By Emily Margosian, assistant editor

Behind the scenes, who keeps your practice running? According to the 2017 AAD Practice Profile Survey, 64% of dermatology practices currently employ a practice manager. Against the backdrop of an aging population with growing health care needs, combined with evolving patient and regulatory criteria regarding quality of care, demand for the role is expected to increase by more than 20% over the next decade according to the U.S. Bureau of Labor Statistics.

As true jacks-of-all-trades, practice managers wear many hats to meet the needs of the modern dermatology office — encompassing finance, billing, marketing, operations management, human resources, quality reporting, and patient-centered customer service. “You put all that into a cauldron, and then you’ve got one of the more complex industries in the country to navigate through,” says Tony Davis, CPA (inactive), president of the Association of Dermatology Administrators and Managers (ADAM), and executive director of Dermatology Specialists, PA, in Minneapolis. “Doing all that without a practice manager is likely very difficult for a physician who’s trying to do the very best they can to give timely and quality care to the patient. No matter the style of practice you’re in, regulatory and compliance-related concerns are hitting you throughout the day. So there are a wide range of reasons why having someone to help man the ship would be valuable to a provider.”

This month, dermatologists and practice managers discuss:

• What makes a good practice manager 
• How to find the right fit for your practice 

What makes a good practice manager?

At the end of the day, a practice manager’s primary goal is to keep the office running smoothly. Although each individual’s day-to-day responsibilities often depend on the size and type of practice in which they work, there are some core skills an outstanding practice manager should have in their toolkit. They are:

Regulatory expertise

In recent years, practice managers have shouldered increased responsibility for helping practices navigate a wide array of federal regulations in order to remain in compliance. “From Meaningful Use and PQRS, to now MIPS and MACRA — that whole alphabet soup of reimbursement models — it can be very complicated,” says Davis. “Even with EHR doing some of the work for you, there still needs to be an adjudication of human involvement in that to make sure that we are doing the right things to meet some of those quality requirements that the government has placed before us.”

“MIPs is significant,” agrees Nichole Holoman, MHA, director of operations at MacInnis Dermatology. “It’s on my mind every day. As the super user for our EHR, I have to go in on the back end, and configure our software to meet our needs, as well as monitor our MIPS data. We’re always checking weekly, sometimes daily, which is labor intensive, although I feel it’s more manageable now that we’ve upgraded our EHR.”

Practice managers also aid physicians on other aspects of practice relating to compliance, including patient care and safety, as well as malpractice concerns. “Doctors have a responsibility to stay up to date on the medical side of things: what’s the latest and greatest,” says Davis. “That all can be a challenge, without even including the regulatory side of things, which sometimes feels as if it changes week-to-week. That’s where we are able to step in.”

Business savvy

From overseeing coding, billing, and collections to managing payroll and keeping an eye on overhead costs, a good practice manager should also feel comfortable taking charge of the business end of operating a medical practice. “There’s a whole industry around just how the revenue cycle of a dermatology practice works. So there’s an intense knowledge that’s required around that,” says Davis. “Finance is my thing. Making sure there are good controls in place for appropriate tracking and recording of transactions that have been going on, and producing financial statements and management reports. Tracking how the practice is performing. There are a myriad of components that go into how a health care organization runs.”

Colleen MacInnis, MD, dermatologist and practice owner of MacInnis Dermatology, attests that Holoman plays a central role in keeping her practice’s financial operations afloat. “She’s in charge of making sure everyone gets paid; she’s in charge of making sure that everyone we owe money to gets paid. Essentially making sure that we run on a day-to-day basis.”

Beyond finance, a good practice manager should play an important role in managing patient care and ensuring that the patient experience is positive during every phase of an office visit. Davis emphasizes that this level of oversight is key, particularly as reimbursement trends toward value-based payment. “We can help address day-to-day patient concerns. The completion of the visit goes beyond the patient just being in the clinic and then walking out the door,” he explains. “Oftentimes the problems we run into are when the ball gets dropped somewhere along the way, which causes an issue with the patient, and then in turn it also causes an issue with the physician. A good practice manager can think through the full transaction of health care delivery and make sure you’ve got good solid folks at each point of care along the way.”

Human resources

What takes up most of a practice manager’s time? “Human resources, 100%,” says Holoman. Between hiring, firing, training, and supervising clinical and non-clinical staff, “People always have questions about their time off, or their pay, or have conflicts you need to mediate,” she says. Practice managers assuming the role of HR within a practice should also be knowledgeable regarding employment law, conducting performance reviews, and compensation analyses. “As the practice has grown, we now have three locations, two dermatologists, two physician assistants, and probably 26 or 27 employees. She’s in charge of all of the staff,” says Dr. MacInnis. “We have managers under her for the front office, for the medical staff themselves, and for billing, which we do in-house. Each of those leaders report to her.”

IT 101

While noting that most larger practices outsource their IT (his included), Davis emphasizes that a good practice manager should be armed with a basic level of tech savvy to troubleshoot everyday hiccups. “Having an internal IT structure is paramount. If the computers go down, it seems like the clinic’s frozen,” he says. “I think it’s awfully hard not to have some sort of IT expertise at your fingertips, someone to troubleshoot on a daily basis who knows if the EHR or practice management system isn’t working, or what to do if your credit card machine is down. It’s good to have someone close at hand who knows enough to be ‘dangerous’ in that sense.”

Dr. MacInnis confirms how helpful this in-house technical support can be. “We have fully implemented an EHR and Nichole is really literate in all of the electronic medical record keeping systems. All the things you have to do to bring them on, and to switch from one to another. You name it, we do it. We’re really an involved practice, and want to keep everything as in-house and under our control as possible,” she explains.

Finding the right fit

As every dermatology practice is different, how can physicians find the right practice manager to meet their specific needs? Despite the varying demands of different practice models, there are some core criteria dermatologists can follow when looking to fill the role:

Shared vision

All three sources identified shared values as the primary factor contributing to a successful physician-practice manager working relationship. “First and foremost, do they fit the culture of the organization? Do they understand the vision that the owners, that the physicians want?” asks Davis. “I think you have to start there and understand that — and you have to believe it — because you won’t be effective in your role if you don’t believe in the vision of where the doctors want to take the practice.”

Dr. MacInnis agrees. “We’ve been together a long time now, so we really understand each other and where we’re going. Times might be hard, things might be tough, but my team knows if they stick with me and with this practice, we’re going to do right by people, and I think that’s been really important as far as retaining my best staff.” Holoman agrees, noting that an ideal practice manager should be, “Somebody who truly believes and buys into your organizational mission, vision, values, and culture.”

Prioritize communication

Not everyone is a people person, but a good practice manager must have exemplary communication skills to succeed, says Dr. MacInnis. “Everything else can be learned, but if you cannot deal with people, then you’re not going to be able to be an effective office manager. You can learn all the EHRs, how to bill, and all those other things, but you cannot learn how to deal with people. We’ve made people the core of our practice, and that’s how we’ve been successful.”

Often mediating between patients, medical staff, office employees, and insurers, practice managers should be experts at navigating between grit and graciousness, according to Holoman. “Something that’s really resonated with me as a key characteristic of a practice manager is to be ruthless with your time, but gracious with people. You have to be strong enough to set the rules, while remaining empathetic. I’ve experienced managers who go on power trips, and they don’t last long. I’ve seen people get so emotional, unable to find balance and they just can’t handle it. I’ve seen people just be extremely harsh with their staff. A manager without emotional intelligence exhibiting these behaviors, will just not work out in the long run.”

Don’t pigeonhole based on credentials

While there are an array of certifications and higher education available to current and aspiring practice managers, dermatologists shouldn’t make them prerequisites to considering a candidate, says Davis. “I don’t think we’re at that point where those sort of certifications are required to do an effective job. In my experience of almost 25 years, there’s a wealth of experienced managers out there who learned on the job. Some of the best administrators and office managers that I’ve seen came from internal growth movement from front desk through the revenue cycle up through administration.”

While Davis and Holoman themselves bring outside education to their roles, Davis maintains that experience tends to be the best bellwether of someone’s performance as a practice manager. “You don’t need to be a CPA; you don’t need to be an MBA of any kind. Those things are helpful, but I also think that folks who have learned through the coding department, or through the clinical side of things — whether they be CMAs, LPNs, RNs even — can be extraordinarily good managers of practices.”

Consider management vs. medical experience

What makes for a better practice manager: a background in management or medicine? Sources are split. “I’m a CPA by trade, so I came out of a public accounting firm that dealt with a lot of physician practices, and I learned my craft by living in boardrooms of doctors’ offices and helping them with their financial budgeting and financial statement preparation,” says Davis.

Holoman’s path to practice management took a different route. “When I came to Florida 11 years ago, I worked for a very big dermatology practice, and on my very first day of work, Nichole was my medical assistant,” recalls Dr. MacInnis. After that initial meeting, Dr. MacInnis eventually left to establish her own private practice, with Holoman electing to join. “Dermatology is my second career. I started as a dermatologist when I was 40. Before that I was actually a farm animal veterinarian,” says Dr. MacInnis. “Nichole is a very bright person, and medical assisting was never her goal either. She knew she would grow, and when I met her I knew she would grow too. So I’ve just been supportive of her, and made sure to make time for her to do whatever training she needed. Last year she finished her master’s in health administration. She did night classes while continuing to be my office manager, and I’ve supported her in that growth all this time.”

Holoman cites her background as a medical assistant as a key part of her success as a practice manager. “I feel that having a background and experience within a medical organization, as a nurse or a medical assistant or working your way through the ranks, really gives you a good foundation and focus on patient-centered care,” she says. “That’s what the future of medicine in dermatology is gearing toward — we’re being judged by the patient now more than ever. I think it’s really important to have somebody who’s worked in the different roles within a medical office, with the capacity to learn, and has an inside perspective, rather than just a business degree.”

However, Holoman acknowledges that a certain level of business expertise is eventually needed in order to do the job. “As far as running the business side of the practice itself, there can be a lot of gaps if you don’t have a mentor to show you the ropes of what a budget is or to help you with the revenue cycle, per se. If you have gaps in your knowledge that come from a mentor or education, you could be at a loss. I personally went back to school to get my master’s in health administration, because I thought I was missing knowledge in some areas that could push the organization to the next level.”

Then and now: The evolution of practice management

While in the past dermatologists may have cast a wider net when looking to hire a practice manager, as the rigors of the health care landscape have heightened, so too have the demands of the position. “It is now becoming a younger person’s specialty,” says Dr. MacInnis. “When I first opened my practice, I brought on two older people in the role — who have both since retired — and they had a lot of trouble. One struggled with the EHR, and the second had a strong background in IT, but couldn’t do the other stuff very well. Nichole has really taken on every facet of the job, and has been able to tackle all the new requirements with less stress.”

Davis agrees that while in the past, dermatologists may have filled a practice manager’s role by hiring, “a receptionist or an office manager who initially just maybe did some payroll, might have done the supply ordering, and did a bit of everything,” he adds that “a lot of dermatology now requires a specialty or expertise in managing those parts of a practice.”

Professional standards regarding the hiring of a spouse or family member as a practice manager are also changing. “ADAM was actually founded by the spouses of dermatologists, who would go along to the AAD Annual Meeting,” explains Davis. “However, for all the complexities that have arisen from when health care was simpler to now, there’s just this desire to take it out of the family environment because of the level of expertise that’s needed to execute a lot of the management functions of the job,” says Davis. “That’s not meant to be any sort of disparaging comment around spouses running practices. I think there is some team component to that which can work quite well. It just depends on the level of education and understanding that spouse might have around health care management — they may be strong in one area and need help in other areas.”

However, despite any changes to the rigor and complexity of the job, according to Davis, “that’s what makes it interesting, what makes it fun, but also very challenging too.”