Don't let social distancing bankrupt your practice with Dr. Paul Firth

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Hi, docs. Welcome to the Entre MD podcast where it is all about helping amazing physicians just like you, embrace entrepreneurship so you can have the freedom to live life and practice medicine on your terms.

I'm your host, Dr. Una. Well, hi, everybody, this is Dr. Una. Welcome back. This is just a series that we're doing to help support physician entrepreneurs right in the middle of the pandemic that's going on. And I have the wonderful privilege of having Dr. Paul Firth on here. And he is an amazing pediatrician, an amazing physician entrepreneur that I followed for years. You know, truthfully, I was just telling him yesterday how we kind of connected. He was doing a training event on how to code properly. And I was one of those. Everything was a 99213 because I didn't want to get audited kind of doctors. And, you know, I signed up for his event, I went for it. Best money I ever spent. It's really helped me run my practice so much better. And we're right here in the midst of a pandemic and. And he was talking about all the changes he was making in his practice. And I was halfway through the emails like, no, I need to get you. I need to get you on the show to come talk to doctors and let them know what you're doing so they can get inspired, they can pick up some ideas, and we can plan to thrive in spite of this pandemic. All right, so welcome aboard, Dr. Paul Firth. Very nice to have you on here.

Well, it's great to be here. I'll admit I've never done a podcast before, but until three weeks ago, I never did telemedicine before. You get as you go on, I think.

Yep, that's exactly how that's working. All right, so today we're really going to be looking at how not to let social distancing bankrupt your practice, which I think is phenomenal. So before we go on, I'm going to give you a moment to introduce yourself to the listeners.

All right, My name is Paul Firth. I'm a pediatrician in a very small town In Oklahoma, about 10,000 people. I finished medical school in 95. We just got our announcement said, hey, it's time for our 25 year anniversary and reunion on May 1st. And I was actually going to go this but I don't think we're going to get to do it unless we do it virtually. Then everybody argues about who gets paid.

For it or whatever.

So I've been in practice for about 22 years now, just private practice. I have two nurse practitioners that work with me and we just work in a little town and do pediatrics.

That's great. Yeah. Okay, so now tell me a little bit about your practice because from the talk that we had, I get the feel that it's very well run, very efficient, and you do a good job with taking care of patients and then also making sure that the money piece is running right so that you can continue to take care of patients. Just talk a little bit about it.

Sure. It's one of those things when you're in medical school and you see how the continuity care clinics work. You think, oh, I never want my clinic to work this poorly or this inefficiently. Like most people that go into owning a private practice, we think, okay, we can do this better, we can make it work better. And I love kids, I love taking care of kids, I love talking with parents. But I'm also one of those weird people that I want to dig into and find the right dial to turn to make things work better. And what can we do to run more on time? And what can we do to make sure that everything that needs to be done for this kid is done for it? And how can we make sure we don't forget to do things like, you know, their second Gardasil or their brother who forgot to get his seven year old well visit or something like that. And so I've always just Been real obsessed with how can we make everything work more efficient and sort of, again, maximize our reimbursement, not to do anything other than get paid for the work we're doing, so that then we then have the capabilities to have more room, more staff, more opportunities to run better for the patients.

Now, you talked about you're always looking for that dial to turn. You also at some point developed your own ehr, right?

Yes, we did. It's really the same thing we developed. Our computer programming is a hobby of mine, which I'm one of those weird people that have weird hobbies. But I thought, well, we can do better than what's going on. And so it's been like eight years ago, and we made our own medical record system, and it worked well, and it worked fast and efficiently, and we loved it. And then all the government said, we have to do these certifications. We're like, okay. And so we went through the big process of getting certified, and then they said, okay, now here's step two. And it just got to be too much. And I decide, do I want to run a computer company or do I want to do medicine or do teaching? And I figured that running a computer company has lots of things like marketing and sales and things that I do not like at all. So we just sort of gracefully bowed out and let other people do that now.

Awesome. But, yeah, and when I saw that, I was like, he developed his own ehr. Oh, my goodness. Okay. All right, so let's talk about the changes you've made in your practice since COVID 19 started. Like, first of all, what challenges did you anticipate that even made you go like, okay, we need to make changes?

Yeah, well, when we first started hearing about this, you know, it was kind of over Christmas break or the first part of January. Nobody knew what was going to happen. And so my mind is thinking, okay, either we're going to be really, really, really busy with sick people or people who think they're sick, or we're going to be not very busy, and people are going to be staying home and staying away. Or the worst one I could think of, and this is because I'm a businessman, is we're going to be really, really busy, but all my staff is going to be sick. We're not going to be able to see everybody. And so we sort of started plotting out, okay, what do we need to do to make sure our staff stays healthy? What do we need to do to make sure we can accommodate a large volume of people? But also, what are Some things to keep in mind. If our volume goes down, what do we do next?

That's a huge thought process. I did some thinking, but I didn't come up with all three scenarios.

That's my problem. I get stuck in my head really a lot.

Yeah, but that's, that's, that's good, though, because it facilitated change. So, you know, that's good. All right, so let's talk about those changes. What are the changes you needed to make?

Well, I mean, the first one we did was when we. Well, basically right before spring break here, where we're at, all of a sudden, everything was getting a little more serious. And then they lifted the restrictions on telemedicine. That was the first thing that we did. We're like, oh, this would be so great. We can do virtual visits and get paid for it. Just like doing a level three or four or five in the office. Of course, we had a lot of hesitation and we were worried, well, what if they go back on their agreement to change the rules and regulations and will we get paid for it or not? And so we sort of jumped in and said, okay, let's start doing telemedicine visits first. And that started working. And then the next week during our spring break here, all of a sudden, our volume started dropping way off because everybody was staying home. And then we started. I mean, one of the first things we did is we tried to really reassure the patients that, yes, you need to come in. Yes, you need to take precautions and be safe. And so part of our reassuring the patients was we made some schedule changes first. We said, okay, we're gonna have only sick kids come in after lunch until we get done seeing the sick kids. And we started saying, okay, only well kids or healthy kids in the morning. But we had to change it to non sick because there's a big crossover there.

Yeah, yeah.

One of the biggest things is just reassuring parents, yes, this is a safe time to bring your child. And then, like a lot of practices, we tried to eliminate the waiting room. We said, okay, we're either gonna send you straight back to an exam room and the nurse will finish, check in one on one, or we're gonna have you wait in the car till we're ready and then you go straight to the exam room. Right now, in our little county, we have only one or two cases. And so we are not a high risk county yet. But if the parents feel like, yes, we're looking out for their best interest and we're taking care of them, then yes, we can go Ahead and get our, for example, our routine, needed immunizations and not worry about this disease, at least at their office.

Okay, so the first one was adopting telemedicine. Did you have any kickback from the staff or from the patients as far as that went for telemedicine?

It was weird. The biggest thing we're going through now is getting the patients to walk through the technology of it. We're like, right now, yes, you can do FaceTime. We're really trying to not do FaceTime or some non secure. We're having them go through the patient portal or the app for doing the telemedicine visits because we figure when all this blows over, hopefully we can keep doing telemedicine. But yeah, the hardest part was me sitting on the screen the very first patient going, how are things? You know, it's just, even though I've been doing interviews for 25 years, all of a sudden it felt so different. And after 20 or 30, it gets better. But really, I think we've had all but one parent overwhelmingly like doing the televisit. I mean, it saves two hours of their day just not to get up, get ready, come in and go home.

Yeah. Okay. So there's an initial hurdle, but once they get over that, they're like, yay, this was amazing.

Yeah. For the most part, everybody seems to like, we love it.

I love it too. I really love it. Okay. And then so the second thing you did was change the schedule some. So where in the morning you have the non sick. I like that you said non sick because we said, well, check and sick visit. But then you have the ADHD visits and all their sick but not contagious. They're not sick in that kind of way. They're not contagious. Stuff like that. Yeah. Okay. And then the third one is eliminate the waiting room. What do you think? I'm curious. Post COVID 19, are you going to go back to a waiting room? Are you going to figure out how to keep that?

What are your thoughts as a pediatrician? And you know this one of the biggest things is, you know, every, about every second or third day we have what's called crybaby day. And everything is loud all day long and you can't predict when that is a baby day.

I didn't know it had a name or 15.

But one thing I like about that is we have much less noise, much less chaos because there's not a waiting room full of people and they're not waiting to check in at the window. And we Even do our check out in the room with the nurse. So basically, they come into the room, they're in the room, and they leave. And even our nurses, we have three nurses for five rooms. Our nurses are in the rooms 80% of the time, which, again, decreases the volume and the chaos that we have to be around.

So overall, it's just calmer. And post Covid, we're going to try and figure out how to keep that going.

Yeah. And one thing we did is we said, okay, no more overbooking, because when you try to overbook and get somebody in, you inevitably run behind. And then people are waiting. And we said, at least right now, we can't have people waiting. And that sure has made it very pleasant to see patients when you're not running behind.

Awesome. Okay, so good. All right. So what other changes did you make?

The big thing we did, as soon as we got slow, my mind immediately turned to, okay, how can we maximize what we're doing on the patients in the room? Because now the patient's here, and our next patient is not for 45 minutes, because nobody's coming in. We started looking at what's everything that needed to be done. Are they behind on any immunizations? Because sometimes for some reason, they haven't gotten some sort of immunization, and those are easy to miss. So they're not coming in for a, well, visit. Are there any necessary procedures that need to be done? You know, if this kid is an asthmatic, has he had a routine spirometry done in the last six months? Have they had their yearly, you know, mental health screenings? Just going through those types of things is all the routine things that we can be done to try to figure out what we can do for the patient. And one of the things we started doing yesterday is we made sure that all these patients were engaged on our patient portal because, you know, a lot of parents come in, they get signed up for it, they get their username and password, and they never log in again. And so, because we want to encourage televisits the best we can in the future, either me or a nurse sits down with them and says, hey, get out your phone. Let's walk through it. Let's get you logged in right now. It took five minutes. And the mom that I was dealing with yesterday, she was like, oh, this is so easy. And she'll use that from now on. And so that's one of the big things that we've done, is just try to get everything done on the patient.

Okay, so we're Maximizing the visits, which is great for the patient in the sense that they're caught up on vaccines or they're caught up on their spirometry and all of that, maybe limiting their need to come in for another visit soon. And at the same time it's also maximizing for you as a practice because yes, you, it's one patient, but then you're getting a lot more value, reimbursement wise out of that one visit. That's awesome. That's brilliant. I love it. Okay, and the other thing you said was the engagement, because you know what I've noticed personally is we have to be a lot better at galvanizing our tribe. We don't necessarily look at, you know, we have our patients, we take care of them and all of that stuff. But there's not that much engagement. There's not one way to reach them and say, hey guys, this is what's going on. Maybe we're not sending out regular emails to give them updates, send them funny videos from the office and stuff like that, but we're in a time where you can't really get away with not doing that. So, you know, emails, we have to be doing portal messages, all of that. So I love that you're like, let's get you on the portal. Because we have the time to do that.

We kind of, one of our biggest.

Things is we, we might have 40.

Parent calls per day, phone calls that we have to triage and go to voicemail.

The nurse has to listen to it.

And write a note and deal with it. And even by rewarding people on the.

Portal that send their questions that way instead of calling, we answer those first. And so sometimes they'll get a response in 30 or 60 minutes. But it saves us so much time.

Because instead of having to listen to.

A phone recording and having a nurse.

Call back, the parent has the question.

In their own words already assigned to the patient's chart and we can deal with it so much faster.

Perfect. Perfect. I love it. Okay, any other changes you made?

One of the huge things we do, and we do this as best we can most of the time anyways, but we're really focused on it now is we make sure everybody that needs to come back has a follow up scheduled before they leave. Because, you know, most people are pretty responsible. 95% of the people will always keep their appointment and 5% will never keep their appointment. And so if they have an appointment scheduled when they leave here, and let's say if you're going to earn X number of dollars. There's, you know, if you're going to earn 100, there's pretty much a 95% chance. So every appointment we make today is going to make us $95 in the next few weeks or months. And of course, it's always has to be necessary. But sometimes, you know, when somebody comes in, they may be overdue for a health maintenance visit. So let's get that scheduled next week, not next month, if they need to come back for a immunization, but it's still about a month or two, let's get that scheduled. If they need their next, let's say their next, well, visit is actually four months from now. We'll get that scheduled. One of the big things we often forget to do is somebody needs to come back in two or three months. Sometimes people say, oh, just call. And we say, no, no, let's get that set up now. And if we need to change it, it's easy because if we set it up now, they come back.

Got it. Okay. And I think I learned that from you when I was at your event in Atlanta about really being diligent about scheduling those appointments. You know, while you have the patient in the office, that's the easiest time. And whether you're a pediatrician or your internal medicine. Internal medicine will be the same thing. When do you need to see your hypertensive patient back? Rather than letting them leave and call or especially call when they have one pill left or they've been out for three days, can have them schedule that before they leave the office. It's so much easier to reschedule than to go find a patient. So that's really good. Okay. Any other changes you have up your sleeve? Did we exhaust them?

No. Two of the things that we do is, especially as a pediatrician, but this is really any practitioner. What family members do we see of this patient that's here in the clinic today? Because if we see any other family members, we do it automatically with the computer. But it's easy to have a nurse do this. You look up that family member and see, are they overdue for something? Is there some reason they need to come in? Because if you say, oh, look, little Jimmy and little Timmy, they're both due for shots, lets them come in next week because there's no school anyways, and we're not going to expose them to disease. We zip them in, do the shots or the well visit and let them go home. And so capitalizing on family members that truly need services, they may not think about it otherwise. And then the other big one we do is when we do have downtime. Now we have started targeting sort of what I call high yield people, people that need to come in the clinic, but it's also people that we're likely to get ahold of. And so like yesterday I pulled a list of our 2 and 4 and 6 month old kids that have not come in for their two, four, six month old shots and they don't have anything on the schedule. And then I sort of whittled that list down to people that live near here because we have Some people drive 60 miles to come here because we are in a rural community.

Wow.

And then I also whittled it down to people that actually show up for their appointments because if they've had three no shows and their kid's six months old, we'll call them another time. Now, yesterday, it's funny because yesterday, mid morning, like 10 or 11 o', clock, I looked out there and all three of my nurses and one of the receptionists was all on the phone calling people, calling people. Well, then we get a Facebook post at lunch that says, hey, are your phones working? I've been trying to call all morning, I can't get through. And so had to revisit that and say, okay, no more than two people calling out because we only have five lines and something we never even thought about. But it's been pretty effective. For every hour that our people call, we get about two people or three people that will come in and do a visit. And financially it makes a tremendous amount of sense, but it also keeps people getting their things done so that we don't get overwhelmed with needed screenings and well visits two months from now.

Got it. Okay, this is really good. So track down the siblings or other family members and then recaller and a really targeted list. I like your list that is so clean, like you know, you need shots more likely to come. You're a baby and you live close by and you're not one of my 5 percenters that always no show. I love it.

We pulled a list of 16 and 17 year olds that were overdue for their meningitis shots or their boosters because they're driving. And so especially with everything that's going on, we just sent a targeted text message campaign that said, hey, are you sick and tired of your teenager being at home? Do you wish you had more social distancing? Well, guess what, they're due for a shot. Send them in and put their phone number and their name. And people have called, said yes, Please do something with my kid. At least give them a shot.

And so I love that line. I am so stealing it. And I'm sending it to my practice administrator today.

They are sick and tired of their kids being at home right now. It has been a long three weeks.

Oh, wow. Love it. Okay. Yeah, I'm totally stealing that line. I love it. Okay, now, how often are you reassessing what you do to say, you know, did this work? Did it not work? What are we tweaking? What are we adding? How often are you doing that?

We try to study what we do. We'll look like for the call list, we'll look and see who they call, did they show up or not? My biggest problem, and everybody that works with me can tell you this is every 30 minutes, I'll jump out of my room and say, hey, I've got a new idea. And so my wife.

You sound like an entrepreneur.

Yeah. And that's the worst thing, is to have eight new ideas a day. And they're like, hey, we did the thing you said yesterday. I was like, what? No, no, no. We're onto something new now. And so that's my wife's biggest complaint, is when you're dealing at the office, write it down and wait a day before you tell anybody anything. But, yeah, just really, just any while we're slow, especially whatever we can do to help get people in or whatever we will do. And any of the nurses that have an idea, they're like, hey, what if we did this? Yeah, let's do that. Let's try it and see.

Okay. So very flexible. Not holding on to any old ideas or this is the way we've always done it. Everybody's just flexible and do what you need to do to get this working.

Yeah. Well, the biggest thing is as a practice owner, if we don't make payroll, I'm the one who doesn't get paid, and everybody else gets paid. And so I think practice owners have a lot more incentive to flex what they're doing on a daily basis to get to the point of, you know, because we had a time 10 years ago where we hit some financial troubles, and one thing we did not do is cut back soon enough. And so, like, today, you know, we know in our clinic, here's how many patients we need to see a day to make payroll. And if we see this many, it's better. But we also know if we get down to this many, we. It's time to let some people go home and not be at the office. And the Office staff know that, too, which also gives them a lot of incentive to say, hey, we're all in this together. Let's make sure we get these people in.

Okay? All right, good.

Perfect.

Now, so for some states, they're a little more hit by the COVID pandemic, and patients are even more terrified of coming into the office. So there's a lot of kickback with that, even though they're hitting the recaller to get those appointments in. What would you say to the doctor who's struggling with their volumes? What would you say to encourage them, to direct them, to empower them, you know, to get through this time?

It's tough, I mean, because, you know, you want to persevere. This is going to be a temporary thing. We don't know how long this is going to be a temporary thing, but it is going to blow over. I'm no expert on this, but I just heard that, you know, the SBA loans that are. They're offering through the government, there are some good loans for business owners, help make payroll, and so I'm still looking into that. I don't know anything about that yet. But the biggest thing is if you don't do that, look and see if things stay bad for a month or two months, how much financially is that going to hurt us? Is there anybody that's ready to take some vacation now? And are you doing everything you can to keep your volume up? Because the biggest thing is if you have a leaky ship financially, you need to cut back. You need to cut back until things get better. Or talk to your bank and say, look, I need an operating loan for the next three months just in case. And not getting behind, that's the biggest thing.

Right? Okay. All right. So do what you can to keep your volumes up. If there's anything with the SBA loans, look into that and get your office set up for it. And then, you know, cut back where you need to cut back. Sounds about right. I love it, love it, love it, love it. All right. Any parting words of wisdom before I let you go?

Oh, I don't have wisdom. I've just been doing this a long time. There's a difference. That is called wisdom and doing it a long time. The main thing is, I mean, this is going to pass, but use this as a time to maximize everything you're doing for your patient's good and your reimbursement, if it's something they need.

Awesome. Awesome. Well, thank you so much for coming on. This was really, really helpful. So, everybody, you got that my charge for you is to please take this episode and share it with another doctor. There's a lot of it's a really challenging time, and this may be that thing that inspires someone to keep going as opposed to quitting or taking it to another notch instead of just staying with the status quo. So thank you guys so much for listening. I'll see you on the next episode. And thank you so much, Dr. Firth, for joining us.

Thank you.

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