Uterine blood flow and tocolysis Tom Archer, MD, MBA UCSD Anesthesia.
Private practice– your next adventure Tom Archer, MD, MBA UCSD Anesthesia.
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Transcript of Private practice– your next adventure Tom Archer, MD, MBA UCSD Anesthesia.
Competition
• Aren’t we doctors above that?
• Doesn’t competition lead to haste and errors?
• Isn’t competition grubby?
• Shouldn’t the public just trust us to do the right thing?
Competition• A fact of life in private medicine.
• You are competing with other anesthesia groups and with other anesthesiologists in your own group.
• The challenge is to maintain a high level of service without compromising safety.
• Whether you like it or not, personal relations are every bit as important as technical or “medical” skill.
• The 3 “ables” of the anesthesiologist: Available, Affable, Able.
Arrogance or Apathy– Not an Option
• You will be expected to be a “team player.”
• If you are apathetic or unresponsive…
• Your customers will take their business elsewhere.
The Patient as Customer
• Patients are more demanding than 30 years ago.
• Scrutiny of medical practice (by everyone) has intensified.
• Physician is still a respected authority figure, but…
• Physician must realize that she has to please customers and is part of a team.
• The days of prima donnas are over.
Are We In Business?Or Are We Practicing Medicine?
• Isn’t business all about money?
• Doesn’t business subordinate quality, ethics and patient care to the Almighty Dollar?
Are we in business?Or practicing medicine?
• Is there a conflict between business and medicine?
• NO!
• Good medicine implies good business, and vice versa.
The Business of Medicine
• In a competitive health care environment, providers will give the best care they can at the lowest price.
• Competition fosters improvement and innovation.
• State health care monopolies foster slow, inefficient and bureaucratic care.
• Academic medicine frequently lacks incentives for production (monopolistic mind-set).
Good doctors and good business people:
• Give the best customer service they can (technical care, bedside manner, punctuality, courtesy).
• Don’t waste time or resources.
• Know their customer’s needs and wants.
• Know how to work in teams.
Service and safety issues• Safety Issues are sacrosanct and must not be
compromised.
• Service issues (start times, cases on Saturday and Sunday, after midnight, etc.) are negotiable.
• You need to clearly understand the difference.
• Monopolies (us?) often camouflage a desire to avoid service as a safety issue.
Customers and the Golden Rule
• Modern business philosophy: patients, family, surgeons, nurses, administration, technicians– these people are all our CUSTOMERS.
• This is really a restatement of the GOLDEN RULE:
• Treat your customers– your fellow human beings-- with respect and with consideration for their aspirations, needs and fears .
Private practice– what will it be like?
• Possible contrasts with academic medical centers:
– Faster pace (no one is in training).
– Great emphasis on good interpersonal relations (being nice) and consistent, good results. No rewards for originality or extra frills.
– Emphasis on collegiality rather than conflict (everyone’s earnings depend on everyone’s actions).
– Pay is based on cases performed– not on salary.
Anesthesia Groups
• Look at more than just:
– Types of cases and how much money you will earn.
– Work hours, call schedule, vacations and CRNAs supervised.
Your Job is to Get Behind the Window- Dressing and Find Out What the Group is Really Like.
Anesthesia Group Culture
• Some groups are healthy and promote the happiness and prosperity of their members.
• Other groups are dysfunctional and full of psychopathology.
What Does Your Gut Say?
• Do people seem happy?
• Do group members seem to like one another? Or do they gossip with a newcomer like you?
• Do members appear over-worked, unhappy, and yet greedy for more cases?
Are New Group Members Treated Barbarically?
• They get poorly paying cases.
• More nights and weekends.
• Buy-ins are excessive.• Many new hires don’t
make partner. They get booted out before they become eligible for partnership.
How are the MDs compensated?
• What is the incentive structure?
• What behaviors are rewarded?
• What behaviors are penalized?
Straight Salary• You get paid the same whether
you do a lot of cases or not.
• More common in academic settings.
• Does NOT reward production or efficiency.
• Disadvantage: slackers can slack off.
• Big advantage: allows time for teaching, research, innovation and careful, methodical care.
“Eat What You Kill” (Type 1)• “Fee for Service” from
individual patient.
• You receive specific collections from patients whom you anesthetize.
• If you have indigent patients, you earn ZERO!
• If you have all insured patients, you earn mega-bucks.
• FTC: Price-fixing via sham corporation?
• Fraught with abuse potential– schedule manipulation, etc.
“Eat What You Kill” (Type 2)
• “Fee for Service” (Based on Group Average Unit).
• Money is pooled for entire group. Your month’s income = Group’s Total Collections X (Your Units / Total Group’s Units)
“Eat What You Kill” (Type 2)
• In my opinion, EWYK Type 2 is the best system for private practice.
• This system rewards work and efficiency and ignores payer mix.
• Schedule manipulation and lies just stop.
Do You Hear About Conflicts Over Anesthesia Service?
• Do surgeons want more night and weekend coverage than group wants to provide?
• Do the anesthesiologists have a “can-do” service orientation?
• Does the group work with nursing and administration to provide service as a team?
• Or does the group blame nursing or other hospital employees for inadequate service?
Who runs the group?
• A group of old cronies, in a murky and capricious manner? Or…
• An elected Board of Directors?
How does the medical community view the anesthesia group?
• As money-grubbing technicians? Or…
• As team players?
Is the “group” really a group, with a clear business purpose?
• Yes, the group takes care of all the patients in an efficient and compassionate manner.
• No, the so-called group is a loveless marriage of convenience between competing individuals.
A Good Anesthesia Group
• Healthy, happy individuals, who enjoy caring for their patients.
• Internally, the group functions as an anesthesia team, with a clear business purpose.
• Minimal to no schedule manipulation, cheating and lying.
A Good Anesthesia Group
• Externally, the group works constructively with nursing and hospital administration to provide care as a hospital-based team.
A Good Anesthesia Group
• The compensation structure aligns individual incentives with business goals.
• Best system is income pooling with individual compensation proportional to services provided.
• Individuals who participate on Medical Staff and hospital committees are respected and rewarded.
Advice for the new member:
• Be humble– there’s more than one way to skin a cat.
• Ask lots of questions– and learn!
• Try to understand why they do what they do– it MAY make sense! (Or it may not!)
• Ask the established and respected practitioners how they would do things.
One Final Note
• Try really hard to be respectful, pleasant and courteous to EVERYONE.
• I am VERY serious about this and this is VERY important.
• Arrogance and being a jerk is our most common mistake.
• This point has nothing to do with your “technical” care, but it has everything to do with your success in your new work environment.