney familiar with the inner workings of the practice and its people is that the attorney can provide counsel that is relevant to the practice versus just generic advice,” Ros says. “Additionally, it is generally less time-consuming to seek guidance from an attorney who has a working knowledge of the practice because they are familiar with the structure of the practice and their operations, and the practice does not need to spend significant time on educating the attorney.”

For a relationship to work, the practice must feel comfortable with the attorney. If there is friction in reaching out to get the attorney involved in a matter or to seek counsel, then the relationship is not working.

“One of the benefits of having an attorney is to allow the practice the ability to be proactive on the legal front, and if the practice is resistant to seeking such guidance, that is counterproductive,” Ros says. “The attorney must also be professional and respectful of everyone at the practice.”

If practices get the sense that their lawyer may lack knowledge in a certain area or suspect the lawyer does not understand the client’s goals, it may be time to consider alternate counsel, or at least obtain a second opinion.

As practices grow and become more intimately involved in patients’ complete health care — including regimens of sleep, nutrition, lifestyle, and even wearables — there is more room for lapses, errors or disagreements that pose questions suitable for lawyers.

How physicians can find the right attorney

An important choice that investors face with every dime might be likened to the dilemma of the narrator of a poem by Robert Frost. In 

 the narrator recalls coming to a fork in the road and pondering which way to go.

For investors, one fork leads to active management — when investors choose investments themselves or pay professionals to do so. Or they could take the other road, into the terrain of passive management; here investors buy shares of funds whose holdings track a given index of stocks, bonds or other asset classes.

In active management, investors rely on their skills (often with poor results) or those of professional investment managers (with widely varying results) to make investment decisions.

By definition, all index funds are passive because their holdings track the movements of given indexes, such as the S&P 500. Most 

 are passive, although more and more new ETFs coming on the market 

Active management versus passive management is probably the most contentious ongoing debate in the investing world. At times, this debate is as contentious as that of Democrats versus Republicans or the merits of dogs versus cats or “Star Wars” versus “Star Trek.” As in all such debates, which is best for you depends on your goals and personal preferences, and making the best decision involves careful evaluation of the right information. Of course, this debate is fueled by investment companies that want your business, so it’s important for individual investors to block out this noise to make unbiased assessments.

Active investment generally means higher fees but potentially higher rewards. Also, many of the better active managers require a substantial minimum investment. These factors often make active management a good choice for at least part of the portfolios of many mid- or late-career physicians.

The argument for passive stock management, as proponents present it, is perennial, centering mainly on the idea that over time the major indexes rise on average. But various issues, including timing, individual goals, time horizon for retirement and risk tolerance, are important in choosing which way to go, making this choice much more complicated than simply relying on long-term market trends.

Moreover, unlike Frost’s narrator, investors can take both roads at the fork by using a combination of active and passive management, attempting to get the best of both worlds for different parts of their portfolios via different asset classes.

Passive can be pretty much set-it-and-forget-it — within limits. Yet even without major market shifts that might suggest advantages one way or the other, passive investing requires periodic rebalancing so that asset allocations don’t get too askew from the original design for purposes of portfolio diversification.

Yet the major stock indexes widely used in passive have their own risks, and this is perhaps the best argument for active investing — to steer around them. Risk management aside, active is also a way to position for potentially better gains.

As an active manager, I have an obvious bias. To my way of thinking, slavish devotion to passive investing is sort of un-American because this approach is inherently noncompetitive. When you buy a fund tracking an index, you will never beat that index, which can easily make you a C-minus investor from day one. Over the long haul, market averages might reduce risk, but during certain periods, you can suffer avoidable losses.

Of course, many investors are so afraid of getting a big, fat F that they go this route. But isn’t this accepting a midlevel finish in the Indianapolis 500 instead of going for the winner’s circle? Granted, many active managers can’t get you even close to drinking the milk or kissing the bricks at the raceway. But some can get you well ahead of the passive pack.

Statistically, most investors lack the psyche necessary for active management. They point to many active managers’ perennial failure to beat the market averages that passive can often yield. Yet, by using the right adviser in the right ways, you can have a pretty good chance of achieving asset-preservation goals, often beating the market to boot.

Criticisms of active management have been widely oversimplified, and the successes of passive over the past two decades came amid one of the greatest bull markets ever. Of course, major indexes are likely to rock during such periods.

The current market is a much different story. Since the long bull market transformed into a bear in January 2022, making money with passive management has become decidedly more difficult. Although the bear is probably now lumbering toward hibernation, tough markets likely lie ahead, with uneven recovery among different stock sectors and some indexes doing far better than others. In such markets, choosing the wrong passive fund can be injurious to your portfolio.

In late 2022, active management was having its best year since 2009 — the start of a long bull market, notably. Because this trend is likely to continue for the next few years, this is a time when active management merits consideration, even from current passive devotees.

Here are some reasons why now may be an especially opportune time to consider active management, at least for part of your stock portfolio:

The market recovery will likely be quite uneven, with some sectors shining early and others lagging for months or years. At this point, some sectors and indexes and the funds based on them are positioned to do better than others in the imminent recovery. For example, although many companies in the Nasdaq are badly beaten up by the bear and will likely rebound significantly, this index is populated by many smaller, earnings-challenged firms that are holding it back. Active management enables investors to select reasonably priced tech stocks with real earnings and profits — what I call 

 index — the larger the company, the greater impact it has on the index’s price movements — is heavily influenced by several huge companies, some of which are currently quite troubled. Though well-run funds tracking this index are often a good idea, owning too many shares in them now exposes investors disproportionately to the current travails of Amazon’s decreased sales in the post-pandemic era; Apple’s likely travails from economic headwinds (to which “not even Apple is immune,” notes analysis firm CFRA); Meta’s (formerly known as Facebook) costly and thus-far-premature commercial vision of the so-called metaverse; and Tesla’s share-price depression (a two-year low in late November) — as Elon Musk made headlines with his tragi-comic takeover of Twitter instead of using his cult of personality to pump his car company, as he usually does. Investors seeking to avoid overexposure to such companies can either choose more promising large-cap stocks or, if they have a penchant for passive funds, can buy shares in an 

. Both would enable investors to avoid excessive exposure to the few stocks that proportionately drive the S&P 500 as a cap-weighted fund.

 presents opportunities for active management. Major shifts like these can send funds downward before the average investor can get out, whereas a good active manager can position clients to exploit the effects of investment shifts that drive up values of equities on the receiving end.

Those approaching retirement should know that if you want income generation from a fund in the form of dividends, this usually narrows your options in actively managed equity funds, which tend to deliver income superior to that of passively managed funds. For those retiring soon, including practicing physicians lacking corporate pensions, dividend income is often a priority. Also, active management can be better suited to achieving wealth-preservation goals — a retirement priority.

Whichever road you take from Frost’s fork, it’s important not to stay at the fork too long, frozen with indecision. Choosing the right investment methodology is important, but a market recovery is imminent, if not current, and many prices will be rising soon. Ultimately, your gains from a stock depend on how low you get in.

is a 40-year veteran of the financial services industry. He is a partner and chief investment officer at 

, a portfolio management firm for individual investors, and at 

, an institutional money management firm. Based in Indianapolis, the firms manage about $1.3 billion in assets nationwide.

Now is the time for active portfolio management

It’s become somewhat of an annual tradition for healthcare market analysts and forecasters to assess the always tumultuous medical practice environment and predict trouble ahead for independent physicians. In recent years the tone has turned even more negative, amplified by pandemic practice closures, shrinking choices for doctors and ever-sharper increases in reports of career-destroying burnout. All signs may seem to point to further erosion of decades of autonomy and individual vision with a short list of options for physicians in 2023. These include becoming employed by a healthcare system, payor organization or private equity firm, retiring early, leaving medicine altogether - or making a change to concierge medicine. I believe concierge medicine is a practice model that can paint a completely different picture of the future, in full vibrant color, by consistently delivering on its bold promise to transform the physician-patient relationship, enhance the sustainability of private practice, reduce healthcare costs, and improve physician work/life balance. Consider these factors as you ponder your prospects for 2023.

Further stagnation of the status quo is a certainty.

 Even the staunchest optimist can’t make a case for financial improvement in 2023 as physicians in traditional fee-for-service practices will continue to battle market forces that place them at a considerable disadvantage.

“Increases in overhead decrease revenue to the operation and the physicians who are already burned out are taking reduced pay.” 2022 MGMA Cost and Revenue Survey Report

Diminishing government, and commercial insurance payments, plus constantly rising overhead costs and unrelenting inflation equals an unsustainable business model. The facts are:

The Medicare conversion factor used to calculate reimbursement was $36.69 in 1998, $34.61 in 2022, and is set to decline to $33.06 in 2023.

The overhead required to run a private practice has 

 in the last two decades, with rises in office rent, utilities, and office staff salaries due to inflation. According to the most recent MGMA survey, 90% of medical practices reported that their costs rose faster in 2022 than revenues, while only 10% said their revenues kept pace ahead of rising costs.

Unlike other businesses, there is scant opportunity to reverse the financial decline with increased production. There are already not enough hours in the day for primary care physicians, most of whom are managing full practices with no capacity for more patients. In fact, recent research from the 

 provided this eye-opening statistic: following national recommendation guidelines for preventive, chronic disease and acute care would take a primary care physician 26.7 hours per day to see an average number of patients.

A concierge medicine practice, with revenues primarily based on annual membership subscriptions, thrives without the need to depend on reimbursements or expanded patient panels. Throughout its 20-year history the model has proven to be robust and resilient in the face of economic downturns, high inflation, sweeping healthcare reform initiatives, and most recently, the pandemic.

“For years I rarely took time off because it affected our office’s cash flow. Eventually I realized I was running too hard and couldn't keep up that pace. Concierge medicine was just a much better way to do it.” – Concierge physician Dr. J.T.

The seismic shift to employment has not proved to be a panacea for physician burnout.

 Acceleration of a trend that had been growing for years was big news in 2022, when for the first time, less than half of U.S. doctors worked in physician-owned settings and were instead employed by hospitals and corporations. Yet physician burnout continued at an unacceptably high rate of 73% in the 

 survey published later that year. Additionally, recent research from 

 and MGMA found that 40% of medical groups reported that a physician had retired early or left the organization due to burnout in 2022.

“Many of the baby boom cohort of practitioners chose employment as a bridge to retirement and the rising number of women entering medicine traded independence for work-life balance.Viewing employment as a solution to work-related stress and burnout has proven simplistic, and many of the clinicians seeking shelter from these problems have not found it.”

The pendulum may well swing back from employed to independent in 2023. For many, including older physicians contemplating retirement from their stress-filled days and women doctors struggling to care well for patients and their own families, concierge medicine will provide a much-needed lifeline.

“Our change to a concierge medicine model has allowed me to continue practicing. I have plenty of energy and I look forward to coming into the office. It's a privilege to practice medicine in this way. And my only regret perhaps is, that we didn't do it five years earlier.” 

- Dr. C. B., concierge physician since 2020

While a great number of independent physicians in traditional, fee-for-service practices are committed to offering high quality care, continuing inadequate compensation will force change.

“Empirical evidence suggests that physician-owned private practices deliver quality that is equal to, or better than, practices owned by systems. These physicians care deeply about their practices and the roles they play in their communities. Some had a difficult time seeing a future for solo, small, and medium-sized physician-owned private practices…others were strategic in the way they managed change, adapting to new technologies, and new practice models.

The hard-working physicians who are already delivering concierge-like care in their traditional practice model are frequently the most frustrated, unable to glimpse any light at all at the end of their personal tunnel. In our experience, these physicians are also most likely to succeed when they make the change to concierge medicine, having built a sterling reputation and an unflaggingly loyal patient panel.

“We were facing not just the financial burdens of COVID and the fiscal realities of decrease in reimbursement, but tremendous burnout. There was always this feeling that you couldn't do enough, you were never finished. In the concierge medicine model, we can spend time with people. They do better, they appreciate that time, and the difference is really remarkable to me.”- 

Final thoughts for the new year: most physicians aren’t formally trained in the business of medicine, having rightly focused on science and the art of healing. But if you’re reading this publication, you probably already realize that independent physicians need that kind of knowledge to avoid becoming another casualty of our broken healthcare system. If you are interested in making a change to concierge medicine, I encourage you not to go it alone. Explore, ask, research and find a trusted partner who can provide guidance and expertise and is fully committed to your success. The choices you make in 2023 will define not just your own path, but the future of patient care in the United States.

, a concierge medicine pioneer that has transformed physicians’ professional lives since 2002.

Consider these factors as you ponder your prospects for the next year.

Where do you want to be in 2023?

For the video of this Bootcamp session, click 

With inflation at all-time highs and stock market returns struggling compared with recent years, physician investors are looking for new investment opportunities to grow their portfolios. One possibility that offers long-term growth plus passive income is investing in multifamily properties. By pooling money with other investors, physicians can participate in an investment through which an underperforming property is purchased, renovated and income boosted through a proven process.

The investor makes money from monthly returns — rents — and on the equity when the property is eventually sold. And the physician doesn’t have to actively manage anything.

This type of investment is different than a real estate investment trust (REIT), which has its own advantages for income and taxes, and gives the physician an alternative to the stock market roller coaster while providing the opportunity to invest in a segment of the real estate market that has proven resilient, even in the toughest economic times.

Introduce hands-off real estate investing for physicians.

Understand how to be an investor, not a landlord.

Build monthly cash flow and tax advantages.


Director, Investor Education
Ashcroft Capital

Travis Watts, a full-time apartment investor and the director of investor education at Ashcroft Capital, reveals how physicians, busy professionals and business owners can invest in multifamily real estate without being a landlord or having to manage tenants. He offered an exclusive look into real estate private placements, monthly passive income, tax benefits and much more.

Building monthly cash flow through multifamily real estate investment

For physicians looking for an alternative to a chaotic stock market, investing in multifamily real estate might be a way to boost their portfolios. When a physician decides to invest in a multifamily real estate fund run by an investment firm, Travis notes that experts at the firm identify the deals, raise the capital needed and manage the business plan, meaning the physician doesn’t have to do any active management. For example, Ashcroft Capital identifies properties that are undervalued with a lot of potential.

“We purchase a property, we rebrand it, we renovate it — the clubhouse, the amenities, the units, the common areas — and we reposition these assets to sell to institutional buyers,” says Watts. “We come in, we modernize and make these units more efficient, and we sell to institutions.”

The investment fund might purchase a property for which rents are lower than the current market rate. After the renovation, rates can be increased because the property is now nicer, safer and a more accommodating place to live.

For example, a 200-unit property in which rates are raised by $50 per month results in $120,000 in new annual income. But this added income also increases the price the property would sell for to a new buyer, and in this example, it could yield an additional $2.4 million to the sale price.

Watts says the potential payouts are much greater versus just being a landlord.

“It’s a lot different game than buying a single-family home where you’ve got a great renter paying above-market rents in a great neighborhood,” says Watts. “Because guess what? If we have a slowdown, if your neighbors have foreclosures and start selling underneath the values that were there one year ago, your house effectively went down in value no matter what you’re doing to it.”

The goal in multifamily real estate investing is to have an asset besides the stock market to diversify a portfolio with better tax benefits than a REIT.

“In most cases with REITs, you’re getting ordinary dividends, and that’s just tagging on to your overall active income tax bracket — and you’re just paying heavy taxes,” Watts says. “These private placements have great tax benefits.” Thanks to the depreciation of the real estate and the assets, it can be more than the distributions from the fund, meaning that in some cases, it can be a tax-free investment.

Watts says that the monthly cash flow can help enhance a physician’s lifestyle, pointing out that even $200 of passive monthly income can equal a house cleaner or a lawn service, which can make life that much easier.

“At the next level, it could be taking an extra vacation or two a year and being able to do something fun with the family,” he says.

Multifamily real estate also has a track record of performance, even during tumultuous economic times. During the Great Recession, Watts points out, national vacancy rates for multifamily properties were about 10%, and within two years, they were down to 7%. Properties with government-backed lending agencies had a default rate of less than 1% in that time period. During difficult financial times, these real estate funds can be a way to offset stock losses.

“With stocks down about 30% this year, just imagine if you had something that was constantly paying you on a monthly basis, 6%, 7%, 8%, 9% a year,” says Watts. “You’d be down that much less and have a buffer of that percentage. If the renters keep paying rent, the price of the real estate can be secondary in the short term (while you’re) waiting for the recovery to happen.”

Watts adds that with vacancy rates declining — because of fewer places for renters to choose from — and a projected 8% average increase in rent growth for 2022, the market is looking positive for multifamily real estate investments in the future.

Invest in multifamily properties as a stock market alternative.

Build your monthly passive income with minimum effort.

Achieve growth potential even in a
down market.

Avoid market volatility with a proven investment class.

Add multifamily real estate investing to your portfolio

Winter Bootcamp: Multifamily investing made simple

To view the video of this Bootcamp session, click 

Medical liability insurance is a key tool for any successful career in medicine, but busy physicians often don’t take the time to understand why coverage is important and the options available to them.

Understand why does you need medical professional liability insurance.

Review different types of carriers, policies and coverages.

Know the implications of “consent to settle.”

Learn the differences between independent physicians and facility employees when it comes to the application process and ratings factors for your application.

Understand the accepted standard of care and what happens when deviations are made (the filing of a lawsuit and why a trial happens).

Recognize the importance of peer support.


President and CEO
EmPRO Insurance Company

Professional liability insurance explained

The first thing physicians need to know about medical malpractice liability insurance is that the rules and carriers can vary dramatically from state to state, says Bruce Shulan, president and CEO of EmPRO Insurance Company.

What you need to know to keep your practice safe

Medical Economics January 2023

The top administrative challenges and what to do about them

How physicians can find the right attorney

Now is the time for active portfolio management

Where do you want to be in 2023?

Winter Bootcamp: Multifamily investing made simple

Medical professional liability insurance - what you need to know