Physicians Squeezed for Time

Bringing value, aligning one’s sales approach with the physician’s objectives, are keys to overcoming diminishing face time

In 2006, Chicago White Sox Manager Ozzie Guillen managed the American League All Star team. In the days and weeks prior to the game, Guillen came under attack for overlooking some talented players, including Boston pitcher Curt Schilling and Yankee Mike Mussina. Guillen responded, “Whoever doesn’t like it, play better next year.”

Simply stated.

Similarly, in today’s healthcare environment, physicians are busier than ever, and many reps are finding face time more difficult to obtain. How should reps respond? “Sell better.” That was the consensus of those with whom Repertoire spoke.

“When you get that elusive face time with the doctor, you must be prepared,” say Sergio Bustamante and Luis Hernandez, account managers for American Medical Supplies. “You cannot wing it on the spot. Make the most of your time with the doctor. Have a purpose, a plan and a product to speak about. Work on your presentation. There is nothing worse in sales than to ad lib and fumble through a presentation. Your customer will be grateful for your appreciation of his/her time.”

“I am a little old school when it comes to seeing customers,” says Bob Miller, vice president of sales, Gericare Medical Supply. “Face time has always been at a premium, in my opinion. The good ones go out and make it happen. The others talk about why they can’t. It seems to me you just need to prioritize more and stop making excuses.”

Are docs busier?
Data is hard to come by, but physicians seem to be busier than ever – and that isn’t likely to change. The population is aging. The Affordable Care Act has extended insurance to about 10 million Americans (with more to come, in all likelihood). And the physician workforce isn’t getting any younger either.

In a recent survey of 21,000 physicians across the United States, conducted on behalf of The Physicians Foundation by Merritt Hawkins, 81 percent of physicians described themselves as either overextended or at full capacity, up from 75 percent in 2012 and 76 percent in 2008. (See December Repertoire.) Only 19 percent said they have time to see more patients. What’s more, 44 percent of physicians said they plan to take one or more steps that would reduce patient access to their services, such as seeing fewer patients, retiring, working part-time, closing their practice to new patients or seeking a non-clinical job, leading to the potential loss of tens of thousands of full-time-equivalents.

It’s true that nurse practitioners, physician assistants and others are taking up some of the slack. But all signs point to a more harried physician workforce. Because of that, practices are taking steps to increase their efficiency. Sales reps who can help them achieve that goal will be rewarded.

Time crunch
“It’s hard for me to find time to see a sales representative,” says Wanda Filer, MD, MBA, a family physician in York, Pa., and president-elect of the American Academy of Family Physicians. Physicians such as Filer are seeing more new patients. “Superimpose on that our pretty intense flu and cold season, and our schedules are pretty packed,” she says.

Last July, the AAFP asked its members in a survey, “Since January 2014, have you seen an increase or decrease in patients seeking appointments?” Forty-four percent responded that they had seen an increase, but 41 percent had not seen it yet.

Many practices are migrating toward a team-based approach to caring for patients, as a way to improve patient care and improve the efficiency of their practices, says Filer. And those teams are broadly spread. “People tend to think of [team members] only as nurse practitioners, physician assistants or doctors. But they can also include LPNs, medical assistants, perhaps a diabetes educator, behavioral health counselor or social worker.” Many practices now have more than one office, so they can share resources across several sites, she adds. This new approach to care helps spread the workload – and presents more entry points for sales reps. “If I’m not available, the representative might see a nurse practitioner, physician assistant or one of the LPNs on our team.”

Robert Tennant, senior policy advisor, Medical Group Management Association, notes that “there’s no new money in healthcare. Reimbursement rates are not likely to increase.” Even so, many practice owners resist the notion of expanding physician hours or decreasing the amount of time doctors spend with their patients. So the only ways to improve the bottom line are to be more efficient, save money, or look for other avenues of revenue within the practice, such as operating an in-office dispensary, offering new services such as physical therapy or imaging, or subletting office space and equipment to specialists, he says. Gastroenterology is a common specialty that partners with primary care to share space and resources. “Everybody wins,” says Tennant. The gastroenterologist avoids the need to finance the infrastructure of an office, the practice gets additional revenue, and the patient gets convenient, high-quality care.

Leveraging electronic data interchange can help improve the efficiency of the practice, including the claims revenue cycle, he adds. For example, electronically verifying insurance eligibility by using the HIPAA “270/271” transactions allows practices to speedily receive information about a patient’s healthcare eligibility and benefits. “These new tools are absolutely critical, especially with today’s high-deductible health plans.” Practices can receive the patient co-pay and deductible amounts from the payer within 20 seconds. Better to capture these payments upfront at the time of service rather than chase money after the patient leaves the office, he says.

“Sales representatives have to keep in mind not only that physicians and administrators are taxed for time, but they’re looking for solutions that meet their needs – that can free up time, make their processes more efficient, and can add some ancillary income to the practice,” says Tennant.

Comes down to value
Today’s physicians are more stressed than ever, says Camille Steele, profitability and equipment specialist, Henry Schein Medical. “I don’t care who you are, there are only 24 hours in the day; no one has figured out how to get more; every minute is precious.

“Even in the smallest practices, there has been a shift in their routine, but most of all, in their attitude,” continues Steele, who calls on practices in the Chicago area. “They’re not looking for one more conversation unless they can trust and perceive its value.

“Most physicians are more aware today of what needs to be done to run a successful practice,” she says. “They’re looking for business partners who are capable of knowing how to help them achieve that success. They may know where they need to go, but not how to get there.”

The sales rep, then, has to stay focused on his or her customer’s success. “And it has to be truly felt, not manipulative,” she says. “We have to become providers of solutions.”

Given the demands being made on physicians today, sales reps will have difficulty maintaining the same kind of relationships with customers as they had in the past, says Andy Rice, national training and development manager, Henry Schein Medical. “Physicians are looking for relationships with people who can help them solve the challenges they are facing.” There’s little time for small talk. What’s more, if the physician practice is owned by an IDN or other entity, the doctors may have limited leeway in the products they use in the office.

Nevertheless, sales reps can continue to provide value to their customers by keeping in mind what Henry Schein calls the 5 Ps:

Patients
Profit
People (i.e., the doctor’s staff)
Process (i.e., the practice’s operations)
Penalties (e.g., OSHA and HIPAA)

Implicit in all this? The sales rep’s ability and willingness to listen. “If you can get the customer to talk to you and tell you what’s on their mind, they are more likely to have a conversation with you,” says Rice. “You might find out that what you’ve been talking to them about has been the wrong thing.”

There’s one more thing implicit in the discussion, adds Steele: Successful selling today calls for different, new skills – but perhaps above all, passion. “If you’re not passionate, you won’t make it, because that’s what really keeps you going to navigate through these times.”

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Value cures many ills

With face time shrinking, sales reps should consider shifting their focus to providing value-add to their physician customers, says John Boyens, Nashville, Tenn.-based consultant and sales productivity expert. Perhaps the rep can share clinical studies, a white paper or blog post that addresses a topic of interest or concern to the doctor.

“If every time I see someone, he or she teaches me something new or shares some best practice, that’s the person I want to see – not the person who brings donuts to my office staff,” says Boyens, speaking of physicians. “Think how much easier a distributor rep’s life would be if the physician actually looked forward to you coming in.”

The key is to focus on what the doctor is buying, and why – not on what the rep is selling, adds Boyens. Resist the temptation to flood the doctor and his or her staff with marketing materials. And when sending materials, be sure to vary the message, the medium and the frequency, he adds.

“Doctors are concerned with things like patient satisfaction, increasing revenues for the practice, lowering costs, minimizing risk,” says Boyens. The opportunity for the sales rep is to focus on how the products he or she represents can help the physician address those things.

“All our research shows that the doctor buys the rep first, the brand second, and the product third,” he says. It is imperative for the rep – particularly if face time is shrinking – to build trust and maintain it. They can do so in five basic ways, says Boyens:

Do what you said you’d do.
Show up on time. Be prepared.
Listen more than talk.
Focus on what the doctor is buying vs. what you are selling.
Provide professional and timely follow-up.

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Face time crunch: From the field

Is face time becoming a scarcer commodity? And if so, how does the sales rep continue to build and maintain relationships, and introduce new products and services to the busy physician? Repertoire asked several readers for their opinion, including:

Read Patterson, CEO, Sound Medical.
Bill Muich, Midwestern regional sales manager, MMS – A Medical Supply Company.
Cheryl Carman Fischer, account manager, McKesson Medical-Surgical, Primary Care.

Repertoire: Are sales reps finding it more difficult to get face time with doctors today than, say, five or 10 years ago?

Read Patterson: Yes. Physicians are experiencing the new landscape of healthcare. Their revenues are declining, and their costs to operate their business are rising. To make ends meet, today’s doctor has to massively increase patient volumes. For example, a primary care doctor who was profitable at 21 patients per day 15 years ago, now has to see 30 to 40 patients per day to maintain status quo. In between the stress and the dizzying pace, there seems to be less tolerance for medical sales reps. But as it is with any change or new frontier, amongst the chaos is opportunity.

Bill Muich: It is harder to get face time with physicians than 10 years ago. With more physicians being employed by hospitals and IDNs, more of the contact is through procurement offices, business managers or regional directors, who are responsible for primary care decisions for the clinics. Face time is still achieved, but may take longer and go through more decision-makers to finally get to the doctor. The doctors who are independent have relegated the business decisions to the business manager/office manager. The independent doctors, though, do want to be a part of decisions in regards to equipment and still want to know about new technologies and products that will help them provide better care to their patients and provide a better outcome for their patients, either clinically or through having a better experience in their office.

Cheryl Carman Fischer: Today’s healthcare environment is so much more complicated and demanding of physician’s time than even two years ago. They are having to learn new technologies, insurance requirements and process changes just to take care of the same patient for often less reimbursement. Time is more valuable than ever for the physician, and understanding their demands can assist you in maintaining a relationship that they value.

Repertoire: What tools or skills are distributor reps employing to maintain their relationship with doctors and to introduce new products to them?

Patterson: I have always held the opinion that the buying decisions are moving away from the clinical operators to the business/administrative personnel. Doctors used to be able to make decisions based on relationships and preferences, but today, they have to focus more on the clinical aspects of the business and trust their administration to make intelligent business decisions. We focus on creating massive efficiencies that decrease the total cost of ownership. That is what today’s physicians need and want.

Moving a customer’s formulary from thousands of items to hundreds of items is the first step in creating large scale efficiencies. This seems obvious, but in reality, it can be a challenge to get a customer to truly standardize. True standardization allows for less moving parts, which equates to efficiencies in time, delivery, accounting, etc. It really impacts the customer’s entire business. We offer a solution where we manage our customer’s inventory based on predetermined par levels across a standardized formulary. We do this through innovative technologies and the relational prowess of the sales reps. Once implemented, the supply chain functions are eliminated from the customer’s operations. This large-scale efficiency allows our customers to focus on the clinical aspects of their business, whereas they can reallocate lost labor back to revenue producing activities. This is a great example of helping our customers to decrease costs, and increase revenues.

In our industry, it isn’t only about the cost of medical supplies. We train our reps to think at a high level, which will impact the customer’s entire enterprise. If we can first prove our value as a true partner, then our access to physicians becomes available. We train our reps to continue to clearly establish alignment with the physician’s objectives. In today’s market, albeit it is simple, the objectives are to deliver higher quality care at a lower cost. Any solution that correlates with this mission will gain the interest of the physicians, because they, too, are compensated along these lines.

Muich: The tools used are technology, e.g., using a tablet device to show a doctor a new product in an effective, concise manner, and being able to send that information to them and the business manager electronically. The skills are to keep updated on new technology and products that can bring real value to the doctor’s practice. Understanding the practice by asking probing questions of the staff and business manager, so when you ask for time with the doctor, you are not wasting their TIME! Being a source of knowledge that you can bring to the office staff will get you the time to speak with the doctor.

Fischer: Physicians are interested in products or services that, first, save them time or bring efficiencies to their daily process, and second, offer additional revenues for their practice. I hear again and again, “If this will save my staff time, I would like to evaluate it.” The greatest skill a distributor rep can bring is knowledge of the current healthcare regulations, such as the Affordable Care Act, ICD-10 and Medicare reimbursement rate changes. Understanding these concerns will greatly increase your ability to show your interest in their business and how your product or service may bring value in a constantly changing environment.

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EMR: Is time on the doctor’s side?

Electronic medical records are supposed to help the physician and his or her staff work more efficiently, and eliminate paper, redundant work, fumbling through medical records to find pertinent data, etc. The federal government is so sold on the opportunity that EMR represents to improve care and cut costs, that it is incentivizing practices that are “meaningfully using” EMR, and penalizing those that don’t.

But many physicians aren’t happy. In a recent survey of 21,000 physicians across the United States, conducted on behalf of The Physicians Foundation by Merritt Hawkins, 85 percent of physicians reported adopting electronic medical records systems, up from 69 percent in 2012. However, 46 percent said EMR has detracted from their efficiency, while only 24 percent said it has improved efficiency.

In September 2014, the American Medical Association took up the cause, calling for a “design overhaul” of EMR systems.

“Physician experiences documented by the AMA and RAND Corp. demonstrate that most electronic health record systems fail to support efficient and effective clinical work,” AMA President-elect Steven J. Stack, MD, was quoted as saying in September. “This has resulted in physicians feeling increasingly demoralized by technology that interferes with their ability to provide first-rate medical care to their patients.”

AMA/RAND findings show physicians generally expressed no desire to return to paper record-keeping, according to the AMA. But physicians are concerned that EHR technology requires too much time-consuming data entry, leaving less time for patients.

“I am on the fourth EMR of my career,” Wanda Filer, MD, MBA, a family physician in York, Pa., and president-elect of the American Academy of Family Physicians, told Repertoire. “Some systems work reasonably well; some are atrocious.”

One reason for the difficulties is that many systems were built for the billing side rather than the clinical side, so they fail to add efficiencies to the medical records process, she says. “You spend a lot of time clicking boxes. And if I do a hospital follow-up visit with a patient who had been in the emergency department, what I used to see in two or three pages now comes to me in 25 pages.” It is difficult to tease out the relevant information amidst the clutter. “EMR should be a tool, not a means to an end,” she says. “My focus needs to be on the patient.”

“The promise of EHR technology was there,” says Robert Tennant, senior policy advisor, Medical Group Management Association, speaking of EHR. But the implementation challenges have been formidable. The first challenge has proven to be the technology itself, which, in many cases, fails to fully meet the practice’s clinical and administrative needs. The second has been the reliance – or over-reliance – on the government’s “meaningful use” program as the driver for the technology. Just as software developers were improving their systems through use of a robust, private-sector certification program, “meaningful use” hit the streets, he says.

The government’s incentive program “was positive in the sense that it freed up capital for physicians to purchase these systems,” he says. Unfortunately, the urgency of implementing the systems short-circuited efforts to improve their usability. “So you may have had a vendor whose system was certified for ‘meaningful use,’ but also was abysmal to use in the real world of seeing patients,” he says. These issues have only been exacerbated as the feds have ramped up the more onerous Stage 2 of “meaningful use” requirements.

“We have to find ways to make these tools really work effectively within the parameters of the physician workflow,” he says. “The goal is to have the physician leverage technology to improve care and efficiency, not to stumble through or lose time. The only way we will move forward with [health information technology] is to make it usable for the end user.”

‘Kicking and screaming’
“EHR systems have been lacking in a number of things – content, support and taking care of what the doctor needs,” says Michael Paquin, MDP Group, Los Angeles, and EMR consultant. And that’s true for a number of reasons, he says.

For one, the Affordable Care Act and “meaningful use” provisions pushed doctors to implement EHR. “But they weren’t ready; they didn’t have time. You’re talking about doctors not only going to an EHR, but updating their practice management systems too.” Throw in ICD-10 and accountable care organizations. “We have all these things throwing the doctor’s office in turmoil.” What’s more, buying an EHR is more complex than buying most medical products and equipment. “A lot of due diligence should be taking place,” he says. No wonder doctors are kicking and screaming.

But things are changing. “Many vendors are redoing their products, and making them simpler and easier to use,” says Paquin. Most have managed to successfully combine their practice management and medical records components, so they work well together.

Doctors are responding. “Doctors who are implementing these systems are starting to be enabled and to see how they can work,” says Paquin. “That’s positive. The disconnect in the past were those doctors who bought a system, started to use it but then stopped. That didn’t do anyone any good.”

There are no perfect systems out there, he says. So it is the doctor’s responsibility to select a system that is best for them, and make it work. Reps who can provide some guidance along those lines will be appreciated.

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How to make EMR more usable: AMA

To leverage the power of EHRs for enhancing patient care, improving productivity, and reducing administrative costs, the American Medical Association has identified what it says are eight “usability priorities.”

Enhance physicians’ ability to provide high-quality patient care. “Effective communication and engagement between patients and physicians should be of central importance in EHR design,” says the AMA. “The EHR should fit seamlessly into the practice and not distract physicians from patients.”
Support team-based care. “EHR design and configuration must: 1) facilitate clinical staff to perform work as necessary and to the extent their licensure and privileges permit, and 2) allow physicians to dynamically allocate and delegate work to appropriate members of the care team as permitted by institutional policies.”

Promote care coordination. “EHRs should have enhanced ability to automatically track referrals and consultations as well as ensure that the referring physician is able to follow the patient’s progress/ activity throughout the continuum of care.”

Offer product modularity and configurability. “Modularity of technology will result in EHRs that offer flexibility to meet individual practice requirements,” says the AMA. “Application program interfaces (APIs) can be an important contributor to this modularity.”

Reduce cognitive workload. “EHRs should support medical decision-making by providing concise, context-sensitive and real-time data uncluttered by extraneous information. EHRs should manage information flow and adjust for context, environment and user preferences.”

Promote data liquidity. “EHRs should facilitate connected health care—interoperability across different venues, such as hospitals, ambulatory care settings, laboratories, pharmacies and post-acute and long-term-care settings. This means not only being able to export data, but also to properly incorporate external data from other systems into the longitudinal patient record. Data sharing and open architecture must address EHR data ‘lock in.’”

Facilitate digital and mobile patient engagement. “Whether for health and wellness and/or the management of chronic illnesses, interoperability between a patient’s mobile technology and the EHR will be an asset.”

Expedite user input into product design and post-implementation feedback. “An essential step to user-centered design is incorporating end-user feedback into the design and improvement of a product. EHR technology should facilitate this feedback.”