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CURRENT CIRCULATION: 7997 DATE: 16 Dec 2012 ISSUE NO: 192 Welcome to Health & Life’s free email newsletter service. This service is to provide Health & Life’s clients, contacts and those who attended our presentations with up to date information on key financial and practice management issues that may affect your practice. Tell a friend that we would be happy to add their email address to the distribution list. Please do not use this as a substitute to seeking professional advice.

Writer in charge: Mr David Dahm BA.Acc, CTA, FCPA, FTIA, Ffin, FAAPM, FGLF.

How to Cope With the Tsunami of Change

Introduction – How do you run a practice?

I know this is a big edition and you may not have time to read it. Efficient and effective practices and people do, find out why. This is a three step plan on how to manage change in your practice. Over the next few weeks we will be broadcasting this edition in three parts. Alternatively you can download the full story here.

Last month at a function, a perplexed doctor in his 50’s said to me “David we have got this large block of land to expand our medical centre but we can’t get the project up”. After some discussion he said “They didn’t teach us how to run a practice at med school”. Like everything in life some structured training is required or there is the hard way!

In this bumper edition, I want to put fire to your feet. Over the last 21 years this is the best advice I can provide to you about how to tackle some of the most difficult “elephant in the room” problems you may or will experience. Are you open to change?

We will cover Big Ideas on how to run a practice for 2013 and beyond. Practices should use this edition as a quick checklist as to whether your practice has a future or not.

A serious prediction for healthcare practices in the next few years

Over the next 2 to 3 years, many practices will either grow exponentially, merge, corporatise or cease operating. Recent main stream media coverage revealed national research that “larger practices of 5 or more GPs increased at the expense of solo and small practices”.

As we head for a fiscal cliff the only thing certain is death and taxes, so my money is still on investing into healthcare with the following exception: make sure the practice is managed well.

The Government has imposed some significant and unprecedented operational and infrastructural changes on practices that will have a substantial impact on the type of skilled staff employed and practices’ IT infrastructure.

Additional external factors such as the national low pay Nurses Union dispute, Medicare and Australian Tax Office computer generated audits means a doctor’s affairs will be more open and transparent and subject to instant scrutiny. Legislative change continues unabated. Practices are going into information overload. This edition is a case in point. It is unavoidable.

In this edition we will cover the three simple but effective steps for how practices can take advantage of this change.

The most successful organisations and people we know employ these steps with discipline, rigour and enthusiasm.

Asking the right questions is far more important than getting the right answers. Ask the following: 1. What? What are the significant external and internal challenges and opportunities affecting our practice?

2. How & When? How are we going to turn these ideas into action?

3. Who? Who do we delegate to and why? Trust but verify!

Table of Contents 1.

Asking the right questions is more important than receiving the right answers!

1.1. What? What are the significant external and internal challenges and opportunities affecting our practice?

• • • • • • • •

The ePIP are you about to lose a lot of money?

E-health the new norm?

Taxation Audits on Doctors reveal big errors in providers’ pay Take Out Personal Tax Audit Insurance Doctors and healthcare workers are being prosecuted without evidence The Australian Nursing Federation low pay claim - do you have a signed contract?

Succession Planning – what really works!

1.2. How & When? How are we going to turn these ideas into action?

• • •

Governance – business ethics is just important as patient ethics Systems – if it can’t be measured it can’t be managed – no more surprises Training – you don’t know what you don’t know – be open and transparent

1.3. Who? Who do we delegate to and why? Trust but verify!

People – Firstly get the right people on the bus • • • • •

Owners & Management Staff Patients or Clients External Advisers Time Management – I am too busy for this!

2.

Seminars and No Obligation Meetings

3.

Where to from here?

How to Cope With the Tsunami of Change

1.1.

What? What are the significant external and internal challenges and opportunities affecting our practice?

Give me six hours to chop down a tree and I will spend the first four sharpening the axe ~ Abraham Lincoln Identifying the most important challenges and opportunities is the key. It is critical to ask the right questions rather than find the right answers. This filters out any bias. Some key challenges and opportunities are below.

The ePIP are you about to lose a lot of money?

The most significant industry change facing practices today is to the (Electronic) Practice Incentive Payment (ePIP) grant system. For some practices the normal Practice Incentive Payment represents up to 5% to10% of a practice’s turnover and nearly 60% of a practice’s st profit. You need to be ready by 1 February 2013 or you may start to find the practice experiencing cash flow problems for not being compliant with the new Pip rules.

Over the coming years up to $25,000 p.a. per full time equivalent GP could be lost if the practice does not comply with the new program. Can you afford to ignore this change?

As mentioned in our last edition, the program is designed to enable a national electronic health records system that patients can access anywhere at any time. This has significant privacy and medico-legal problems, many of which have not been completely resolved with medical indemnity insurers. So don’t believe all the glossy brochures and reports, practice owners are personally liable if things should go wrong.

The ePIP requires practices to start re-evaluating their software and hardware systems, IT protocols and staff training. Furthermore, doctors are expected to clinically code entries correctly into this new national system or future funding may be put at risk.

A lot of this has not been in the main stream media. Yes, it is pretty much an Australia card in disguise, however for patients it is a voluntary opt-in arrangement.

How practices are legally set up and who is the responsible officer are not straightforward issues when it comes to registering.

For legal and operational reasons, make an owner and not your practice manager the primary responsible person in charge. Also make sure if you have a service entity that this is the registered entity. Contact us at pa@healthandlife.com.au if you are not sure.

Getting ready for new the ePIP is not a user friendly process and involves a lot of management time, including that of owners and all providers.

The AMA ePIP checklist is useful starting point. Like practice accreditation if you are not ehealth compliant practices will miss out on Government grants, they will make it hard to cheery pick. The Government has spent over $500m on this program to date.

The Australian Association of Practice Managers also has a very useful E-Myth series that can help with any compliance issues.

E-Health the new norm?

It is interesting to note practices focussed on e-health a number of new on line booking systems and Skype consults on line for scripts and minor issues appears to be the new way of delivering or enhancing services. See https://gp2u.com.au/ which has recently been in the mainstream media. Practices need to have a strategy or they will miss out on what can be perceived the easy work. More importantly it has the potential to disrupt continuity of care with your patients. Patients should be educated with the up and downside of this trend.

It can be beneficial if a service could be provided by local practitioners. It can offer more flexible working arrangements for providers.

The role of social media should not be underestimated in this environment from explaining common treatments to promoting what and how people use your practice services see GP2U video tutorials.

For the record they are not clients nor do we have any arrangements with them other than showing this as an example of how the future of healthcare may look. For many practices how they will respond will depend if patients start to use the service. It is worth thinking about if a more offensive strategy is a better defence.

Taxation Audits on Doctors reveal big errors in providers’ pay Due to the Global Financial Crisis we are seeing more computer generated tax audits based on data matching a doctor’s income to that reported in practices.

Of serious concern, many of the major and popular medical software companies do not prevent past billing information from being edited or tampered with.

We have noted many practices have no audit controls and significant and frequent errors from $100 to $4,000 per person/pay period are being made, where doctors and providers are paid on a percentage of their income.

This is adding significantly to a practice’s accounting costs. Note: many practice accountants do not check this area because they say it is outside their responsibility. They don’t have the experience or tools to check this area. It is important to ask and get any advice in writing.

These errors are embarrassing. They can make the practice liable in a tax audit or pay dispute and have a serious impact on recruitment and retention.

Health & Life have successfully developed (which we have had the ATO scrutinised) an alternative solution. Please contact us if you would like further information.

Take Out Personal Tax Audit Insurance We highly recommend taking out tax audit insurance for the practice and individual doctors.

Check with your medical indemnity insurer. We understand Avant offers this insurance automatically. Please check the terms and avoid the problem this poor doctor had with his insurer see GP $12,000 out of pocket after ATO probe.

Doctors and Healthcare workers are being prosecuted without evidence Another interesting development flowing from ePIP is how the Government Professional Services watch dog will use the patient electronic controlled records system to data-mine doctors for inappropriate practice see PSR software will extract GP patient records. This means you can easily attract an audit for seeing too many patients. This is regardless of your situation - if you are busy solo GP in a rural town, right through to not documenting a patient’s treatment correctly.

The new Professional Service Review laws have been extended to practice owners and management. They can be implicated if they do not comply.

We are concerned that the doctor/patient relationship is being unconstitutionally interfered with and services are being unnecessarily withheld.

We have produced part one of a social media video called “I want to get in between your legs”.

The title is meant to be confronting as it is a public awareness campaign, it is meant to attract attention. I am sure you will be just as upset by the content as we are.

It reveals how the Government unfairly prosecutes healthcare workers without evidence in Australia. This seems to be more for budgetary than clinical reasons. This audit anxiety is stifling medical/healthcare innovation that meets your patients’ needs and is reducing patients’ freedom to choose their provider.

This is a sneak preview of the full 15 minute video to be launched in late January which will explain all. We would appreciate any feedback as we are planning a national campaign. I hope you will share the full video with your patients so we can lobby the Government for fairer rules.

The Australian Nursing Federation low pay claim - do you have a signed contract?

We have widely reported this year the need for practices to have prepared Fair Work friendly employment contracts. Employment agreements have to be signed by your staff in order to avoid an underpayment of wages claim. This issue continues with over 1,000 practices in the eastern states being forced to provide evidence against the Union’s allegations of underpayment. This will spread nationwide if the Union’s action is successful.

We have worked pro-bono for our clients to successfully argue before the Fair Work Tribunal that these are false allegations. The Union was on a fishing expedition successfully soliciting copies of employment contracts. Many practice owners and staff (including those in corporate practices) are being forced to give testimony before the Fair Work tribunal.

Succession Planning – what really works!

Every practice has a lifecycle. Are you throwing good money after bad if you can’t sell your practice? What is it really worth? Doctors will pay to get into well run practices.

Practices must ask themselves what they will look like in 5 years time. Do we want to grow from 2 owners to 5, from 4 doctors to 6? Why would anyone want to join or buy our practice? What income do we hope to earn for how much effort? Is there really any point in owning 100% of nothing when you could own 50% of something? What is our business model?

If you can’t answer these questions, you probably have more ‘low hanging fruit’ opportunities than problems. It is possibly also the main reason why you cannot recruit and retain your staff.

Nobody wants to join the Titanic anymore than they want to work in a practice that is not keeping ahead of the times.

Health & Life can prepare an annual The Good, Bad and Ugly Report for clients. This helps give a “MRI” view of your practice.

One of the most common mistakes that practices make is that they sell a percentage and not a future to younger practitioners. Well structured practices offer owners from 90% to 110% of billings and can be sold for this very reason.

Ownership should be sparingly offered to potential recruits that can work on and not just in the practice. For example, a part-time GP owner is a good catch if they can recruit and train GP Registrars. Practices need to ensure specific skills sets and expertise that complement the existing Board.

Our clients use a Directors Pathway Program that vets potential owners to ensure they are the right fit. What do you do?

1.2 How & When? How are we going to turn these ideas into action?

Efficiency is doing things right; effectiveness is doing the right things. ~ Peter Drucker Leaders do the right thing, managers do the thing right!

Highly successful practice owner leaders know how to capture information and leverage from it fast. This includes setting priorities and managing key tasks without the need to micro-manage the outcomes. How do they do it?

Governance – business ethics is just important as patient ethics Governance means ‘to do no harm’. It is now part of the new accreditation standards. It is a thinking process that involves a structure as described below. It is there to promote openness and transparency as well as sound and efficient decision making. The ability to delegate the day-to-day issues without micro-management is a key benefit.

For example if you have 5 owner doctors charging $300 per hour, each meeting costs $1500 an hour. So you don’t want the practice manager to carry on about getting a $200 discount on a photocopier machine. Good governance prevents this poor use of everyone’s time.

Where there is more than one owner, they have a Board and should elect a Chair. The role of the Board is to hire and fire the CEO/Practice Manager and ensure policies and protocols and the strategic direction of the practice is being complied with. We have a delegations policy for a CEO/Manager that stops unnecessary meetings on the small stuff. An example would be authorised spending limits and a limit when to get Board and/or Chair approval.

The Chair, on behalf of the Board, deals directly with the CEO/Practice Manager. No Board Member or the Chair can publicly undermine the CEO/Practice Manager. The CEO/Practice Manager is directly accountable to the Chair and Board to implement any Board decisions.

All parties must abstain from conflicts of interest. This means walking out of the room and abstaining from voting on a decision where there is a perceived conflict e.g. whether to employ a family member or friend.

Governance training should be for all owners and the CEO/Practice Manager. It should be mandatory from the practice perspective and not just learnt in the classroom. This helps solve and contextualise real time issues.

We offer a governance training service to our clients to help resolve those elephants in the room in a humane way.

Systems – if it can’t be measured it can’t be managed – no more surprises Great systems help you to delegate, so you can work on more complex issues that others cannot. They protect you from making mistakes or when key staff leave or go on holidays. They help you from having to repeat yourself and free you up for more profitable activities. This is the most efficient, effective and profitable area to work on. You can do it because the thought process is easy to understand and inexpensive to implement.

There is no point in making the same mistake unless you have learnt from it. Well documented systems are proof of this point.

This leads to greater job satisfaction and less job distraction. People know where they stand on how and when to do a task consistently and competently.

A key annual question the Board should ask if a key owner or CEO/Practice Manager was hit by a bus what would happen? Is there a backup so we can continue to operate?

Systems are the key to delegating high level and complex work to staff less experienced or trained. It enhances and up-skills your good staff which is great for recruitment and retention.

There are companies that do offer cost effective templated and customised healthcare practice manuals. This saves you reinventing the wheel. Contact us for further information.

Monitoring tasks and regular reporting is the key. There is no point in receiving reports 12 months old. It leaves no opportunity for corrective action (see our example of a regular reporting cycle our established clients use).

The key is to enforce any governance systems that have been implemented. Correct errors and deviations immediately. Modify systems when necessary. They should be signed off by the Chair.

Training – you don’t know what you don’t know – be open and transparent You can’t have successful training without effective and well documented systems and procedures. It is as simple as that. There is no magic. 100% of your operational issues are resolved in a depersonalised way by establishing and training your staff on clear procedures.

1.3 Who? Who do we delegate to and why?

People – Firstly get the right people on the bus.

The wrong people can be a dangerous distraction when you need to keep you eyes on the road. Always attract like minded people if you want to remain focussed on what you need to do.

Owners & Management “Trust but verify”! ~ George Bush Snr

My advice is to sack the owners! Why? A great practice is one where the owners don’t have the responsibility to meet the overheads and micromanage the environment. Eat well and sleep well. Earn while you sleep. It should be a choice not a responsibility to come to work.

They should have at least one day a week off to think. Use this as a key measure.

Owners and managers need to lead, coach, enable and inspire. They must clearly state what they want. What is the end point? Are we getting there? To maintain trust they must be open and transparent and use a governance framework. This will allow them to empower and delegate responsibilities efficiently and effectively. Owners should delegate one of their own (the “Chair”) to monitor their strategic plans, budgets, systems and training are actually working. They in turn delegate this role to the CEO/Practice Manager who implements and reports back weekly. This is called working on the practice and not in it. The Chair and CEO/Practice Managers do this by walking the floor. Observe if all their staff have a smile on their face. Try test checking employment agreements to see if they are really being prepared and signed off. Make sure it is done, don’t actually do the task. Another example is receiving timely monthly financial reports. The Chair needs to feed back to management if there is a problem.

Owners need to be the navigator in the taxi cab and not the driver. The CEO/Practice Manager is the driver. It is about giving the right directions and making sure you are not about to go over a cliff. Advisers should act like a Global Positioning Satellite (GPS). Most importantly owners need to know when it is time to retire. Passing the baton by selling out or down to the next generation at a fair price is critical. Mentoring the next generation of owners will ensure their is a smooth and dignified transition. A fair price will be paid for your practice.

About Staff Your staff can be the best or the worst risk management tool outside the consulting room. A great practice culture is critical for success. Is it time to kill Bambi and start celebrating your success?

A good CEO/practice manager plays a crucial role. They are in charge of money and morale.

They are the hub in the wheel. I also call them the air traffic controller. Make sure they get the support they need.

The CEO/Practice Manager is probably the most isolated person in a practice. If they are not keeping the owners happy, then it is the staff. It is a real juggling act. It does not have to be.

Ideally always have more than two staff backing up roles. Remember to annually ask the question “if that person gets hit by a bus what are we going to do”?

Staff may have good technical know-how and an ability to apply this theory to the task at hand, however they must want to. This is the most critical quality you need to find in your staff. It only takes one staff member to pull down the rest.

I know patients who say they will not go back because of the defensive or grumpy receptionist at the front desk. I do understand the reluctance to kill Bambi, the person who is not open to change.

You know Bambi; the loyal staff member who is loved and respected by everyone at work. At the end of the day, from patients to staff they are just are hungry for a result. We live in an impatient, instant gratification society. I don’t agree with it, but it is what it is.

Bambi could be damaging your brand which makes recruitment and retention of staff and patients more difficult than it needs to be. This can be a huge medico legal risk. Doing nothing is the worst thing you can do. Nobody is bigger than the practice. Six monthly staff reviews are critical. The most effective thing to do is to correct people on the spot when it happens.

Any later and it is too late. People don’t respond well to a six monthly shopping list of complaints about themselves.

Key staff members and owners must inspire, coach and enable people. Morale is the key to ensuring you have a successful and efficient outcome on any task delegated. Try using staff surveys to monitor morale and workloads weekly.

Are your poor performing staff not working out? First blame the system, then the training before the person. Only then give them 3 opportunities to improve their performance. If there is no improvement, ask them if they are unhappy working with the practice. People should not work in jobs they are not happy in. Don’t allow them to lose face and encourage alternate employment. Please seek specific external advice from us if you are not sure.

Get the right people on the bus. Remember to hire slowly and fire quickly. Everybody loses if the person is the wrong fit - especially the patient.

Recruiting the right people from the beginning is the key. We have an unorthodox way we recruit our staff see our job ad flexibility and culture statement. It takes a little longer to recruit but it actually works and saves a lot of time. It attracts people with attention to detail and persistence; they want a career not a job. Google does something similar but in a different way.

The message is make it hard to get in.

Reward and Recognise Most importantly don’t forget reward and recognise. It does not always take money. We have an annual practice trophy for the team player of the year based on a peer reviewed team player of the month to be announced at our Christmas lunch.

About Patients or Clients Getting the right fit extends to attracting the right type of patients you want to help. We are only after aspirational and ethical clients who sincerely want our help. People have to meet you half way for anything to work. Work to the contrary and you open yourself to criticism and a possible law suit.

So make your intentions clear. It is unethical to see patients you really do not want to help (unless it is an emergency) because at all times the practitioner must act in the patient’s best interest. Doing otherwise will only put more stress on your workforce and make your staff burn out. It is better to have a happy doctor than none at all. It is important that they enjoy their work; indifference can lead to serious medico-legal issues down the path. Look at innovative ways of

developing your workforce to meet this need by sub-specialising. For example, train nurses to do more women’s health screening issues.

For one-off projects, establish a task force with set terms of reference and a time frame handed down from the Board. Potential owners and or future management team members could chair these meetings. This provides an excellent training ground for key role players looking to step up.

External Advisers The buck stops with owners! You can’t delegate this. You can delegate tasks but not responsibility. The buck always stops with the owner. So delegate well.

Owners don’t have the luxury of blaming advisers, staff or anyone else but themselves when things go wrong. Ignorance of the law is no excuse and being an ‘honest fool’ is not a legal defence. If you don’t sight written and signed documents e.g. Fair-Work Compliant employment contracts that are material to your practice, assume it never happened. Ask yourself what are the real consequences (e.g. a $33,000 fine from Fair Work Australia and the staff finding out there is a problem in the lunch room).

Not all advisers are the same and they have limitations. Remember all advisers have limitations in experience, skills and overall capability. Often a problem not addressed may be answered as “you never asked me” or “I assumed you would have told us”. There is a lot of “free BBQ advice” out there you can get burnt by. It is important you compare apples with apples when it comes to advisers. All important advice should be confirmed in writing.

Phone advice fades with memory and removes accountability and any legal defence.

Wherever possible, seek the advice of specialists. With a specialist there is a greater likelihood that all issues are covered, not just the tax issue by your Accountant, the legal issue by your Lawyer and the commercial issue by your Business Advisor. Real value comes from the comprehensiveness of a service that can holistically embrace all your specific needs.

Use industry specialists – it is expensive acting on incomplete advice. Common sense should always prevail. There are many Accountants who are a Jack-of-All-Trades. For 21 years we have been mastering the healthcare industry because it is so complex and heavily regulated that it needs to operate with an integrated thought process. If your adviser is not aware of all the specific Health Care Regulations, their advice is incomplete.

Yes, we are registered tax agents and have benchmarked practices. We also deal with national nursing union disputes, tailored Practice Agreements, practice valuations, and national Pathology and Allied Health Leases (see what we do).

You can spend a lot of time receiving untimely disjointed and one-dimensional opinions. It is important to tread with caution if this is the case. Make sure your advisers can back up their advice with research and proof, not just hearsay.

Good advisers are independent, dispassionate, open, transparent and ethical. They avoid conflicts of interest. They declare when they have one that may affect a material decision (for example; the practice Accountant should not also do personal work of any owners where there is more than one owner). It sets a discordant tone and is actually a conflict of interest. It is the breeding ground for discontentment and expensive disputes amongst owners down the track.

Good advisers will make you money and reduce your risks from day one. This why we can afford to offer a no obligation review of your practice affairs. Please email us at pa@healthandife.com.au for more information.

If we can’t help we will tell you straight away, at no cost to you. At least you will receive some thought provoking feedback.

There is no point in paying for advice if you are not going to follow it. This can only end in disappointment. A good adviser will tell you this.

Time management – I am too busy for this!

This is the number one excuse we all make. The reality is, if I had a million dollars in my office to give away next Monday, people would make it a priority. Reality Shot - your practice is worth more than a million dollars. It is your single most important asset. It puts food on the table for your staff, plus a few extra luxuries for the owners family, but most importantly it provides for your greatest debt in life: retirement.

Don’t gamble with the most important thing that can give you a lifetime of financial security.

Unfortunately the stock market, real estate and the fixed term investments can never give a greater tax effective return, control, independence, self determination and kudos than owning your own practice can.

2.

2013 Seminars and No Obligation Meetings

If you would like your Medical Local to host a seminar, forward them this email with our seminar details and copy us at pa@healthandlife.com.au. We will contact them directly about presenting in your local area.

We thank you in advance for your interest and support. You would be surprised how it only takes one person to make things happen!

Catching up with David Dahm and the Team

We can talk about succession planning, business structures, effective tax planning, employee vs contractor agreements, benchmarking and many more topics.

We are using this time to catch up with existing clients. If you are not an existing client, this may be a good opportunity to tell us what is on your mind.

Ask yourself the following questions: • • • • •

What new challenges am I facing?

What new opportunities do I anticipate?

What kind of support or expertise would be most helpful to me now?

What changes do I anticipate over the next year or so?

What more can Health & Life do for you, if anything?

We are now planning trips and one to one to meetings for next year. Please let us know if you are interested and we will be happy to schedule you in! Please note that this is on a first come first serve basis.

In the meantime, please feel free to contact us to arrange a no obligation teleconference to get you started on any significant issues. Email us at pa@healthandlife.com.au.

3. Where to from here?

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Consult your professional adviser in relation to any advice suggested; If you require any back issues of our news alerts please email us; and If you are not sure about any issues raised in this broadcast, contact David Dahm on 1800 077 222 for an initial no obligation consult or email us at pa@healthandlife.com.au.

Health & Life provides comprehensive Practice consulting, accounting, taxation and financial planning advice for group Practices and individuals. Email us for information about our Employment Template kits for providers and support staff and our Doctors pay Calculator.

Which topics would you like to hear about?

If there is a particular topic that you would like covered in one of our future News Alerts, please email pa@healthandlife.com.au and let us know what it is. We will then endeavour to cover your requested topic.

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It is apparent in feedback we are receiving that there are persons receiving this regular email who are not on our email list. If you are receiving this email ‘second-hand’ from another source, we would be delighted to receive your email address and we will add you to our database so that you can receive it first-hand on the day it is sent. This invitation is open to all Medical Practices. Please send your email address to pa@healthandlife.com.au.

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David Dahm BA (Acc.), FCPA,FITA, CTA, FFin, FAAPM, FGLF,Registered Tax Agent, Former AGPAL Surveyor - 10 years of service

CEO & Founder Health and Life Pty Ltd National Tax Accountants and Practice Management Consultants Phone: 08 8415 5400 or 1800 077 222

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