Administrators wrestle with new challenges and skill sets

August 1, 2005

The radiologists are frustrated and do not understand why things just don't seem to be getting done anymore. After their long-time manager retired, they decided to hire someone with an MBA, but he has been struggling to understand radiology operations. His mistakes have not been too damaging-so far-but he seems overwhelmed and unhappy. How can the job be that difficult?

The radiologists are frustrated and do not understand why things just don't seem to be getting done anymore. After their long-time manager retired, they decided to hire someone with an MBA, but he has been struggling to understand radiology operations. His mistakes have not been too damaging-so far-but he seems overwhelmed and unhappy. How can the job be that difficult?

Experienced, long-term radiology managers, and their counterparts in billing and management companies, agree that one of their greatest challenges lies in grooming their successors. The problem has been discussed for more than a decade, but the gap between the top person and the second in command still appears to be widening. Smaller groups and imaging centers may offer an entry point for managers, but how do they develop the skills necessary to take over a large, complex radiology practice or a hospital radiology department? The situation is becoming more critical as experienced managers anticipate retirement.

Most senior radiology managers have spent 15 to 20 years in an evolving healthcare adventure. They have worked through the rise and fall of managed care, capitation, and independent physician associations, all of which still exist in various parts of the country. They have incorporated regulations associated with the Mammography Quality Standards Act and the Health Insurance Portability and Accountability Act. They have implemented voluntary corporate compliance programs to avoid violating Medicare regulations, learned the ins and outs of joint ventures, opened imaging centers, and started billing/management companies.

Managers have developed sufficient contracting expertise to deal with the requirements of Medicare Plus Choice plans versus those with National Committee for Quality Assurance accreditation. Along the way, they have become conversant with medical malpractice issues, physician recruitment, nighthawk coverage, retirement plans, teleradiology, and PACS.

They have probably been through more than one practice management system conversion and are familiar with the advantages and perils of new technology. Their distinct advantage, however, lies in the fact that they faced these issues sequentially. Multiple simultaneous challenges occurred from time to time, but generally they were rolled out over the course of a manager's career.

Today's top managers share certain characteristics. They are highly self-motivated, with the ability to seek out resources and apply knowledge quickly, although nearly all developed their expertise on the job. Those with advanced educational backgrounds usually have degrees in nonmedical disciplines. Radiology-specific education occurred through programs offered by professional associations, and peer relationships developed through those associations also provided valuable knowledge. Finally, the management elite demonstrate an ability to both adapt to and lead change while surviving professional near-death experiences. The penalty for making mistakes is dire, and the environment unforgiving.

The supporting workforce adds another dimension to the challenge. The long-standing tradition for the radiology administrative workforce, most of whom are involved in registration, billing, and collections processes, focused on hiring inexperienced personnel, often directly out of high school, and training them on the job. Knowledge was transferred verbally, with training often provided by the last person to hold the position.

Through no fault of their own, many experienced administrative employees actually have one year of experience repeated 20 times. This means that the executive-level manager must attempt to upgrade staff skills to keep pace with regulations and technology while also dealing with an intergenerational, culturally varied workforce.

EXISTING PROBLEMS

Radiologists place a high value on additional training when they hire a new physician into the group, to the point that fellowship training is often a requirement. But in some cases, they continue to widen the gap between themselves and those responsible for maintaining the business infrastructure.

Their solution when hiring a radiology administrator to replace a departing manager is to look for an advanced degree or certification. They assume that a candidate with an MBA knows all about business, or a CPA understands the financial ins and outs. The MBA/CPA, however, faces a steep learning curve in healthcare issues and must quickly identify and master those applicable to radiology. All this happens in a highly regulated environment, where a concept that makes good business sense in any other arena might be illegal.

Most radiology administrators will affirm their concerns about next-generation managers who must be groomed to assume leadership positions in the coming years. What will it take to be successful? What skills are required now and in the future?

FUTURE CORE COMPETENCIES

The American College of Medical Practice Executives offers a detailed "body of knowledge" document, available for review at its Web site, www.mgma.com/acmpe/bokguide.

cfm. This reference provides an excellent resource for physicians determining a candidate's qualifications and also serves as a guide for the administrative employee seeking to develop an ongoing personal education program.

The ACMPE document covers five general competencies and eight areas of technical and professional knowledge and skills (see tables). It presents a strong core curriculum for radiology's emerging leaders and includes specific areas of priority for today's administrators and those of the future. In addition, however, it is important to focus on certain core competencies.

- Billing and collections. Many larger radiology groups employ both a practice administrator and a billing manager. While this configuration is not likely to change in the near future, due to the sheer amount of work each party does, the radiology practice manager of the future must develop a solid fundamental knowledge of the billing operation.

Administrators usually rely on various summary reports to review operations and predict future revenue. When variations are evident, it is normal to ask the billing manager or supervisor for an explanation. Over a history that includes numerous standardized practice audits, general "what happened" questions usually receive superficial answers. A detailed knowledge of billing/collections processes and payer requirements enables the administrator to quickly identify and correct operational problems, especially those egregious system collapses that can be career-fatal.

The administrator's first "home run" often occurs with the correction of basic operational problems. And the ability to identify and respond to processes-related issues allows for more responsive course corrections. Far-reaching problems in the billing process are not a matter of "if" but "when," and a lack of in-depth knowledge is one of the vulnerabilities of many old-school managers. As reimbursements continue to decline, closely monitoring, managing, and correcting these core processes is more important than ever.

- Regulatory landscape. The regulatory requirements in healthcare are extensive and evolving. Compliance is normally considered a necessary evil and, too often, is dismissed by physicians as an unimportant nuisance.

While the "abuse" portion of Medicare Fraud and Abuse compliance is potentially problematic to radiology, HIPAA ups the ante. And compliance is no longer exclusively a Medicare issue. Nongovernment payers have expanded their investigations of fraud and abuse, while concerns about patient confidentiality have resulted in increased regulatory activity at the state level.

Rather than focus strictly on penalties for noncompliance, it is important to note the relationship between compliance and good business practices. The formal compliance plan emphasizes standardization of processes, employee training, periodic audits, and mechanisms to correct problems. As healthcare becomes more dependent on technology, HIPAA provides a framework for conducting business in a responsible manner, similar to how other industries that deal with the transfer and protection of highly confidential information are expected to behave.

- Contracting. Radiology contracting is becoming more complex, especially as entrepreneurial activity in imaging centers evolves. Radiology administrators face creative proposals regarding global billing for centers in which they do not have ownership, options to lease scan time (including equipment and staff), ownership of equipment situated in other physicians' offices, and more. Rather than attempt to master the legal complexities of each type of deal, the best route is to develop a relationship with an experienced healthcare attorney, which often means not relying on the organization's local legal counsel for advice.

Insurance contract terms appear to evolve every few years, and "pay for performance" initiatives will introduce new contractual requirements in the future. Effective insurance contracting begins with knowing more about the payer relationship than the insurance company does. This includes how often claims are paid accurately, denied for seemingly invalid reasons, and/or paid appropriately.

Finally, the manager should be able to identify operational issues associated with insurance agreements, including billing and payment requirements, as well as those associated with communications and quality programs.

CHANGE MANAGEMENT

The effective manager of the future will have to overcome many outdated, manual processes. Technology offers numerous options to reduce overhead and improve productivity, but only if new features are actually used. Advanced practice management systems are only as good as the core manual processes they enhance, and it is not unusual for the staff to demand revisions that take them back to the more comfortable (and inefficient) way of doing things.

Moving people from the security of their old work patterns and expecting that they will accept unfamiliar territory, question the status quo, and offer ideas is problematic, even when everyone agrees that this is a desirable way to work. Any manager who has installed a new time clock can verify the short-term loss of productivity and the difficulty of introducing change, so it is only natural to anticipate higher levels of resistance as processes embrace technological advances.

Radiologic technology has been changing at an increasingly rapid pace for many years. The business/billing side is also changing quickly, but most practices and billing companies continue to work with old technology platforms. With the integration of PACS, radiology informations systems, and billing systems, the administrative office is meeting headlong the need for technology upgrades.

HIPAA has already forced many practice managers to take a look at their outdated computer systems, and many offices upgraded to new systems when they realized that vendors would no longer support legacy systems. While some billing system war horses remain, emerging companies are offering advanced features that will force a fundamental change in the industry.

More billing systems are moving to Windows-based technology and, consequently, are finding a warmer reception among users who grew up using Windows programs. The new systems are more intuitive for those accustomed to a mouse, drop-down menus, and other familiar features.

In addition to the benefit of simple familiarity with newer billing platforms, the radiology manager of the future must evaluate the impact of new technology offerings. Document scanning, for example, has evolved to the degree that it can offer significant productivity increases and simplified storage options.

On the other hand, advances in imaging technology are taxing older storage options and forcing rapid development in secured storage areas. Associated challenges lie not only in the selection of appropriate storage media but also in maintaining or moving information stored in older formats. Technology promises to offer tremendous advances but requires certain basic knowledge and skills from practice management.

Moving from a reactive to a predictive management style means that the manager of tomorrow will deal with a storm of external forces as well as drive change internally. The ability to communicate effectively with a wide range of educational and skill levels is essential, as is introducing and managing change in a staff with varying levels of understanding and adaptive skills.

PREDICTIVE MANAGEMENT

The manager of the future will be expected to move from the traditional role of managing from a rear-view mirror, with reports of past activity, to using real-time data to proactively and predictively drive business activities. The tools to accomplish this are becoming available and will evolve quickly, although they will also change the business landscape.

For the near future, the burden will still be on radiology administrators to use available industry resources in their personal self-development programs. Over the long term, it will be incumbent upon radiology as a field to develop educational programs on the business side of the fence to equal those offered in medical fellowships.

Ms. Kroken and Dr. Carmody are principals in Healthcare Resource Providers in Albuquerque. Ms. Kroken is a past president of the Radiology Business Management Association and a fellow in the American College of Medical Practice Executives. Dr. Carmody is board-certified in diagnostic radiology and nuclear medicine and has been involved in various aspects of practice management for more than 25 years. Ms. Amann is operations manager for Radiology Consultants of North Dallas. Ms. Kroken has received honoraria from the RBMA and is a member of its speakers' bureau.

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TABLE 1. GENERAL COMPETENCIES FOR MEDICAL PRACTICE MANAGEMENT

Professionalism Achieving and preserving professional standards

Leadership Supporting the organization's strategic direction

Communication skills Interacting and presenting information clearly and concisely

Organizational and analytical skills Solving problems, making decisions, and developing systems

Technical and professional knowledge and skills Developing the knowledge and skills necessary to perform activities unique to the job, role, or task within the eight performance domains or areas of responsibility (Table 2)

Source: ACMPE Guide to the Body of Knowledge for Medical Practice Management

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TABLE 2. TECHNICAL AND PROFESSIONAL KNOWLEDGE AND SKILLS

Financial management

Human resources management

Planning and marketing

Information management

Risk management

Governance and organizational dynamics

Business and clinical operations

Professional responsibility

Source: ACMPE Guide to the Body of Knowledge for Medical Practice Management