Scott D. Hayworth, MD

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This is a situation that arises commonly and is fraught with potential difficulties. One obvious question is what happens if the daughter's on-the-job performance is disappointing. If you have to dismiss her, your relationship with her mother will likely be permanently damaged. But if you decide instead to preserve your relationship with her mother (particularly if she has an important position within your staff, and you would like to retain her), then tolerating her daughter's deficiencies will play poorly with the rest of the staff. And for good reason. Even if the daughter does her job well, coworkers may feel she's received special treatment because of her mother's position within the practice. 

On the other hand, if you have a large group practice with multiple departments, perhaps you can set a more liberal policy and hire children into departments that are completely independent from those of the parents. But if so, make sure that your employees understand from the outset what the rules are, and counsel them to be sensitive to the concerns of management and other staff members should their children be hired. 

Should we purchase or rent office space? 

Q My practice needs to move into a new office. Should we purchase a property or rent?

Depending upon the particular situation, both options present potential advantages. First, think about the amount of space you need: Consider not only your current requirements but also what staff and services you plan to add in the future. Also keep in mind how long you plan to use the office space. If you'll only need it for 5 years or less, leasing is preferable. Unlike leasing, ownership of a facility allows you to control what is done with it; it provides you with equity; and it can also offer certain tax benefits. Your accountant can advise you regarding the tax ramifications of leasing versus purchasing, and this may influence your decision as well.  

For the longer term, deciding to lease or purchase depends first upon whether or not you can afford to have a mortgage on a property of appropriate size. If you have the resources to cover a down payment, be sure to evaluate the local market to ensure that an investment in real estate will be wise. Key questions to answer include:  

If the answers to these questions favor purchasing, consider establishing a separate financial entity to own the property; this will protect the investment if your practice is penalized in a lawsuit. Having a separate real-estate corporation also enables you to determine whether or not you want physicians who join your practice in the future to buy into the real estate. 

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Hiring a staff member's relatives; Should we purchase or rent office space?

Managing Your Practice: Answers to your questions about. . .

Q. I have a patient who is refusing a procedure that I believe she needs to have. What should I do to protect her health and to reduce my liability exposure?

Q. I'm an ob/gyn in search of a job. Should I sign up with a headhunter or is it better to apply directly for positions?

If you prefer to search without a recruiter, there are many good sources of information on available positions, including the classifieds in journals such as 

 and the "Ob/Gyn Employment" section of the ACOG Website (

). Another option is to send a cover letter and your CV to the practices and hospitals in the geographic area you're targeting. Craft your letter and CV carefully and be sure they contain no typos, because they are your introduction, and they make a critical first impression on a prospective employer. In the cover letter, explain what type of position you are seeking and highlight your qualifications. Your CV should follow a well-established standard format, such as is available on the Web at 

									http://jobsearch.about.com/od/cvsamples/a/cvtemplate.htm

If you're in your final year of residency, start your job search early, and ideally, no later than October. It's common for practices looking to add a young colleague to recruit between September and December. 

Q. We occasionally encounter a patient whose attitude is so difficult that we feel it would be best not to have her in our practice. How do we discharge a patient with minimal offense to her and maximal protection for our practice?

To discharge a patient, I recommend the following, which is generally consistent with ACOG guidelines: First, notify the patient that you feel it's best for her to receive obstetrical/gynecological care from another practitioner. Do this via a certified letter similar to the one in Figure 2 that uses neutral language and does not specify a reason for the discharge. In the letter, stipulate that you will provide medical services to the patient for a period of 30 days and will see her for emergencies during that time period. In closing, refer the patient to an appropriate local medical society or hospital that can give her names of ob/gyns in the area who can assume her care. Make sure that your staff is aware of the discharge, and authorize them to make emergency appointments, but no other appointments, for the discharged patient until the termination date.  

Send the patient two copies of the letter: one by registered mail with return receipt for proof of delivery, and the other by regular mail, in case your patient refuses to sign for the registered letter. Finally, document the letter and its mailing in the patient's chart and file the signed return receipt as well. Retain the chart in your records for the period required by law in your state (typically 7 years for a nonobstetric patient), or longer if you deem fit. 

A patient who declines care; Finding an ob/gyn position; Discharging a patient

What are the financial advantages and disadvantages of having members of our practice assist each other in surgery? Is it more profitable to assist, or to keep seeing patients?

 First look at the schedule of the colleague who would be assisting. Does he or she have free time? If so, using it to generate revenue as an assistant surgeon is better than sitting idle in the office. 

With that information, you can determine when and if it will pay to assist on a given case or type of case, rather than staying in the office. You may find that it's never advantageous to assist during what otherwise would be office hours. If so, consider scheduling surgical assistance only at times when you would not be seeing patients anyway, such as lunch. Or, if a member of your group is assigned to remain in the hospital during the day on obstetrical duty, you might find it profitable to have that physician assist, since he or she is already on site.  

If the numbers and your practice situation really don't favor serving as assistants, consider working out an arrangement with other practices in your area to have their members assist you. Maybe their physicians would welcome the income. 

Should we invest in an electronic medical record?

, "plastics" represented the future. Today in ob/gyn, it's "electronics." Without question, all ob/gyn practices eventually will need an electronic medical record (EMR). Computerization is essential for accurate and prompt information exchange within a practice and between other entities involved in patient care. That having been said, the best time to implement an EMR and the choice of a vendor vary from practice to practice. 

Small groups should seriously consider an application services provider (ASP). With an ASP, your practice leases software and a server and your data are kept off-site. The key advantage is the minimal investment in the equipment and maintenance. For a small practice, it makes sense to look outside for expertise in information technology, rather than buying equipment and burdening staff with managing an EMR in-house. An important new option for mitigating the cost of going electronic has been made possible by a recent modification of Safe Harbor regulations: hospitals are now allowed, with certain restrictions, to finance much or most of the cost of EMR software for private practices, so do check with your local hospital(s) to see if this is feasible for you. 

Managing your own data and investing in software, servers, and staff to optimize control and customization may be a good choice if you have a large group practice. The key here is doing your homework before making an investment. Have one or more members of your group who are computer-savvy and know how to manage overhead evaluate products and vendors at a large, national meeting, such as ACOG, American Medical Group Association (AMGA), or Medical Group Management Association (MGMA). Gather information about the range of products available and their costs, and survey your physicians and staff and consider how they operate so that you can match the EMR to your practice's needs.  

If you have existing practice- and laboratory-management software, you'll need to determine how the EMR will interface with it and you may need to purchase a comprehensive IT package. Make sure that any vendor you're considering is well-established and financially stable, and check multiple references. Also make sure that the vendor is ready and willing to provide comprehensive and convenient technical support, which you will definitely need regardless of how carefully you select the product. Discuss the need for and timing of future software and equipment updates with the vendor .  

Once you have narrowed down the list of EMRs to a few "finalists," find out how well the products work in the real world by visiting ob/gyn groups similar to yours that already use the technology. Demonstrate the products to members of your group and your staff to test their usability. The more intuitively a system fits into your practice's work patterns, the better. Compute the cost of implementing your chosen EMR, including the software, hardware (don't forget terminals in every office and pod), and support, and make sure that there is space in your budget for it, both as a capital investment and as an ongoing expense. 

If you follow all of the steps outlined here, it will take you several months, at least, to fully consider and put into action an EMR. The sooner you start the process, the better it will be for your practice. 

Managing Your Practice: Answers to your questions about...

Q. My patients are asking when my practice will offer the new HPV vaccine. Is it usually covered by insurers? How should I charge and bill for it?

 Most insurance policies will cover the HPV vaccine-but it may be considered preventive service. So, if a patient does not have coverage for preventive care, it may not be reimbursable. Before you administer the vaccine, check with the managed-care companies with which you have contracts to determine whether they cover the vaccine and if there are any restrictions on reimbursement. Keep in mind that to fully cover your costs, the reimbursement must be enough to compensate for wastage and loss, not just the cost of the vaccine and its administration. Most carriers will not allow you to bill the patient beyond contract allowances, so it's important to include wastage when you compute the necessary reimbursement. If reimbursement from a particular insurer isn't enough to cover your costs, advise covered patients to call the company and request an increase. Ob/gyns shouldn't have to shoulder the burden of insufficient reimbursement. 

Q. Pharmaceutical representatives are calling on our practice at all hours of the day and taking parking spots from patients. How do we establish limits on their visits? 

Policies regarding visits from pharmaceutical representatives vary among practices, depending upon their philosophy and logistics. Some physicians totally ban representatives. Some allow representatives to call only during specific times and/or on specific days. Some practices prohibit sampling because they feel it promotes the use of branded drugs in cases in which generics can treat a condition at lower cost. And some offices don't have storage space for samples. 

Whatever your practice's preference, it should become policy agreed upon and adhered to by all partners and staff, and it should be stated in writing for the pharmaceutical representatives. Those who fail to comply should be asked to curtail their visits. 

Q. Our local hospital requires us to cover the emergency room in order to retain privileges. The ER keeps getting busier and most of the patients are uninsured. Besides increasing our liability exposure, attending to the ER takes us away from the patients in our office, inconveniencing them and causing us to lose revenue. How can we mitigate the financial harm that this obligation entails?

 In some areas of the country, specialists are being paid a fee by hospitals to cover the ER. Meet with the administrators of your hospital and make the case that they either reimburse you for covering the ER, or hire physicians for coverage. Prepare for the meeting by analyzing the financial details-including losses from uninsured care and from cancelled office hours-and demonstrate how unpaid ER coverage threatens your practice's viability. If there is more than one hospital in your region, consider switching your admitting privileges, and/or negotiating with one hospital versus the other for more favorable treatment. Hospitals are motivated not to lose your paying patients, so you should be able to turn this motivation to your advantage. 

If the hospital(s) at which you have privileges can't afford to pay you for ER coverage and your privileges depend upon providing that service, then you'll be compelled to continue to take a loss on this obligation and consider it to be-and call it-public service.

Reimbursement for the HPV vaccine; Dealing with sales reps; ER coverage

Author | Scott D. Hayworth, MD

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Managing Your Practice: Answers to your questions about. . .

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