If you knew you would be engaged in a future physical altercation, you would be best served by getting into shape and learning how to defend yourself well in advance. Even if the altercation never occurred, you would greatly benefit from the exercise and training involved in preparation. The same principle holds true when a medical practice prepares for a PE transaction.

Preparing for a PE transaction can help strengthen your practice’s business structure, even if you ultimately forgo potential PE opportunities. PE funds look for certain characteristics in target practices that maximize the potential for the practice to generate EBIDTA (earnings before interest, depreciation, taxes and amortization), which is essentially a fancy term for profits. If you follow the model of an ideal PE target practice, you will be in the best position to maximize your opportunity for success.

This article addresses five key areas in preparing for a PE transaction:

Focusing on these areas will improve your practice whether or not you intend to enter into a PE transaction.

PE funds seek investments that maximize profits and minimize risk. A very profitable target practice engaged in questionable regulatory behavior may be viewed less favorably than one that is not as profitable but squeaky clean. Potential recoupment actions by payers, along with possible federal or state government investigations, jeopardize a practice’s stability and future profitability. A practice anticipating a PE transaction should take basic steps to ensure regulatory compliance.

One step is to retain a third-party coding compliance firm to conduct a thorough audit of coding practices. Upcoding, improper use of modifiers and billing for services deemed not medically necessary all increase a practice’s risk of a recoupment action. It is important to understand that a procedure may not be deemed medically necessary even if it is reasonably determined to be needed for a patient’s care, if the documentation does not support doing the procedure. In other words, medical necessity requires appropriate documentation as much as it means that the procedure was literally necessary. A coding compliance firm can evaluate your practice’s coding and billing procedures and make recommendations on how to improve your process and reduce risk.

Another critical step in achieving regulatory compliance is to conduct a legal review of the practice’s business relationships. Sublease arrangements can be particularly risky if they are entered into with referral sources or recipients. Contracts with marketing companies or other third-party suppliers of health care services to the practice should also be analyzed. For instance, we have seen many internet marketing services whose compensation structure is tantamount to an illegal kickback scheme. Additionally, there are many providers of services such as mobile imaging and in-office infusion that may, often unwittingly, run afoul of the Office of Inspector General’s suspect joint venture fraud alert. The practice’s performance of in-office services such as physical therapy and laboratory should also be reviewed for compliance with the federal Stark law.

Maximizing your practice’s profitability or EBIDTA may seem obvious, but it is often approached in only one direction — working harder and increasing billings. Most PE transactions involve a payment based on some multiple of EBIDTA. If the PE firm pays seven times EBIDTA, every additional $100 of profit yields an incremental $700 in purchase price.

Cutting unnecessary costs has a direct, undiluted effect on a practice’s bottom line. Contact your medical malpractice broker and other insurance broker to see about lowering your premiums. Negotiate with your landlord — COVID-19 has placed pressure on landlords to reduce rent. Review your vendor agreements and try to shave a few percentage points. Review your health insurance and employee benefits plans to maximize benefits while minimizing cost.

Obviously, cutting costs will only go so far, so your focus should also be on changes that increase revenue. Review coding practices to see whether you are being overly conservative. Consider adding ancillary services such as specialty services, laboratory, imaging and in-office procedures. Evaluate whether bringing on an associate will increase the practice’s profitability.

Physicians and midlevel providers should spend as much time as possible performing billable work. Time spent by providers on administrative functions reduces profitability. Look for ways to optimize provider time.

Infrastructure consists of staffing, physical plant/equipment and processes. Practice leases should be reviewed and extended, unless the practice intends to move. Equipment should be reviewed to ensure that it is up-to-date and properly maintained. The practice should determine whether the best people are in the right positions, whether it is overstaffed or understaffed and whether the employee manual is current.

The practice should review information technology hardware and software systems, update, upgrade or replace as needed, confirm that it has all necessary software licenses and ensure workers are properly trained on the latest software. If all software user knowledge resides in a single employee, start training at least one other to create redundancy.

Health care delivery and payment models are increasingly data driven. Practices that understand their data are in a better position to maximize productivity, improve patient care and reduce overall cost of care delivered to patients. Payers have access to claims data but limited access to clinical data. Medical practices have access to both. Frier Levitt works with a number of vendors who can help practices establish a data warehouse consisting of clinical data pulled directly from patient records. We believe that establishing a data warehouse will, if not immediately, at least put practices in a position to better negotiate value-based contracts with third-party payers because they will know how their own practice performs better than the payers do.

Most medical practices have not reviewed their corporate documents in years, sometimes decades. This is a mistake that can cause shareholder disputes and dissuade potential PE suiters. Ownership documents should be reviewed approximately every three to five years. For professional corporations, this means reviewing the shareholders’ agreement, bylaws and shareholders’ employment agreements.

For limited liability companies, this means reviewing the operating agreement. Issues such as management decisions, retirement buyout formulas, termination provisions, restrictive covenants (such as noncompetes), shareholder/owner compensation and distribution formulas for a capital transaction (such as a sale event) should all be carefully reviewed and discussed with experienced legal counsel.

The following are some issues that warrant consideration:

Do the practice’s voting requirements make it difficult for the practice to effect needed change? Can a single owner veto the will of the majority?

Does the buyout formula for a retired owner fairly compensate the retiree without overly burdening the practice?

Is there a noncompete that prohibits a retiree from taking practice patients, opening an office next door and harming the practice? Is the retirement buyout still payable if the retiree competes?

Are owners fairly compensated for the professional and administrative services they perform?

Are owners responsible for recoupment actions by third-party payers related to their coding and billing practices?

Are the company documents clear about how proceeds will be distributed in the event of a sale?

Are the documents clear about how much notice must be given by a retiring owner, whether that owner can enter a wind-down phase prior to retirement and, if so, what that means in terms of voting rights, etc.?

The above process will likely take several months and require several consultants, including legal, accounting and coding issues. At the end of the process, not only will your practice experience noticeable improvements, but it will position itself to maximize its value to third parties, including PE funds, hospitals and other large practices looking to expand.

 is cofounder of Frier Levitt, LLC. Send your financial questions to medec@mjhlifesciences.com. You can reach Daniel B. Frier at 

Articles

Preparing for a private equity transaction can help strengthen your practice’s business structure, even if you ultimately forgo potential opportunities. 

Prepare your practice for a private equity transaction

We have now passed the 1-year anniversary of the pandemic in the United States and more than 28 million Americans have become infected with COVID-19. More than 500,000 have died. Our economy has taken a huge hit — businesses have closed, and millions of people are without work. Our hospitals are stretched to the breaking point.

No one is left untouched by the effects of this pandemic. It is laying bare the inequities of our health care system, the lack of access to basic care and community coordination. It has shined a light the decades of underfunding of our primary care and public health infrastructure

The solution to the current economic and public disruption starts with getting the pandemic under control. That means vaccinating our citizens as soon as possible.

It will take an all-hands-on-deck approach of vaccine supply, distribution, personnel and access points to accomplish. We must enlist our primary care physicians and pharmacists to take on a larger role in ending this pandemic.

Primary care and pharmacy are the backbone of a community’s health care system.

Of all outpatients visits to a health care provider, 47% were to a primary care office. That is over 415 million visits to primary care physicians office per year while primary care only represents 31% of the physician population in the United States.1Visits to a pharmacy exceed that of all health care providers by an almost 2-to-1 ratio.2

Primary care and pharmacy, therefore, clearly represents a major health care access point for the citizens of this country. In addition, that is also where a majority of immunizations are given each year. Of the 174.5 million influenza vaccines given last flu season, primary care and pharmacy was the place of vaccination of over 65% of the vaccines administered.3

Rural and underserved communities are also more often served by primary care and pharmacy as their source of health care, making them a vital access point for vaccine administration.

Although mass immunization clinics involving hospitals and health departments were necessary under limited supply and technical requirements in the early days of COVID-19 vaccine availability, it is clear that primary care and pharmacy must be a coordinated part of any successful plan to fully vaccinate U.S. citizens.

In the last year, primary care practices have experienced a major disruption in patient visits and revenue, and uncertainty in how to best care for their patients and communities. Many practices have suffered significant financial loss. With approximately half of family physicians nationally still in physician-owned practices, this disruption is worrisome.1

According to a recent survey by The Larry Green Center, 61% of practices are having severe or near severe stress with 91% experiencing staff shortages due to quarantine or COVID-19 infection.4 While 57% of their vulnerable patents asking their PCP for the vaccine, only one quarter of practices know where they will get the vaccine when it is available to them. Some are worried about being able to purchase the vaccine to administer to their patients.

Knowing my primary care colleagues, they will answer the call to get their patients vaccinated despite these difficulties. They just need some help now to get ready.

COVID-19 vaccination rates need to be higher than flu shot rates

Our flu vaccination rate last year for adults was 46.8% — nearly half of the U.S. adult population. This community vaccination rate is good, but still nowhere near where we need to be to achieve herd immunity for COVID-19.Some estimates say that we must reach 70% to 85%.

We must act quickly, as our citizens are suffering, and the racial disparity is stark, both in terms of hospitalizations and deaths. COVID-19 hospitalization rates are 3.7-times higher for Black and 4.1-times higher for Hispanic patients than white patients. COVID-19 death rates for both these groups are 2.8-times higher than that for white patients.

Getting the vaccine to these populations is critical, but the challenges loom large, both in terms of access and vaccine hesitancy. Again, using flu shot data for comparison, the vaccination rates for black and Hispanic adults is 38.5% and 37%, respectively.5

National polls have continued to show significant numbers of patients who are either hesitant or decline to receive the vaccine.

While those numbers have improved during the last month, in order to achieve herd immunity, we must convince most of the hesitant and a few of the refusers to get the vaccine.

In a recent Green Center patient survey, almost half the population distrusted the CDC and public health institutions. But there’s good news here: more than 80% trusted their primary care clinician.5

Whether it is by local public appeals or during one-on-one interactions with their patients, our community primary care physicians and pharmacists are our best ambassadors for vaccination and achieving the rates needed to protect patients. As it is for most complex tasks, the last mile is the hardest. We need our primary care physicians leading the charge on the anchor leg of this race.

Coordination needed — and a call to action

We need a call to action from our federal and state leaders to get our primary care providers and pharmacies involved. Furthermore, we need short term financial and technical assistance to make sure they are prepared.

In the end, it will be the personal relationships between physicians and pharmacists and their patients and communities that will get us to the herd immunity levels we need to stop this pandemic and get our economy open and moving again.

, is a family physician and Editor-in-Chief of


1
www.graham-center.org The State of Primary Care in the United States 2018

2
www.jamanetwork.com Evaluation of Frequency of Encounters with Primary CarePhysicians vs Visits to Community Pharmacy among Medicare Beneficiaries, Berenbrok et alJuly 15 2020

3
www.cdc.govEarly Season Flu Vaccination Coverage- United States 2018

4
www.green-center.orgCovid-19 SurveySeries 24 Executive summary

5
www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-race-ethnicity.html

It is time for an all-hands-on-deck approach.

To solve the COVID-19 pandemic, empower primary care physicians and pharmacists

Taking out a loan is a major financial decision. Whether you own a medical business or are an employed physician, you may need financing for continuing education courses, investing in technology and equipment, funding new initiatives or growth and expansion. Not all lenders or loans are created equal. Asking the right questions in advance can help you find the best solution.

One of the biggest disadvantages with many loans is that they can be challenging to obtain unless you have valuable collateral. Although some lenders require it, others do not, enabling you to safeguard what you own. You worked incredibly hard to acquire your assets — are you really willing to risk them?

Applying for a loan could put your credit score at risk. During the application process, some lenders will do a hard credit pull, which provides a full report of your credit history and credit score. This type of inquiry can hurt your credit score and stay on your report for up to two years. Other lenders perform a soft credit pull, which neither affects your credit score nor ends up on your report.

Loans will have either a fixed rate or variable rate. This dictates whether the rate will stay consistent for its entire term or will fluctuate based on market conditions. With a fixed rate, you will always know what your interest costs will be, making your payments and monthly budget more predictable.

Establishing the approval timeline can help you anticipate whether the process will take days, weeks or months. This is critical if you urgently need funds.

Do you have experience working with others in my industry

Physicians have unique needs, so partnering with a lender experienced
in the industry matters. Some lenders have a process that does not differentiate a physician from any other borrower, whereas others specialize in working with physicians or with customers whose profiles are similar.

Each lender or loan is different. Understanding the fundamental components can help you confidently evaluate loan quality and overall experience. By examining a lender’s expectations about timelines, deliverables and expertise, you will decrease the risk of surprises.

Some lenders can take weeks or months to deposit funds into your account after loan approval, whereas others can do so in days. If you need funds by a certain time, ensure the lender’s timeline aligns with yours.

The length of your loan dictates how much you will pay each month. Longer terms typically mean your monthly payment will be lower and more manageable. If you need more monthly cash flow, look for a loan that offers longer payback terms.

As a physician, you deal with a large amount of paperwork. Your time is valuable, so find out how much may be required for the application process. Knowing in advance what paperwork you need to provide can help you estimate the time you will need to commit.

Chris Panebianco is chief marketing officer for Bankers Healthcare Group, a provider of financial solutions for physicians. Send your questions to mjhlifesciences.com.

Before taking out a loan, ask these 8 essential questions

Put lenders to the test

While physicians worked to keep their practices financially afloat and dealt with COVID-19, hackers kept busy, too. From January through October of last year, there were 730 publicly disclosed security breaches with more than 22 billion records exposed, according to the cybersecurity firm Tenable. Health care made up 25% of those breaches with nearly 8 million records exposed. Ransomware was by far the most popular attack method in 2020, making up 46% of the breaches.

“The success that cybercriminals had in 2020 extorting sizable payouts from medical practices of all sizes ensures that ransomware will indeed remain the top cybersecurity threat in 2021,” says Dave Martin, senior director, product management, threat response, at cybersecurity firm Open Systems. “Ransoms like the $670,000 paid by University Hospital (in) New Jersey last September only encourage further attacks. And while larger institutions can clearly pay bigger ransoms, cybercriminals do not overlook smaller practices, which can be tempting targets of opportunity — particularly those with lax security.”

With health care workers focused on the pandemic response, experts say hackers are taking advantage and ramping up their attacks, meaning it is vital that practices of all sizes be more vigilant than ever about cybersecurity.

Ransomware — malware that encrypts a practice’s data and demands a fee to unlock the encryption — is entering a new phase that makes a security breach even more costly, says Gary Salman, CEO of Black Talon Security, a cyber defense firm.

“Now doctors are seeing two ransom notes,” says Salman. “The first ransom note says, ‘I’ve locked all your data; if you want (them) back, pay me $50,000.’ The second note says, ‘And by the way, maybe you have a good backup, but guess what. I have all your data and if you don’t pay me an additional $50,000, I’m going to publish all your data.’ ”

Salman says sites on the dark web are run by these threat groups, and data from doctors’ offices show patient information, including photographs, health history forms and other private details.

Many of these hacker groups operate as businesses and can be very sophisticated, says Matt Ferrante, market leader, cyber and information security services, for Withum. “They sometimes know exactly what your cyber insurance policy is, and they know what’s going to potentially be covered under the policy,” says Ferrante. “And if they don’t know, they’ve often already done the intelligence on your business and they know what it’s worth.”

If a practice experiences a ransomware attack, Matt Reid, senior health IT consultant with the American Medical Association, says there are two actions to take immediately: Contact the FBI and the practice’s IT vendor. “Federal agencies have resources that can support medical practices during a ransomware attack — and that’s clearly an important component — but also work with your health IT vendor or internal IT support staff to try to partition off the segment of the network that has ransomware as fast as possible,” says Reid.

Martin says that all compromised devices, including desktop PCs, laptops and smartphones, should be disconnected from the network by unplugging ethernet cables, disabling Wi-Fi networks and switching to airplane mode.

If a practice has cyber insurance, Ferrante recommends contacting the provider and ensuring all requirements are met. This may involve an assessment of the attack. “If it’s not independently assessed, it may not be covered under the cyber insurance policy,” he says.

Although some experts advise never paying a ransom to regain access to data because doing so just encourages more attacks, that is often more idealistic than practical.

“What we find in almost 100% of the cases is that the doctor has to pay because the threat actors are very sophisticated nowadays, and they will find all the backups,” says Salman. “And many of these doctors have their data being backed up into the cloud, and with a majority of the attacks that we’re dealing with right now, the hackers have figured out how to get into the doctor’s cloud backup and destroyed them.”

Physicians often have a false sense of security when it comes to cloud storage. “We see that a lot of people are either in the cloud, or they’re moving to the cloud,” says Ferrante. “Cloud simply means somebody else’s computer. Just because Amazon and Microsoft are secure doesn’t automatically translate to you being secure or your organization being secure. It has to be secured appropriately within those environments.”

During a ransomware attack hackers will also encrypt the server and all workstations, so when the doctors attempt to recover their data from their backups, the data are not there. “So as a practitioner, you’re basically put into a situation where you have no choice; you have to pay the ransom, because under the HIPAA (Health Insurance Portability and Accountability Act of 1996) laws, the patients’ data (have) to be available,” says Salman.

In most cases, paying the ransom results in the data being released because if the hackers don’t turn over the data, victims won’t pay any more. The more sophisticated players have customer support lines and will offer to fix any data corrupted from their software, Salman says. “They literally have testimonials on their website encouraging you to pay because these people were victims, and they got their data back, so you should pay me too because you’ll get your data back,” he adds.

Following a breach, practices will often go on a cybersecurity shopping spree, buying all kinds of software to prevent it from happening again, but Ferrante says that’s usually not effective. “It has to be applied the right way, and you really need the expertise to make sure that it’s scalable and set up correctly. Otherwise, it’s not going to function properly.”

Ransomware may constitute the biggest threat to most practices, but it is far from the only one. As regulators require more patient access to data, payers interchange more data with providers, and services like telehealth grow in popularity, increases in the number of connected devices will make practices more vulnerable to hackers.

Experts say that the pandemic has created many new threats to a practice because people are working from home. Hackers may use COVID-19 information as the lure for office staffers to click on links that install malware. Emails are made to look like they are from health departments offering the latest on vaccine distribution or other vital information. In other cases, hackers exploit a weak point of the worker’s computer.

An employee’s home computer might be connected to a secure virtual private network, but if it isn’t being monitored, patched and protected with antivirus software, it could put the main network at risk, says Salman. “The network considers that remote computer part of the main network, and information flows freely back and forth,” he says. “Let’s just say your practice manager is working from home and she’s on the same network as her kids’ computers and one of her kids downloads a malicious game. Now that spreads from the child’s computer to the practice manager’s and then from there into the network at the office.”

Reid says cyber hygiene practices used at the office should be replicated for home workers as much as possible, and physicians should not overlook devices like smartphones and tablets as possible entry points. Multifactor authentication — where a user gets a code via text to input along with a password — should be used whenever possible. “Also, using a home network that is not secure, where the password is easily guessed, or you don’t have a password at all, could be potentially problematic,” he adds.

Hackers are opportunists and will often target the practice or facility with the lowest level of security.

“I can spend a couple hours trying to hit this small health care provider, or I could spend weeks or months trying to get into the hospital,” says Salman of hacker mindsets. “And in the end, if I hit a whole bunch of smaller practices, I’ll probably walk away with more money. If you take down a big hospital system, you’re going to have every government agency coming after you, but if you take out some smaller businesses, you might fly under the radar if you’re a criminal.”

He says another issue is that practices often put too much faith in their IT vendor, who may not have a depth of security expertise. Physicians are told their practice is protected and assume that’s true.

In one case, an IT vendor’s system was hacked and then was used to attack every health care practice on its customer list because it had access to every network. All the practices had to pay the ransom to get their data back, and the hackers walked away with $1 million.

“What medical practices should be doing is asking their IT companies who’s protecting them,” says Salman. “If hackers break into the IT company and attack the practice, there’s probably nothing that practice can do to defend themselves against that. Ask them if they are being independently audited on a monthly basis by a dedicated cybersecurity firm. If the answer is no, they need to understand why.”

IT vendors also have many employees working from home, and practices need to know how they are being protected, as well. “These are the people who have credentials to your environment,” says Ferrante. If their security is lax, hackers can gain access to a physician’s network by breaching an IT worker’s home computer.

Ferrante adds that a cybersecurity expert should conduct a full assessment of a practice’s vulnerabilities, particularly because of the number of devices utilizing the network during COVID-19.

For practices working with local hospital systems, Reid recommends checking with them about receiving donated cybersecurity services. Thanks to changes in the Stark Laws, hospitals and health systems can now legally offer expertise and assistance to medical practices to help protect patient data.

As practices start to transition back to the office, Reid says, it is important to remember to change network access. To support home workers, extra access may have been granted to IT vendors, electronic health record providers, consultants or support staff who no longer need it. Also, office computers that have sat dormant for months need to be checked to make sure they have been patched with the most current operating system and security updates.

One of the best things a practice can do is budget for cybersecurity, says Salman. “This isn’t 2017, when the risks were a lot lower than they are now,” he says. “They have to implement cybersecurity solutions from a specialty company, not just their IT vendor.”

Preventing a breach in the first place with proper security is far cheaper than dealing with the business disruption and ransom payment, he adds.

Practices also shouldn’t rely solely on cyber insurance. Ferrante says that after a major data breach, a policy may not provide enough money to cover all the expenses and can’t do anything to repair the practice’s reputation.

But above all, a practice always should make sure it has the basics in place, such as antivirus software and firewalls.

“There are a lot of simple things that can be done to improve your protection, minimize the severity of an attack and ensure a speedy recovery,” says Martin. “First off, you need to routinely back up your files to a device that is not connected to the network. This is important because the latest ransomware tools, such as Ryuk, actively seek and delete backups on devices attached to the network. These secure backups will be key to your restoration efforts.”

Avoiding common password mistakes is another way to dramatically improve your practice’s security posture. They should be at least eight characters long and consist of a mix of letters, numbers and symbols, be changed regularly and not reused. Also, be sure to change any default passwords on any devices, says Martin.

“Lastly, be sure to continually remind yourself and your employees to never click on an even remotely questionable link, regardless of who the sender is,” says Martin. “When in doubt, check with the person.”

Experts in the cybersecurity field often recommend a practice conduct a cybersecurity assessment. This will look at all the organization’s digital entry points, and then the cybersecurity firm will do a penetration test, where it acts like hackers would and looks for weak points.

“It’s not just about data loss, it’s about also potentially being able, like a hacker would do, to be able to cripple an organization,” says Matt Ferrante, market leader for cyber and information security services at Withum. “Data shows that about 70% to 75% of backups fail during a critical incident.”

He says many practices don’t do an assessment because they think they are cost prohibitive for smaller organizations. “This sounds like kind of an expensive prospect to have all this done, but it’s not because it’s scalable, and it really depends on the size of your footprint.”

A small practice might have an assessment done for $1,000, which is far less than the cost of the average breach.

Ferrante says assessments should be done by true cybersecurity experts, not just a general IT firm, because just like in medicine, there are general practitioners and specialists, and cybersecurity requires specialization to be done right.

In most cases, experts say an assessment can be done remotely and when complete, the practice is provided a list of vulnerabilities it can address as money allows.

How hackers plan to attack your practice — and what you can do about it

The cyberwar against health care practices

Physicians are hardworking professionals. But did you know that many of your colleagues work multiple jobs?

® Physician Report, nearly one out of three physicians told us that they earn secondary income by moonlighting. The most popular forms of secondary work include consulting, teaching and, perhaps surprisingly, work that does not involve a medical degree. The average income earned from these jobs? About $40,000 per year.

Many physicians may now be wondering: Where do I find these opportunities? And how do I know what is the right fit for me? 

® sat down with Suneel Dhand, M.D., an internist who moonlights and co-founded a company called DocsDox that helps physicians find secondary income opportunities, to discuss ways you can find opportunities for yourself. The transcript has been edited for length and clarity.

®: What is secondary income or moonlighting? What kind of options are out there for physicians?

Dhand: Basically, secondary income is any type of income on top of a physician’s main source of income. That could be a full-time job or it could be a part-time job..

ME: How many physicians are taking on secondary income? Is this common? And is there a growing interest in this kind of career diversification?

Dhand: Yes, we are seeing a vast expansion in the number of doctors who are going down this route. It used to be an absolute minority of physicians, especially when we were in the era of physicians basically owning their own practices. Where was there ever time for secondary income? … Some estimates suggest it’s now the majority of physicians who in some ways are pulling in secondary income.

ME: So how do you find secondary work, as a physician? Where do you go to find good opportunities that may fit your own circumstances?

Dhand: I did it all. From my own networking, I tried to maintain a larger professional network, which I met through previous jobs, at conferences and so forth. I’ll give you an example: My current main outpatient practice is in a wellness and preventive medicine clinic, and I basically found that on LinkedIn. It was random; I didn’t go through recruiters. So it really depends on the physicians’ own circumstances, what their network is and what they’re looking for.

ME: What are some of the benefits of this work?

Dhand: There are lots of benefits for the physician. First, it will give you variety in an era of exploding physician job dissatisfaction and burnout, which we’ll come back to soon. It obviously helps with that. It avoids anything becoming too monotonous in terms of what we do. Also, purely in terms of income — I mean, let’s be realistic from the financial perspective — it can really work out well for the individual doctor.

ME: What are some examples of secondary income? What’s out there?

Dhand: Physicians, as a group of professionals, don’t understand the value we can bring to many different organizations, even those that are outside medicine. We historically undersell ourselves. We’re not trained in marketing. ... And many doctors end up being one-dimensional thinkers; they think in terms of “I’m going to have this job and go down this route.”

Some examples would be if you’re going down the clinical medicine route, you could find many organizations — probably in your immediate vicinity — that would need your services for exactly what you want to do if you wanted to try something different. Say you are a generalist, and you are working at an internal medicine practice. You could check out urgent care facilities or you could work in educational institutions. As far as nonclinical opportunities go, a myriad of them are available. If it’s your cup of tea, you can work for the insurance industry or you can work in chart reviews. There’s a ton of startups out there that desire the physician perspective. And then you’ve got the pharmaceutical companies, of course, which will always need physician advisers and a physician perspective, and they value that if you can bring your clinical experience to the table.

ME: What factors should physicians consider, broadly speaking, as they’re evaluating different opportunities?

Dhand: Well, once a physician decides to go down this route, it’s important to be clear about what you would enjoy. I’ll give you a personal example. I know I’m a very clinical, hands-on person; I like the patient contact. And I know that the secondary income opportunities I choose should be in that field. If I were to, say, do chart reviews, or work for an insurance company, it may be lucrative and it may suit me for a bit, but I know, long term, I wouldn’t be happy. So it’s important for a doctor to really be honest with themselves and ask: What do you enjoy about being a doctor? If they don’t really enjoy clinical medicine … go down a nonclinical route. Don’t just go for something because it sounds like a cushy opportunity. These opportunities will come physicians’ way. But they’ll realize very quickly if they do that, if it’s not for them, they’re not going to be happy.

ME: Let’s stick with the happiness discussion. Earlier you mentioned rising career dissatisfaction among physicians, and we all have heard about physician burnout. It may sound counterintuitive to some to say that taking on more work may help your burnout. Can you talk a little bit about the relationship there?

Dhand: The explosion in physician burnout and dissatisfaction is clear to everybody out there. I’ve seen research suggesting that the majority — 60% — of all doctors are clinically burned out. We need to take a step back for a moment and ask: Why has this happened?

Well, 30 years ago, doctors used to finish residency and enter practice. They used to be small-business owners and had a lot of autonomy and ownership. In this … world of employed medicine, which has escalated over the past 20 years, (most) doctors will finish residency and become employees in large organizations.

I feel that there is an inevitable conflict that will arise because the types of people that go into medicine are very independent thinkers, and the corporate world really doesn’t fit well. And sooner or later, a doctor will reach that conflict in their career where they’re not going to like working for a big organization.

So how can secondary income help? Well, physicians have to again realize everything doesn’t have to be a set career path; they can cut back on their regular clinical work. So it doesn’t mean that your secondary income is necessarily adding to it, and I actually wouldn’t advise doing that if you already work 80 hours a week. And again, using my own example, I was practicing internal medicine, doing the same thing week in, week out, and then decided to pull back on that. I thought: Well, let me think. … What can I do that will be satisfying but also avoid that sense of monotony? … If you can reach that kind of balance, it can really add a lot of variety to your career.

ME: Another factor is volunteering. Are there any ways to approach a volunteer opportunity differently from something that you’re paid for?

Dhand: If a physician is looking for an outlet away from clinical medicine and finances are not an issue, volunteering is always a great thing to do. It’s a wonderful thing to give your time to a good cause, one that you feel passionate about. I know a lot of doctors that volunteer, but I don’t know many, to be honest, that do it so much, that it’s anything more than, say, a few hours a week.

ME: If you are a physician who works for a large organization, what should you check before taking on a secondary gig?

Dhand: The only potential conflict or reason for any concern from an organization would be if you’re going to work with a direct competitor. From what I’ve seen, though, having met thousands of physicians, medicine is usually the last one that is particularly strict about that because there’s just such a need out there. I’m in the Boston area, and lots of doctors will go and moonlight in the neighboring organization, and it’s very rarely a big deal. It’s something that is commonly done.

But yes, you should check with your organization and make sure it’s OK. But rarely will it be an issue as long as you can go and do your own job when you’re paid to do it and not take side phone calls during working hours.

ME: Is there anything that we haven’t talked about that you think is important for physicians to keep in mind as they look for secondary work?

Dhand: If you have that itch to try something different, you feel that your job is not where you want it to be, whether that’s because you’re burned out, or you just feel a general sense of drudgery, go ahead and try secondary work as soon as possible. I wish I had years before I did because there are so many opportunities out there for doctors, we historically undersell ourselves and don’t market and understand our value even in other arenas. So, if you feel the urge to do that, go ahead and do it as soon as possible. Don’t wait, and you will surprise yourself.

If you don’t want to go part time in your current job … try something a couple of evenings a week or on weekends and see whether it suits you first. There’s no point, if you’re already bored or unhappy with your job, (doing something) you know is going to be equally draining for you. Pick something that you’re passionate about.

Physicians are hardworking professionals. But did you know that many of your colleagues work multiple jobs? In our 2020 Medical Economics® Physician Report, nearly one out of three physicians told us that they earn secondary income by moonlighting. 





How physicians can earn money, expand their careers with moonlighting

“Medicine is a really difficult language with a lot of unfamiliar terms,” says Docimo. “It’s important to simplify. For example, instead of saying ‘hypertension,’ use ‘high blood pressure.’ Or instead of ‘hyperglycemia,’ use ‘high blood sugar.’ ”

Physicians can also direct patients to UHG’s free glossary of thousands of health care terms defined in plain, clear language. The glossary is available in English, Spanish and Portuguese.

Train staff to reinforce the care plan and answer patients’ questions, says Docimo. “The whole team needs to help the patient be compliant with what can be a complicated, multistep care plan,” she adds.

Carly Hood-Ronick, M.P.A., M.P.H., an expert on health equity, agrees. “Often a social worker or medical assistant has more time than the physician to sit down with the patient and provide education,” she says.

Use video and other visuals to support patient understanding

“There are simple ways to show the patient and family what’s going on,” says Hydok. For example, physicians can draw a picture, use a model or show an illustration or video online.

For example, Docimo says physicians can say: “I know this is a new diagnosis for you, and I want to make sure you understand all the details. In your own words, can you tell me about your condition and treatment plan?”

Organize information so the most important details come first and pause to allow patients to digest what you said, says Maureen Hydok, MBA, RN, senior director at Huron, a consulting group.

For example, physicians can download and print or provide online links to educational materials from the American Diabetes Association, American Hospital Association, American Cancer Association and other reputable organizations that publish patient-friendly brochures and fact sheets. In addition, many specialty societies publish pamphlets for common conditions, and these materials are available in multiple languages.

Ask patients to read these materials, make a list of questions and schedule a follow-up appointment, says Hydok.

“Assuming that everyone speaks or understands English is not appropriate and not effective,” says Ronick. Instead, ask patients what language they prefer to speak and read, and whether they would like an interpreter. Plan for interpreter services in advance. Consider scheduling appointments on specific days or times when appropriate interpreter services are available — for example, Spanish interpreters available Thursdays from 1 to 5 p.m.

Also try to match patients with qualified bilingual clinicians or staff members, if possible. For example, Hydok worked with one clinic that scheduled patients of a particular ethnic background on days when a culturally informed medical assistant was working. “You really need to understand a person’s culture and be able to communicate with them in a way they’ll understand so you can get them to change,” she adds.

Follow these guidelines to improve patient understanding and obtain better outcomes.

7 tips for clear patient communication

Physicians can create a treatment plan, but if patients do not understand the what, why and how, they may not be able to adhere, says Natalia Southerland, MD, a family medicine specialist in Waxahachie, Texas. Southerland, who is also a certified personal trainer and health coach, strives to ensure patients are health literate, meaning they can find, understand and use information to make appropriate health decisions.

Addressing health literacy does not necessarily require much of Southerland’s time or effort. For example, she frequently gives patients educational materials and handouts, explaining the information as succinctly as possible. This includes handouts she has created as well as those from organizations like the National Lipid Association.

“I consider myself an educator,” she says. “If I provide information, teach patients how to find credible information and make sure they understand and know how to use that information, they will become independent health care consumers who can take control of their own health.”

Health literacy is also associated with significant cost savings. Improving health literacy for Medicare beneficiaries alone could prevent nearly 1 million hospital visits and save the health care system more than $25 billion annually, according to recent data published by UnitedHealth Group (UHG).

That is because patients who follow treatment plans, take medications correctly, complete needed screenings and receive recommended care are more likely to achieve their best health, says Anne Docimo, MD, chief medical officer at UnitedHealthcare, where she is responsible for the clinical, cost and experience outcomes of more than 50 million members in the company’s commercial, Medicare and Medicaid health plans.

“The extent of limited health literacy is not generally recognized,” says Cindy Brach, M.P.P., senior health care researcher at the Agency for Healthcare Research and Quality’s (AHRQ) Center for Evidence and Practice Improvement and co-chair of the U.S. Department of Health & Human Services Health Literacy Workgroup. “Limited personal health literacy, which affects more than a third of adults in the United States, is associated with lower receipt of preventive services, poorer ability to demonstrate taking medications appropriately, poorer ability to interpret health messages, greater hospital and emergency care use and, among seniors, poorer overall health status and higher mortality.”

What is important for physicians to remember, Docimo says, is that health literacy is not only about a static population, such as individuals for whom English is a second language. Someone with relatively high health literacy could face challenges when trying to understand a new diagnosis, she adds.

It is also important for physicians to realize that unlike other social determinants of health such as food or housing insecurity — solutions that require significant investment and partnership with other organizations — they and their staff can improve health literacy using simple strategies, says Brach.

Experts agree that telehealth presents opportunities to improve health literacy. “The access alone can improve it because you don’t have barriers related to transportation and physically getting from your home to the doctor’s office,” says Docimo. Physicians can also use visual aids just as they would in person, she adds.

“In this day and age when everyone wears a mask, it’s almost easier to do a telemedicine appointment because you can see the patient’s facial expression,” says Hydok. “Sometimes you even get a glimpse of the patient’s home — and that can give you more information.” For example, a physician can ask patients to show where they keep their medication. If they see unrefrigerated insulin on the counter next to various pill bottles, they know there has been a communication breakdown.

Populations struggling with health literacy before COVID-19 will struggle during the pandemic, says Southerland, who tries to stave off misinformation by providing patients with links to credible websites such as the Centers for Disease Control and Prevention. She also curates some of that information herself so patients do not become overwhelmed by the volume of content available. For example, she compiles answers to questions her patients ask most frequently (such as “If I’m exposed, do I need to get a test?” or “When can I go back to work after testing positive?”) and then sends mass communications through the portal to educate patients.

“There’s going to be a need for coordinating care, educating patients and staying on it to make sure they complete the series of two vaccines — the initial one and the booster,” says Docimo.

This is especially true for patients with low health literacy who are part of diverse communities, says Ronick. “Many populations in the U.S. today speak different languages at home and have different cultural practices than the dominant White culture,” she says. “As we look at administering the COVID-19 vaccine, we won’t be successful unless we address potential cultural barriers.”

Addressing patient health literacy

We know relationship building is critical to improving patient outcomes, and strong communication is especially important. Good communication can result not only in more efficient, effective care, but also greater patient satisfaction with treatment, and this is particularly true with aging patients.

Although the manner in which physicians communicate with patients is incredibly important for better outcomes, the means by which they do so also have a big impact on care. One of the primary ways provider-patient communication has evolved, particularly this past year as a result of COVID-19, is through the rise of technology-driven communications, specifically virtual care and telehealth.

Many may argue that virtual care and telehealth will never fully replace in-person care for seniors, and research shows that is likely true even after increased adoption during the pandemic. According to a June 2020 survey of adults 50 to 80 years old by the University of Michigan, more than 50% of respondents still perceive office visits as providing higher overall quality of care, and barriers to adoption and accessibility of technology remain for many seniors. Even if they do not become the primary sources of health care for seniors in the immediate future, telehealth is providing an opportunity to improve communications to meet the needs of this rapidly growing patient population.

An obvious way technology can improve patient communication is by making it more accessible. Physicians can meet in person with a limited number of patients each day, and many seniors face transportation challenges. Telemedicine in the form of traditional, video-enabled primary care doctor visits alleviates many of those challenges and makes it easier for patients to connect with physicians or support staff between appointments. According to the same University of Michigan poll, 72% of respondents expressed interest in using telehealth for follow-up questions with a doctor they had already seen. Offering telemedicine as a supplemental method of communication with patients helps open more channels of communication throughout the care journey.

Another benefit of virtual communication is its ability to drive better care plan adoption among patients. For example, a study looked at patients’ understanding of newly prescribed medications after hospital discharge. It found that although 86% of patients were aware they had been prescribed new medications, only 64% could identify the name of the medication and merely 11% could recall being told of potential adverse effects. Digital communication can better ensure patient adherence through increased follow-ups, whether through physicians and support staff personally checking on a patient’s status or automated call or text messages about medication reminders or lifestyle changes. Increased engagement can also enable providers and patients to bring more stakeholders into the conversation, including family members or caretakers.

One of the most significant advantages to virtual care is the real-time lens it provides into a patient’s home life and social determinants that may exist. Whether it is the clutter that may increase a patient’s risk of falling or the isolation that may negatively affect mental health, the information you can gather by connecting with a patient in their home environment can have an important impact on care plan adherence and overall health outcomes. Most importantly, these real-time insights enable providers to intervene more quickly and collaborate with other members of the patient’s care team to develop solutions before deterioration or hospitalization occur. With close to 75% of Medicare hospital readmissions being identified as preventable, the real-time insights gained from various aspects of virtual care can play an important role in necessary proactive care management.

Many aspects of virtual care can lead patients to feel more in control of their health care journeys. Empowering patients to decide where, when and how they prefer to engage with their care team means they are more likely to have a satisfying care experience. Best of all, increased payer reimbursement and revenue sources for telehealth means practices no longer can have greater confidence in pursuing virtual health, and reap the many benefits of virtual patient communications, a win-win for all stakeholders involved.

David Hunt is the founder at Cosán Group. Send your technology questions to medec@mjhlifesciences.com.

Good communication can result not only in more efficient, effective care, but also greater patient satisfaction with treatment, and this is particularly true with aging patients.

Improve senior patient communication with technology

The American Heart Association warns that cardiovascular disease — be it coronary heart disease, heart attack, congestive heart failure or congenital heart disease — is the leading cause of death for men and women in the United States.

Proper prevention includes not smoking, lowering cholesterol, controlling high blood pressure, maintaining healthy weight and exercising. However, many patients are not going to make these life-changing moves without some persuasion.

According to the United States Preventive Services Task Force, there is convincing evidence that counseling interventions improve blood pressure, lipid and fasting blood glucose levels, body weight/adiposity and eating habits. Improvement in these areas will strengthen heart health. Changing behavior can be difficult, so physicians must have conversations to ensure their patients stay healthy. Such relationships can help patients and providers work through health challenges and reach desired outcomes.

Nicole Harkin, M.D., FACC, founder and cardiologist at Whole Heart Cardiology in San Francisco, says up to 80% of heart disease is considered preventable, so these conversations can literally save lives. “It’s so important to talk with patients about heart disease because it is the No. 1 cause of death in the United States for both men and women,” Harkin says. “We know from studies that patients are more successful with personalized plans. Generalized health guidance is rarely successful, and most people need advice that is applicable and customizable.”

Erica Savage-Jeter, M.D., a primary care physician practicing in South Carolina and regional medical director for Partners in Primary Care, a senior-focused medical practice, notes creating dialogue with patients is vital to establishing relationships and building trust. “In my counseling, it is my goal to understand the patients’ perspective when talking about interventions that lead to proper heart health,” she says. “I need to understand their sense-making related to their health. Until patients have buy-in and feel the advice I am providing is meaningful to their health, I will have very little impact.”

David Cutler, M.D., family medicine physician in Santa Monica, California, says the keys to bringing up the topic of cardiovascular health are being a good listener, providing accurate information and making the discussion relevant to the patient.

“Active listening requires putting the patient’s concerns above those of the health care provider,” he says. “Dispelling inaccurate myths is important to maintain credibility. And recognizing that the cardiovascular health needs of a 40-year-old male with a family history of premature cardiac death are different than a 90-year-old nursing home resident with dementia means a ‘one-size-fits-all’ approach to heart health will not work. Diet, medication and activity modifications must be individualized.”

When talking to patients and their families about heart health, Cutler notes it is important to spend more time listening than talking. “Only after eliciting all their health concerns, prior experiences and fears associated with treatment and changing behaviors is it likely to achieve positive results,” he says. “A comprehensive and continuous approach to care will provide reassurance to them, and they will have a partner in the process of achieving better heart health.”

Tiffany Sizemore, D.O., FACC, a cardiologist in Fort Lauderdale, Florida, notes heart disease was proved to be a risk factor for COVID-19, so physicians must do all they can to prevent heart disease. “Seeing that 2020 has been the year of illness, I hope that we have learned the importance of preventive health,” she says. “I encourage all my patients to know their blood pressure, know their blood sugar, know their cholesterol and take charge of their own health. Unlike many illnesses, heart disease is preventable in the vast majority of people.”

Cardiologist and internist Leonard Pianko, M.D., working in Aventura, Florida, says COVID-19 is a vascular disease, so it affects blood vessels, big and small, and it is important to remain focused on all leading causes of health impairment during the pandemic. “By cutting down on the risk factors for COVID, including losing weight, monitoring your blood pressure and cholesterol, etc., you are lowering your risk not only for COVID but also for cardiovascular disease,” he says.

Pianko notes the media has made it easy to bring up the subject with patients, who are confronted daily with sobering statistics on the number of individuals hospitalized with COVID-19 or who have died from the disease. “The COVID conversation provides an easy segue to prevention tips for heart health,” he says. “Even when the vaccine is readily available, it might be anywhere up to (a) year for us to achieve herd immunity. It is unpredictable who will have COVID as well as who will survive COVID.”

Proper health tips have not changed with COVID-19, but patients are more receptive because of ongoing concern about the disease. “My top tip for discussing proper heart health with my patients is tailoring the conversation to their specific health needs,” Pianko says. “By knowing their personal history and their family history as well, I can personalize the experience and focus specifically on those tips that will make a difference in their lives. It’s the investment of time and energy into the doctor-patient relationship which promotes success.”

To have dialogue with patients, Savage-Jeter says it is important to create a cadence with appointments to provide that opportunity. “Episodic care does not allow patients the occasion to spend time with their providers that may not be related to an acute issue,” she says. “Creating routine follow-up allows for discussions that are more relaxed and may not compete with pressing issues.”

There is convincing evidence that counseling interventions improve blood pressure, lipid and fasting blood glucose levels, body weight/adiposity and eating habits. Improvement in these areas will strengthen heart health.

Medical Economics March 2021