Strategic Engagement of Recruiters

Undoubtedly, bringing on a talented physician or practice manager will help to ensure your medical practice operates more efficiently, is profitable, and has happier employees. Finding such an individual, however, can sometimes be challenging, since your practice is not the only one attempting to recruit that stellar candidate. So, if you like gambling in casinos and/or have plenty of time to spend interviewing countless candidates, you should put an advertisement in your local paper or online. Otherwise, your time and money would be better spent using a recruiter to find your ideal physician or practice manager who you will value for years to come.

A good recruiter will weed through the candidates and give you just a few (no more than three) who appear to be a good fit for you and your practice. Additionally, seasoned recruiters will do thorough reference checks and logistical coordination of interviews, which frees up your already tight daily schedule. They also are great at being the “go-between” when it comes to compensation negotiations, so after the hire is made there is no bad blood between employer and new-hire. Of course, when it comes time for the interview, there are several items you need to ensure are covered.

Top Characteristics

Here a few things that you should ensure the candidates have when you are conducting your interview:

  • Appropriate education level
  • Practice managers (Do they need a high school diploma? Specific type of college degree? Master’s degree?)
  • Physicians (Are they trained in the procedures that you currently provide? Are they trained in procedures that you would like to add to grow your practice?)
  • Business acumen
  • Practice mangers are your business person, so don’t skimp on this criteria. You are not hiring them to perform surgery; you are hiring them to keep the practice in order.
  • Physicians will most likely be partners someday, so while they don’t need to be business savvy from day one, they should at least have the interest in learning about the business side of running a practice.
  • Leadership capabilities (Are they motivating? Can they delegate? Do they communicate well? Are they empathetic? Do they have a sense of attention to detail?

Warning Signs

Recruiters should be interviewing candidates in great detail before they ever send them your way. Joe Ciaramitaro, President of CorpSearch Int, notes:

“The proper vetting practiced of candidates are being done by professionals that do this type of work the entirety of every day. You want essentially a short-term hiring partner here, where success is achieved and measured by the ability to work and trust the recruiters experience and shooting straight with the recruiter so they can trust and help you through the entirety of the process the most. It will be sometime an arduous journey to the end result of the successful hire you really want but timely and well thought out communications between presenter of your opportunity to the world of candidates out there, the recruiter and yourself, will ensure the greatest efficiencies and outcomes of your search.”

It is the job of the recruiter to be acute and to have a thorough selective process. Even the best of recruiters may miss something when they screen candidates, so here are a few red flags you should be on the lookout for when conducting your interviews:

  • Did the candidate ask about salary upfront? (Actually, when using a recruiter, the candidate should not even bring it up since the recruiter should have already covered the salary range, benefits, etc.)
  • Did the candidate ask about long hours?
  • Did the candidate slam their former co-workers?
  • Does the candidate appear to have poor people skills?
  • Does the candidate appear to miss the point about patient care? (This can sometimes be the case with practice managers if this will be the first job they have in a medical practice. Obviously, patient care is a priority. The candidate that does not get that will not do a job well since they will be unable to relate to the tasks the clinical staff perform on a daily basis. The manager does NOT have to have clinical experience to do a great job as a practice manager.)

A new physician or practice manager is a crucial member of your staff and critical to the success of your practice. Finding the right individual is not easy, but being open about your requirements to a recruiter can help to facilitate the search for a perfect fit. Engaging a recruiter as a trusted member of your strategic hiring needs will ensure they have a good grasp about the type of candidate that will be ideal for your particular practice.

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Contact ABISA for healthcare consultancy support or speaking engagements.

Follow on Twitter @ABISALLC

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Introduction to Medical Practice Valuation

At some point, there will come a time to sell your practice. It could be in part to a partner or as a whole to another group or hospital. In any case, the practice will need to undergo a valuation, which is a detailed and complicated process, oftentimes confusing because let’s face it, it is not like you sell your practice every year. One thing that can help you on your path is to understand some of the basic tenants of practice valuation.

Understanding Terminology

If you are considering selling your practice, make sure you understand terms and appraisal definitions. Oftentimes a physician will ask their accountant to appraise the business, but the physician may be surprised to find that the “book value” given by the accountant is far different than the “Fair Market Value (FMV)” that he could actually receive at time of sale. It is not that the accountant is incorrect at all. Rather, the accountant and the physician may be operating under a different set of terms and definitions, without knowledge of each other’s perspectives. Realizing that there is no absolute sales price is the essence of FMV. When determining valuation, look for a price range with a reasonable floor and ceiling.

Understanding Value

For starters, value isn’t an absolute number. A medical practice’s tangible and intangible assets can be grouped into two broad categories: physical assets and non-physical assets. Examples of physical assets include accounts receivable, leaseholds, medical equipment and furnishings, medical records, and real estate. Examples of non-physical assets include buy/sell agreements, goodwill, managed-care contracts, restrictive covenants, and staffing. Estimates of value differ significantly, depending on the purpose of the appraisal, the acumen of the appraiser, etc. Astute appraisers will consider a host of questions. What is the value of the practice for purchase or sale? What is the value of a practice for merger? What is the value of practice assets for joint venture with a corporate partner? What is the value to establish buy-in or buy-out arrangements for partners? What is the value of practice assets for purchase or sale, apart from ongoing operations? To answer these questions, physicians must understand how practices are valuated.

Informal Terms of Valuation

The “asking price” is often arbitrary and difficult to substantiate, and typically is reduced by a significant percent during negotiations. The “creative price” is derived by way of creative financing.  For example, the practice may provide the down payment. The “emotional price” may involve either a motivated buyer or seller, who pays an under- or overinflated price for the practice. The “friendly price” is reserved for associates, partners, or other colleagues. The “realistic price” is one that both buyer and seller believe is fair.

Formal Terms of Valuation

Practice appraisers use FMV as the standard to derive a reasonable value for a practice.  FMV means an arm’s length transaction between an unpressured, informed buyer and an unpressured, informed seller. The “business enterprise value” of a practice equals a combination of all assets (tangible and intangible), and the working capital, of a continuing business. The value of “owner’s equity” equals the combined values of all practice assets (tangible and intangible), less all practice liabilities (booked and contingent). The “working capital value” equals the excess of current assets (cash, A/R, supplies, inventory, prepaid expenses, etc.) over current liabilities (accounts payable, accrued liabilities, etc.).

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Contact ABISA for healthcare consultancy support or speaking engagements.

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Entering Your Practice into Strategic Joint Ventures

A joint venture agreement is an agreement between two or more healthcare entities usually entered with a specific goal in mind.  Each party is invested in terms of capital contribution, the time devoted to the project, and the effort put forth to complete the defined tasks.  These business partners pool their resources and expertise to achieve a particular goal.  The risks and rewards of the enterprise are also shared.

The reasons behind forming a joint venture include business expansion, development of new service lines, or moving into new markets.  Each party who enters into a joint venture agreement will want to maintain their separate business/entity and  enter into the business arrangement with a strategic goal in mind.

Overview

Your practice may have strong potential for growth, with innovative ideas and services.  However, a joint venture could give you more resources, greater capacity, increased technical expertise, and access to established markets and marketing channels.  In a very broad sense, joint venture formation should consider legal, tax, business, and cultural issues.  Joint ventures may take the form of different legal structures, but beyond legal and tax considerations are a large number of broad business and cultural issues. As a start, you should carefully consider and/or define:

  • The purpose of the joint venture
  • Specific goals for the venture
  • The resources and value to be dedicated to the venture by the participants
  • The cultural “fit” between the participating entities
  • The specific responsibilities of the participants
  • Potential impact to your current practice’s reputation
  • The control mechanisms in place
  • How you will handle cash calls and personal guarantees if required

Assess Your Readiness

Setting up a joint venture can represent a major change to your practice. However beneficial it may be to your potential for growth, it needs to fit with your overall business strategy.  Consequently, it is important to review your business strategy before committing to a joint venture. This should help you define what you can realistically expect.  In fact, you might decide that there are better ways to achieve your business goals.  You may also want to look at what other practices are doing, particularly those that operate in similar markets or specialties to yours.  Seeing how they use joint ventures could help you choose the best approach for your business.  At the same time, you could try to identify the skills they apply to partner successfully.

You can benefit from examining the business of your own practice.  Be realistic about your strengths and weaknesses and consider performing an analysis to discover whether the potential joint venture entities are a good fit.  You will almost certainly want to find a joint venture partner that complements your own practice’s strengths and weaknesses.  You should take into account your employees’ attitudes and bear in mind that people can feel threatened by a joint venture.  It can also be difficult to build effective working relationships if your future joint venture partner has a complete different way of doing things.  If you do decide to form a joint venture, it may well help your business to grow faster, increase productivity and generate greater profits.  Joint ventures often enable growth without having to borrow funds or look for outside investors.

Due Diligence

Conducting due diligence on any potential partner is a top priority for practices considering joint ventures.  Before entering into agreements with another entity, check into the credentials of potential member(s), including the existence and availability of the resources, property, and human capital that potential partners bring to the joint venture.  The ideal partner in a joint venture is one that has resources, skills and assets that complement your own. The joint venture has to work contractually, but there should also be a good fit between the cultures of the two organizations.  Broadly, you need to consider:

  • Do you share the same clinical and business objectives?
  • Can you trust them?
  • How well do they perform?
  • What is their attitude to collaboration and do they share your level of commitment?
  • What kind of reputation do they have?
  • Do they already have joint venture partnerships with other entities?
  • What kind of management team do they have in place?
  • How are they performing in terms of clinical operations, marketing, personnel, etc.?
  • Are they financially secure?

Consulting with the proper legal counsel prior to establishing the agreements is of course crucial when deciding whether to pursue a joint venture.  Regardless of the length or breadth of the legal agreements you may use, if there is not a high degree of consensus and willingness to work through upcoming problems with your new joint venture partners, you may find yourself bogged down in unpleasant and costly disputes.  Try to make sure your new partners are a good fit with you and define the business as much as possible ahead of time.  An experienced consultant should be able to guide you.

Taking the time to fully understand the process, evaluating potential outcomes, and conducting due diligence on potential partners are three great first steps in moving forward with a joint venture.  While all of this may seem overwhelming, joint ventures, if executed thoughtfully and correctly, can lead to new revenue streams, shared resources, and incredible results.

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Contact ABISA for healthcare consultancy support or speaking engagements.

Follow on Twitter @ABISALLC

Strategic Diligence of Physician Practice Mergers

In recent years, there has been noticeable increase in practice mergers among physician groups.  Undoubtedly with the ever-evolving reform of the U.S. healthcare industry, there is a lot of uncertainty for private practice physicians.  Some practices are content with no organizational changes and some have decided to be acquired by hospitals. Others have gone the route (or are pondering) of merging with another private practice (either same specialty or different specialty).  The decision to buy, sell, or merge a medical practice is more complicated than ever, and determining a medical practice’s worth is just one element crucial to this process.  For those that are considering merging with another private practice entity, there are many things to strategize about and that’s assuming there will be a windfall of benefits by consummating a merger.

Physician owners must have a clear rationale for a transaction or truly understand a deal’s impact on their practice’s long-term financial future.  Too often, however, there’s a misguided sense of why the merger should take place at all, and there’s far too little time spent defining how the merger enables them to beat competitors and increase organizational value.   Those that fail to take this into account contribute to the failure rate of physician group mergers.

For many physician groups, the link between strategy and a transaction is broken during due diligence.  By focusing strictly on financial, legal, tax, and operations issues, the typical due diligence around a proposed merger fails to test whether the strategic vision for the deal is valid.  To do so, physician groups should bolster the usual financial due diligence with strategic due diligence. They should test conceptual rationale for a deal against more detailed information available to them after signing the letter of intent. They should also see if their vision of the future operating model is actually achievable.

A strategic diligence should explicitly confirm the assets, capabilities, and relationships that make a buyer the best owner of a specific target acquisition.  It should bolster the physician owners’ confidence that they are truly an “advantaged buyer” of an asset.  Advantaged buyers are typically better than others at applying their established skills to a target’s clinical and business operations.  They also employ their privileged assets or management skillset to build on things like a target’s practice reputation, patient experience, or relationships with referring physicians.  Naturally, they also turn to their special or unique relationships with vendors and the community to improve performance, leading to advanced synergies that go beyond what’s normal.

When change comes suddenly, it can turn strengths into weaknesses and sweep away dreams of success.  The aim of a merger should be to achieve mutually reinforcing advantages.  Michael Porter wrote that competitive advantages stem from how “activities fit and reinforce one another. . . . creating a chain that is as strong as its strongest link.”  By undertaking strategic diligence, physician owners will be able to not only define their main objectives, but also gain greater control over the desired direction of the new entity after the merger is consummated.  Some of the strategic diligence questions to ponder include:

  • What are the strengths of each practice?
  • What could our practice be doing better?
  • What opportunities exist as a result of this merger?
  • What threats do we face by completing this merger?
  • What is the current culture of each practice?

It is critical for physician owners to be honest and thorough when assessing their advantages.  Ideally, they develop a fact-based point of view on their beliefs — testing them with anyone responsible for delivering value from the deal, including physicians, physician extenders, clinical staff, and front and back office personnel.  Above all, when it comes to the merger of two physician groups, culture is a key decision criteria.  Culture should be evaluated and discussed prior to any financial considerations. In my experience this is of paramount importance for practice-to-practice mergers and is meticulously examined only through strategic diligence.

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Contact ABISA for healthcare consultancy support or speaking engagements.

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2016 Drug Trend Report

The topic of drug prices in the United States is a conversation of ever-growing frequency and intense debate.  Compounded with healthcare reform legislation and high-deductible plans, it is an issue of high importance to all Americans.  Although there are mountains of data regarding this topic, a study by Express Scripts summarizes the top 15 of therapy classes in an easy-to-follow format.  Express Scripts recently released its 2016 Drug Trend Report based on pharmacy claims from 30 million members of Express Scripts.  The report shows a 3.8% increase in drug spending and an 11% increase in list prices of brand drugs.  Here is a snapshot of their top 10 therapy classes, ranked by per-member-per-year (PMPY) spend (dollar amounts rounded):

  1. Inflammatory Conditions. With a PMPY spend of $118 and an average cost per prescription of $3,588, this class topped the chart.  These drugs are used to treat conditions such as arthritis, psoriasis, and Crohn’s disease.  The report states that this PMPY spend trend will continue at 30% year over year through 2019 and also noted that over 41% of patients are nonadherent.
  1. Diabetes. This class demonstrated a PMPY spend of $109 and an average cost per prescription of $126.  The report states that this PMPY spend trend will continue at 20% year over year through 2019 and also noted that over 37% of patients are nonadherent.
  1. Oncology. This class demonstrated a PMPY spend of $61 and an average cost per prescription of $7,891.  The report states that this PMPY spend trend will continue at 20% year over year through 2019 and also noted that over 35% of patients are nonadherent.
  1. Multiple Sclerosis. This class demonstrated a PMPY spend of $59 and an average cost per prescription of $5,056.  The report states that this PMPY spend trend will continue at 10% year over year through 2019 and also noted that over 24% of patients are nonadherent.
  1. Pain / Inflammation. This class demonstrated a PMPY spend of $52 and an average cost per prescription of $49.  The report states that this PMPY spend trend will continue at 3% year over year through 2019.  These medications include opioids and nonsteroidal anti-inflammatory drugs, and this class is prolific with generics and has a 95% generic fill rate.
  1. HIV. This class demonstrated a PMPY spend of $40 and an average cost per prescription of $1,556.  The report states that this PMPY spend trend will continue at 20% year over year through 2019 and also noted that over 24% of patients are nonadherent.
  1. High Blood Cholesterol. This class demonstrated a PMPY spend of $38 and an average cost per prescription of $36.  The report states that this PMPY spend trend will decrease steadily year over year through 2019 and also noted that over 36% of patients are nonadherent.
  1. Attention Disorders. This class demonstrated a PMPY spend of $36 and an average cost per prescription of $145.  The report states that this PMPY spend trend will continue at 3% year over year through 2019 and also noted that this class is dominated by generics with a 74% generic fill rate.
  1. High Blood Pressure / Heart Disease. This class demonstrated a PMPY spend of $35 and an average cost per prescription of $14.  The report states that this PMPY spend trend will decrease steadily year over year through 2019 and also noted that over 28% of patients are nonadherent.
  1. Asthma. This class demonstrated a PMPY spend of $30 and an average cost per prescription of $69.  The report states that this PMPY spend trend will eventually decline by 2019 due to oncoming generics and also noted that over 73% of patients are nonadherent.

The next five therapy classes shown in the report are:  Hepatitis C (#11), Depression (#12), Contraceptives (#13), Heartburn / Ulcer Disease (#14), and Skin Conditions (#15).  The 2016 Drug Trend Report can be found here.

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Contact ABISA for healthcare consultancy support or speaking engagements.  Follow on Twitter @ABISALLC

Shifting Practice Model of Some PCPs

In the United States, physician practice acquisitions were on the rise over the past few years as healthcare reform incentivized hospitals to do so.  During this time, however, studies have questioned the relationship between physician employment and quality of care.  Physicians of all specialties have been impacted by healthcare reform legislation and the subsequent acquisitions, perhaps most notably are the primary care physicians.  Consequently, there has been an increase of these physicians converting their practices into concierge medicine or direct primary care.  A recent study by Kareo and the American Association of Private Physicians sought to study key trends in some independent medical practices.  Rob Pickell, Chief Strategy Officer of Kareo, notes:

“The majority of Americans continue to receive their care from independent medical practices due to the superior combination of patient focus, healthcare outcomes, and lower costs. Emerging practice models such as direct pay and concierge medicine represent exciting new ways to preserve and enhance the independent practice model.”

The survey targeted physicians who are adding or converting to a direct primary care or other membership model for payment rather than a conventional fee-for-service practice model.  Here are some brief points found in the survey:

70% of respondents reported they wanted to spend more time with patients; 41% wanted to improve their work/life balance; 40% wanted to separate from the insurance payer system

65% of respondents using some variation of a concierge medicine membership model reported their cost for membership was under $2,000 per year; 32 % have one quarter of their patients in membership; 30% have all their patients in membership

58% of respondents are out-of-network with health plans; 57% participate in Medicare; 54% participate in health plans in network

Telemedicine

Virtual care has its place in many practices currently and is certainly gaining momentum, though there are many things to consider before jumping in with both feet.  This survey also demonstrated the growing use of telemedicine.

23% of respondents currently use telemedicine

42% plan to grow and expand the use of telemedicine

Conventional vs Concierge/DPC

Along the lines of different practice models, Rob Pickell stated:

“These newer models also address patient and physician demand for more proactive care, care coordination, and wellness programs. For these reasons, these new practice models should be of interest to both healthcare professionals and patients.”

The survey also shines some distinguishing light on the different models.

79% of physicians employing concierge medicine membership or direct primary care payment models spend an average of 30 to 60 minutes or more on each patient visit

75% of physicians in conventional fee-for-service practices spend 30 minutes or less with each patient

60% of physicians in conventional fee-for-service practices have a patient panel of over 1,000; nearly all of physicians employing concierge medicine membership or direct primary care payment models have a patient panel of less than 1,000

38% of the direct primary care private practices call recruiting new patients their single biggest hurdle

35% of conventional practices said their biggest challenge is remaining financially viable

The survey can be downloaded here.

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Contact ABISA for healthcare consultancy support or speaking engagements.

Generational Attitudes About Healthcare

Millions of Americans are starting to become more engaged with how they manage their health and wellness, but each generation approaches medical care quite differently.  The changes to the healthcare industry are increasingly focused on addressing patients as consumers. Such a change means that providers must of course emphasize quality and work toward price transparency, but they must also seek to determine what patients desire most.  In a recent national survey by Vitals, researchers explained great differences between Baby Boomers, Generational X, and Millennials.  For the purposes of this survey, Millennials were classified as 18-34 years old, Generational X as 35-54 years old, and Baby Boomers as 55-70 years old.  Here is an overview of the survey’s findings:

35% of Millennials have a Primary Care Provider; 64% of Generational X have a PCP; 83% of Baby Boomers have a PCP.

25% of Millennial patients reported using an urgent care center when they are sick.

25% of Generational X patients reported having lost trust in a physician or healthcare organization in the last 2 years.

83% of Millennials trust physicians with their personal information; 77% of Baby Boomers do as well; only 64% of Generational X patients do.

Baby Boomers seek out a physician based on a referral, whereas Millennials look at online reviews.  Generational X patients tend to use a combination of these two approaches.

Millennials tend to trust their physician and follow the medical advice provided, whereas only 50% of Baby Boomers do.  Generational X patients are quite the skeptics, believing that physicians “pretend to know” when in reality the physician is not sure.  Additionally, Generational X’ers are inclined to wonder “if docs really know what they’re doing.”  Consequently, Baby Boomers are open and honest with their physicians and quite agreeable to a team approach to medical care, whereas Generational X patients hold back information from their providers.  Millennials are quite open, but (as with other facets of their daily lives) they will often challenge a physician’s diagnosis.

Vitals also references a study from JAMA Internal Medicine, noting

“Baby Boomers have higher rates of chronic disease, more disability and lower self-rated health than members of the previous generation at the same age.”

This research supports what I often tell clients as we engage in strategic growth initiatives.  To grow your healthcare practice, the group cannot stereotype all patients, but rather must thoroughly understand the unique differences of the particular patient demographics that they serve.  This, combined with understanding your market, can help to differentiate your practice and set it on a path of continued future success.

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Contact ABISA for healthcare consultancy support or speaking engagements.