Dr Emil Djakic:
Welcome to our presentation. I'm Dr Emil Djakic and I’m sharing tonight's platform with…
Dr Maria Boulton:
My name's Dr Maria Boulton. I’m a practice owner and hold numerous leadership roles with AGPA, AMA Queensland and the RACGP, including being a member of the REC Funding and Health System Reform committee, and the steering committee for this event.
Dr Emil Djakic:
I’m a rural general practitioner in northwest Tasmania and also sit on the same committee as Maria and enjoy the contribution to our membership and the college's role in helping sustainably in our businesses through challenging times, which is the title of this particular presentation.
During this presentation we hope to highlight and cover the impact that COVID-19 has had over the past 15 months on practice viability, discuss billing strategies to ensure that your practice remains financially viable, how to work with and avoid staff burnout and highlight the RACGP resources that we have to assist you - our members - at meeting your financial goals.
The first presentation is the negativity or negative impact the pandemic has had. This was a study presentation that came through the college’s survey which showed that 25% of our practitioner members had a significant reduction in their billings in that period of time, 46% lower than the same time, and 23% neutral.
My experience in my practice was that we were actually in the neutral range, but we had to undergo a very rapid amount of adaption to new tools. Of course, the online, telephone and video billing strategies and also dealing with a whole range of different presentations and accommodating for them. So I was fairly fortunate, but Maria's experience in her billing mix and pattern was a different story.
Dr Maria Boulton:
Yes, it was.
Dr Emil Djakic:
This of course felt more heavily in the urban areas, specifically linked to the fact that there was an obligatory bulk billing obligation attached to the new telephone item numbers and a substantial number of urban practices who were already using non-bulk billing strategies in their business found the move to telephone basis really quite a negative impact.
There was also a substantial number of practices who had a drop in their traffic through the door because the urban centres – particularly in the very city centres - were abandoned by people who are either isolated at home, or not traveling into their job and work.
A huge amount of their business either focused on other practices further away, or people just did not access their health care, which of course the college has flagged as a real potential problem, and one that perhaps is coming to roost in this current year.
Dr Maria Boulton:
This is a snapshot of my clinic. I run a clinic called Family Doctors Plus which is located in the inner north of Brisbane. We are a privately billing clinic and we had been growing steadily and really nicely for about five years since we opened our doors. The pandemic really slowed down our growth noticeably from about February 2020. This is when I started keeping daily figures to see what our income was doing.
At the same time, we experienced an increase in expenses such as PPE, staff hours and cleaning expenses. During the lockdown in April last year, we saw a dip in billings of approximately 31%, and this was mainly due to the mandated bulk billing for telehealth, reduced patient attendances and also reduced income from our corporate business side.
Some patients thought we were too busy caring for people with COVID-19 so they weren't coming into the clinic, when in fact we only treated one patient with COVID-19 and we did that over the phone. Others were just too scared to venture out.
We worked really hard at turning things around by doing a lot of communications with our patients, media and setting up a fever clinic next-door where we could see people with symptoms while keeping the rest of our clinic safe.
Let's talk about detailed cost analysis. For anyone who knows me, you know that I really love business plans. I run everything through our business plan. It is so important, especially at times of financial strain or changes, to review your business plan, review what your costs are, and review what your income is.
We did that very quickly and we included all the extra costs, so the extra hours that it took to respond to the people ringing up and thinking ‘what am I going to do? Or do I have COVID-19? Do I need to be tested?’ There were also extra costs covering people who were on sick leave, PPE, cleaning solutions etcetera.
It's also important to review the expected income in your business plan, so is it still correct? Are you where you think you should be? Are you going to be there in a month's time? And if not, do you need to reassess what you're doing? Are there unnecessary expenses you can avoid? It took us a little while to stop ordering the travel vaccines at the same quantities we were ordering them, and by doing that we saved a lot of money.
Also, have you approached your suppliers for a discount? Last year I saw an unprecedented amount for flu vaccines and we were able to approach our supplier and say ‘we're doing thousands now, can we please have a discount?’ and they obliged.
Did you approach your landlord for a rent reduction or deferral? GP practices make great tenants so that gives us a little bit of bargaining power. And above all, have a think about are your fees at the right level to cover costs? They may have been right for you a year ago, but are they right now? And are they right going forward? If not, you need to reassess that.
Dr Emil Djakic:
Moving to looking at the way you go about the billing and bulk billing. As a universal insurer is looked upon by a large part of our population as the only source or the only guide or reference point for how we go about setting fees and passing on costs. That of course is a complete delusion and I’m afraid our federal government would like us to stay like that. The truth of this is that we need to start from the other end of the elephant.
You need to develop an understanding about what your service is worth, what your value is worth. Obviously, we are dealing with patients who are in our arrangement a consumer of our services and we have to ensure that the value that you're creating is seen by them as well.
So, in moving from focusing purely on bulk billing to introducing private billing you have to be planned in bringing your patient base with you, using some promotional activity to ensure that they understand the relationship between the costs of running a business - I don't mean the full details of Maria's business plan, but I do mean the realisation that just having the doors open and the building full and staff present and all the things required to run a quality general practice including accreditation are actually costs that have to be accommodated for.
Explaining why there might be costs is an important one. Charging co-payments in particular services - again, in our practice we do quite a lot of small operating theatre work around skin lesions and the like, there’s a clear recognition that those services value add and are passed on to our patients very cost effectively compared to them being done in the day surgery for, say, a local surgical team - explaining that our costs, in fact, are going to save them quite a bit of money, but if we choose not to include co-payments in those areas you really do run the risk of finding yourself going backwards if you're purely relying on the MBS item numbers. Particularly by the time you've accounted for your additional disposable costs and things that are part of the procedure you've done.
Focusing where you choose your discretion or largesse around discounting down to just the rebate rate or bulk billing, it’s important that you don't need to necessarily have a wholesale approach, you can choose to try and work out which part of this community you feel needs your best support.
The healthcare card as a discriminator is useful but it's clearly not seen as the absolute truth in everybody's capacity to pay. But you do need to be able to focus on which groups you might choose to carve out of that whole group of people your bulk billing.
Being very certain that those other people who want to purchase your services are billed appropriately by other insurers, around workers compensation, other private insurers. The work you do for your patients around things that relate to their money. Obviously, insurance reports and medical reports for lawyers and insurers are all things that you need to value yourself, and only through valuing yourself and setting a price on it will you find that you can make that sort of work worthwhile.
And then there are alternative income streams and that means looking outside your immediate practice into more than likely industry in your area in terms of doing work under the occupational health and safety role for them, site visits or industry visits, all can be part of what adds to your capacity to generate the income that you feel that you should be worth.
Dr Maria Boulton:
Can I add there that it is important that you do go through all your costings. So, for example, the rebate for our 30071 (a shave excision) we went through that in detail and actually the rebate is not enough to cover our costs. And just a plug for alternative income streams, there is going to be a session on innovative billing strategies, and it might be a good one to catch if you're interested in bit more.
Looking at rebuilding post-COVID-19. It is important that you debrief with your team. COVID-19 has created so many changes and there are more changes to come. And it is important that you keep your team up to date to avoid all the confusion. Many general practices are now busier than ever. I was speaking to a colleague who owns a practice in Brisbane that's been open since the 1950s and he said that he has never seen it as busy as it has been lately, which is why effective communication is essential.
We used multiple means of communication to let patients know how to reach us during lockdown, and to let them know we were still open and seeing patients face to face when appropriate. We do the same now as patients want more information on the COVID vaccines.
We find that it is best to spend time on proactive communication strategies rather than have hundreds of patients ringing in with the same questions causing more work for reception staff. For example, we make sure that our Facebook page and our website are up to date with all the latest. When I see a patient, I will say look this is the information as it is today, keep an eye out on our website or on our Facebook page for any updates.
Looking to the future, make sure you future-proof your practice. I think any business that makes it through COVID-19 is going to stand a good chance to making it in the future, but you just have to make sure that that is you.
And ensure that you're reaching your billing potential. So, if there are areas that you think you could be doing better in, now is the time to make changes. And, as we spoke about in the previous slide, just start thinking about other income streams that you might be able to try at your practice.
Dr Emil Djakic:
At our practice, we regularly have an ‘item number of the week’ type discussion in our group meetings where we look at the data of the utilisation of things like chronic disease item numbers or other… I won't say obscure numbers, but numbers which are there to serve and support patients with costs, and it does surprise some GPs to find that you've been using that number, and how have you been using that number, and - of course - how it works positively both for the patient and for you as the billing provider. So have a discussion with your colleagues about how you are doing this, and understand the numbers that have been used within your immediate colleagues.
Dr Maria Boulton:
That's a great idea. We actually keep track of how many of those item numbers we build per practitioner, and the other thing that we do is that we print out a number every month and we put it in the back of the bathroom door so people can't miss it. Because, otherwise, you'll always have the hallway question from another doctor saying what was that number again? And we find that that's a really good solution.
This is really important, especially at the moment. And it's essential that you avoid burnout. This event has been highly stressful, not just for GPs, but also the nursing staff the admin staff and our practice managers.
Our staff have had to cope with so many changes and we're also finding that patients have been a little bit short lately because when they're stressed (for many reasons), they just seem to take it out on the phone with the poor receptionists and it's really important that you look after them. We've heard from recruitment companies and other practices that everyone's having problems recruiting reception staff as many have left the industry due to burnout. Your team is the biggest asset that you have you need to take care of them rather than wasting money training and hiring new staff.
Another thing is that self-care is extremely important. This is a marathon and we're not in view of the finish line yet and you have to think about whether or not your practice is viable without you working there. If the answer is no, you need to make really sure that you are looking after yourself. Number one.
One good thing that has come out of the pandemic, though, is the feeling of collegiality among GPs as we have all shared ideas with each other. I still remember Todd Cameron's photos when he put all the ribbon in his waiting room and in his consult rooms when COVID-19 first came and sharing that idea. Many more have shared many ideas and it's been great. I just really hope that we can continue to do this moving forward.
Dr Emil Djakic:
Maria, the time in our area when the Bernie Hospital became involved with the COVID outbreak and things were really becoming very difficult here, at about midday on a Friday, I can remember I could see the look of terror on our receptionist's faces as to how to deal with what was coming through the door. I ordered the doors be locked at that stage and said it's time for a meeting, team. We've got a problem we need to change our reaction here.
And outlined that nobody was coming through the door until a phone conversation had happened with the doctor involved, in order to try and more thoroughly screen. The reception staff's appreciation of that was just remarkable. Every single one of them was able to speak to me and say thank you because they were vulnerable. They were the employees in the system that didn't feel empowered at all. They felt very disempowered, and yet here they were in the very frontline. So, as Maria pointed out, I realised then they were the important bit in our team, because if we couldn't get the work done with them, or if we lost some of them very quickly, then we were going to be very hamstrung in how we were to continue trading. So, look after them.
Dr Maria Boulton:
Look after them and ask them what they want. We were just running through an exercise next week asking people what you appreciate about your workplace, and we've had already a couple of replies. One reply was ‘we really like it when Maria brings donuts every week’ and another reply was ‘we really like it how everybody always comes and says hello’. So, working on those things just to keep your staff engaged.
Also, I think the point about protecting them… that is really key. Our staff need to be safe. For example, we did everything possible to make sure that our staff had access to the COVID vaccines. We actually get got them paid time to go and get them and they really appreciated that. I think that just grows loyalty as well, and at the moment it is so important because in Queensland we're having mass vaccination hubs setting up and let me tell you that they pay a lot of money. So, you have to retain your staff by doing other things. Perhaps you can't afford the same fee, but you can certainly afford to look after them. And they appreciate it.
Dr Emil Djakic:
We'll move forward to pointing at some of the resources that the RACGP has on their website. There's been a very significant amount of work going into the General Practice Business Toolkit, and I can commend members to go online on the side and have a browse through it and open up bits and pieces of it. It's a very literate document that's been written to use, with lots of interesting very readable short sections that can just give you insight into your finance arrangements, employee management, building design; a whole raft of stuff that's really important to use to spread your knowledge about what it is that you can do in your business that you might be able to value add.
The next one we'll talk about in more detail in a moment relates to the billing calculator, which is a web-based app designed just for us as members to have a bit of a play with some of the key parameters around the billing and patient numbers, and the way we go about setting goals for our life.
This has been something I’ve been very keen on, which started with me deciding quite a few years ago that my business plan was required to be written first rather than just sitting down and working like a hamster every day, hoping that I would get there somehow in the end.
I know Maria's smiling at that because a lot of us were still working in that model, so you really do need to start with where is it, you're planning to get to, and work in terms of your actual worth or dollars, and then work backwards from that allowing for all those other things in your life related to holidays or the number of sessions you work or the style of the way you work. We'll talk about that in the moment.
The third one, the college has done lots of good work in transitioning into an electronic form is the Medical Benefits Schedule online tool which we'll point to. It's worth going to the website.
The billing tool itself, broken down into bite-sized magazine type modules that you can read a bit of for a couple of minutes, and then move on and then come back to it. It really is just trying to raise awareness. It is intended to help peak people's interests in realising that if they're moving into a role in general practice ownership, that they really need to equip themselves with a skill set that didn't come with your FRACGP qualification. Perhaps it should, but it doesn't. So it's there as a membership tool to be used, and the billing calculator part of it is accessible on that site and you can go to that directly.
We'll move to showing the tool in a moment, but this is really about finding a way to balance your capacity to earn with the lifestyle that you feel you need to earn with the professional role that you wish to live and work with as well. And it's not an intention to try and drive everybody into abject over billing or over earning, it's up to each individual to choose what they feel their outcomes need to be and which way they're going to get there. That really is the essence or the higher function of a business plan; to start with where are you trying to get to.
This page of this document each of these fields are able to be adjusted by you as the individual member. I do encourage people to just have a play with some of the parameters to see what it does to your outcomes. Setting a default desired annual income if it was a target of reaching a take-home $200,000 - that's exclusive of tax at the moment - you can adjust your service percentage fee depending on which way you work in your arrangements, number of sessions you work, hours, the number of patients you see.
It's not entirely designed to try and fully pick up the granular nature of the multiple item numbers we use in our world these days, it's more about focusing on the core and saying well, if you continue to work this way in these arrangements with these sorts of numbers around bulk billing and these sorts of fees, this is the outcome you can expect.
I also encourage people to make sure they include the number of weeks that you're away from the practice, whether it be through holidays or sabbaticals, or working in other roles just so you can look at it and say is that where I want to be? I think this is can be a big driver in people, realising that small adjustments - and that might mean just changing the amount of billing you use - can lead to fairly substantial outcomes. Or it can actually improve your lifestyle by allowing you to realise that you don't need to see 40 patients a day. You might well be able to achieve your outcome on 28 patients a day.
That happened for me, and I relaxed and looked at my partner across the corridor and said well you keep doing what you're happy doing, because I’m actually more comfortable now, knowing where I should be. So, it's a tool to help you with your business plan.
The second page of it is a little bit more granular in the nature of the way it sets up item numbers. But do take the time to have a look at it and load in the numbers that you've got and adjust a few things to see whether it fits your outcomes.
The MBS online tool - and this links partly to what Maria's hinted at as well - the better use of MBS is about knowing what's in MBS. I think their online portal is very difficult. This tool is divided into five spreadsheets, so covering the short guide to general practice item numbers which are really the core of what we mostly know and use, an expanded guide one which allows you to search it to look for those slightly more obscure numbers that relate to not regular usage, but you can find and use. I use them all the time for the various surgical procedural ones because I just can't keep them in my head. The telehealth guide one, which clearly came into play with the COVID-19 stuff was very important for making sure we could keep track of that, and as is the Aged Care guide change, and then a unique one for create my own list celebrating the diversity of general practice. And that is that some of the numbers that aren't in there you can actually add in yourself. You can also add in the additional practice-based prices that you might use.
Again, it's a tool that's been updated and maintained. We've moved away from the paper-based one because a once-a-year update clearly, as exampled by the last 12 months, isn't a waste of time. Things move too quickly and the government's enthusiasm for changing item numbers… well it looks a bit like a Saturday night the pokeys really. The number of times numbers come up differently. I think, again, it's one to look at and download and have that on your desktop so that when you need to find that item number, you can.
The other very exciting thing about it; there is also the capacity in this to directly access the MBS. If you move across to the left-hand column where there's the little blue access code, you can click on that and that will take you to MBS online for the complete descriptor for that number, including the various links then from MBS online. I think that by itself is gold dust in you being able to remind yourself about that number, or just say is that the one I want to use? I think we're all obliged to develop our familiarity around item numbers, because as Maria highlighted, broadening our palette of item numbers where Medicare provides for patients is an important service that we can do. I think it's an excellent tool for people to be looking at.
Dr Maria Boulton:
Here's where you can get some further information. The RACGP has a website that has the latest updates on COVID-19. We run our COVID-19 vaccination clinic, and we find that there's new updates every week almost and then we have to change the consent form every week which takes a bit of time.
It also includes links to the Department of Health resources as well which can be very useful. There's also the RACGP Events webpage and you can find out about all the different webinars on-demand sessions and podcasts that are offered by the RACGP. Also, there are various events, for example in Queensland the faculty runs a lot of get-togethers and networking events where you can mingle with other business owners and perhaps learn some useful tips.
Above all, it's been a tumultuous time. And, for us, what helped was just keeping a track of our numbers. We just had to innovate like crazy and it just brought me back, Emil, to when we first started and opened up the practice where we were just trying all these different things and keeping track and seeing whether they were working. It was pretty crazy, and I think it's going to be a little bit interesting for a little bit more time to come.
Dr Emil Djakic:
Yes, Maria, thank you. I think the two things that I picked up off you really is ignorance is no excuse. You have to look at your finance data, you have to be following it, you have to be reviewing it regularly to ensure where you're tracking. And if you're not, you need to sit down because the answer to this is you then need to design for success, and that is if something's not working then you need to work out what you need to change to make that work, or what it is you might need to stop doing full stop.
Because there's no point finding out at that final wash up of your accountant's meeting in whichever month of the year that something was going wrong. So, interrogate your data and then design your responses to the current arrangements with the focus on what the goal is. And when you've done, then go back and do it all again so that you know where you're at. Because it's not a case of doing it once.
Dr Maria Boulton:
Absolutely and please share. I think if you come up with some excellent idea, I love sharing any tips that we find at work in our clinic. I think that we just need to be a little bit more kind to each other and share anything that you think might work.
Dr Emil Djakic:
Very good. Thank you, Maria, it's been a pleasure.
Dr Maria Bouton: