Aggregation Aggravation: Solving the Most Common and Costly Problems of Merging Medical Practices

In our latest webinar, industry experts Glenn Morley of BSM Consulting and Ryan Miller of Etna Interactive explore the most common problems of operations and communications that arise when multiple medical practices aggregate. Whether you are operating in a post-merger organization or anticipating acquisition, follow along as they cover real-world case studies and innovative strategies employed to improve culture, patient satisfaction, and financial performance.

Click here to download the medical practice merger checklist mentioned by Glenn Morley during the live webinar.

Webinar Transcription:

All right everyone welcome and good day we’re just at the 11 o’clock hour so one more quick review as I see we’ve got some new arrivals. Today we’re using the Zoom webinar interface, for those who haven’t used it before we’ll be able to speak to you but we won’t be able to hear you. So as a result the only way that we can get your questions during today’s session, and this is very much your session so be sure that you get those questions in in real time, is if you use that Q&A interface at the bottom of your screen. For some tablet users you may see the Q&A button at the top of your screen. Click Q&A, it’ll open the new window, you can toss your questions at us in real time. I’ll be monitoring so I’m actually going to apologize in advance, there’ll be a few moments where I have my camera on and you may notice me peek just off camera, that’s going to be happening because I’ve got a second screen where I’ll be monitoring so I can see both things at once, and you know I think really what we’re going to do today is just go ahead and get things started so we can make the best use of your time.

I’m very excited to introduce my co-presenter today Glenn Morley, Senior Consultant with BSM Consulting, and Glenn has been a huge supporter in this particular topic for both of us right now. Mergers and acquisitions among the clients that we serve is a really big deal and I felt like we’ve had some common questions come up that Glenn was uniquely positioned to address. So I’m going to be asking Glenn to present in the first half, I’ll present a little bit at the end, and then collectively we’re both going to spend time today with you in Q&A. Today’s session is being recorded so if you want to share today’s session with colleagues after the fact we will be sharing it within a couple of business days, usually Friday afternoon on a Wednesday webinar is when we get that out. So that being said, Glenn I’m going to go ahead and turn off my video camera and ask you to please take it away.

Thanks Ryan, it’s such a pleasure to be here and I’ll share a little bit about myself and BSM Consulting. We are a health care consulting firm and we specialize in plastic surgery, dermatology, ophthalmology, and ambulatory surgical centers and it’s a delight to be a part of an Etna Interactive webinar, especially on this topic. BSM Consulting works with health care providers and organizations around the country and what we have seen over the past several years is a trend towards some consolidation. Mergers, acquisitions, and transactions of all sorts and so we’ll be exploring today why that makes sense for some practices. We’ll talk about some of the key strategies for success including financial strategies, organizational, operational, financial etc., and we’ll talk about what best practices may help practices position themselves for success as they begin thinking about mergers, as they become involved in mergers, and even post-merger what that looks like and what pre-planning can do for success.

So first we’ll talk a little bit about why a practice might be considering a merger, and those reasons really run the gamut. In most recent months, March, April, May, those were quieter for transactions but starting in late April and sort of ramping up since then to now where we are today, we’ve seen a lot of increased activity in mergers. And the primary reason that we have seen is overhead expense relief succession, plan interest, the interest in gaining a competitive edge in the marketplace, and so there are a lot of things in play for a lot of different practices, many different things can be a catalyst for this including another practice potentially being interested in you. So if that’s your position, if you are thinking in terms of you know what can impact our valuation this course is also for you.

So we’re going to talk about a few different things that can be success factors or stumbling blocks depending upon how you look at it, and the number one thing that we talk to clients about at the very beginning when a merger is even contemplated is are the two organizations aligned from the standpoint of mission, vision, and values and what does that mean. We see practices whose owners are in alignment, they like each other, this seems like an excellent idea to go forward, but when we drill down to what the corporation or the practice mission and vision looks like sometimes those are not aligned. Sometimes the culture is very, very unique in one practice and it’s very difficult for another practice to adapt to that unique culture, and then values, values is you know everything that goes into how you make decisions every day, the decisions you make around hires, around how you care for patients, around how you develop individuals that are part of your organization. So these are critical success factors and understanding how well you are aligned as an organization with another organization is absolutely critical and so that’s going to be a first step that you should really put some time and effort into thinking about, and seek out great resources for, you know, kind of work throughs for two different organizations to ensure that alignment exists.

The second thing that I’ll mention, and it’s self-evident for some organizations not so much for others, and I mention it because very often we will hear about problems after a merger has begun. After two organizations have attempted to merge without any external professional help and they run into problems because there’s you know potentially a critical step that was missed. It may have been step number one: Are our cultures aligned? But there can be a myriad of reasons why it may be really important to seek out advisors as you enter into merger conversations. Those advisors and my experience certainly include a practice management consulting firm, attorneys, advisors around tax compliance risks, risk management and mitigation, accountants, so don’t neglect to seek out professional advice.

Number three on the list of things that we really encourage practices to do is great due diligence, in fact it’s impossible to do too much due diligence in most situations. So I’m involved right now in a merger and we’re really in the beginning stages of this merger, and to date, some of the due diligence that has been done includes on-site practice evaluations, operational assessments, financial assessments of both organizations. Some of the some of the key things that you want to look at are forecasts and projecting what provider revenues will be after a merger, what kind of staff consolidation can occur as a part of a merger, and so a five-year forecast is very commonly included as part of the due diligence. When I talk about operational assessments, and practice assessments, both parties really want to know both the opportunities that exist emerging, but also the risks, and what we’re trying to tease out when we do an operational assessment is not just those two things but it’s also what are the best practices for each and every operational protocol or process. And if it’s two let’s say it’s two solo practices and we are looking at a single process, what is the best practice, which organization does it better if you will, and can we adapt that best practice to the larger organization once it’s merged. In simplistic terms this looks at every single step of the patient journey, every operational piece, all the moving parts within a practice and examining how each of the two entities performs those, and if either is embracing a best practice if so can it be adapted, and if neither practice has embraced the most current up-to-date best practice how can we how can we incorporate that that higher level from a performance standpoint into the new organization. So no unexpected surprises because completing due diligence is just one of those key steps that we recommend to every client contemplating a merger.

Number four is not having a post-merger plan. So you just heard me sort of talk about the due diligence that we do prior to a merger, out of that due diligence comes that plan. Part of the plan must involve excellent communication and we’ll talk a little bit more about the hazards of not having excellent communication in a minute, but excellent communication means that at the onset you are creating work teams in both organizations and then for the newly merged organization another work in and you have a checklist. We actually have a merger checklist which I’d be more than happy to share with anyone and having a plan A, plan B, plan C, plan D, you always want to have a backup plan and a little bit of a flow chart and how things should go. Ryan do you see the same thing when you are working with practices?

Yeah absolutely, I just wanted to take a moment and mention that that resource that you that you offered to share if you don’t mind, I’ll take a pdf of that from you and when I distribute the recording to everyone and we publish that I’ll make sure to get that resource included as a download for anyone who’s contemplating it wants that checklist. But definitely that that plan for what happens after, after the merger or acquisition is such an important step and we see that so often overlooked.

Ryan are you involved pre-merger often with your clients when you have two different entities, you may be working with one and not the other, are you are you frequently pulled in pre-merger to assess best practices for both?

Yeah we’re more often pulled in in one of two ways, so the most common way that we engage in the merger and acquisition game is actually post-merger when there is a new imperative from the stakeholders, whether it’s an independent investment group, the new shareholder group that’s a joint group of physicians, or private equity that’s backing the group and they now really want to see significant growth, so that’s the most common thing. But we’ve had a number of occasions where we’ve actually had to participate on either side to assist with evaluations looking at online presence and digital assets as a contributor to practice evaluations and that comes up a little bit less often, but you know it’s certainly, you have the opportunity to look at the advisors around you and leverage them to help you put those plans together.

Are you a part of assessment of systems to understand which practice may have a better system if neither is using a best practice and making recommendations at that point?

Yeah and more often Glenn, what we’re looking at there would be the level of sophistication in the lead generation apparatus so how effective bringing new patients in, and then also get engaged to assess what’s happening in terms of communication standards. You know we can see fairly significant disparities often between the merging parties where there’s usually one that has invested more significantly in communications and technology, where they are offering SMS customer service, they maintain a contact center, and you know emerging partner who perhaps is still trying to figure out how to deal with email. So what that’s to mean for those two cultures as they come together is a big part of where we focus.

Yeah well that’s so interesting, and obviously having that plan is absolutely important and, as I said, having what-if scenarios also in place is critically important.

Number five is a value proposition, and this may feel self-evident to some but you’d be surprised how often I have this conversation and it’s a real ‘aha’ for practices. So we all think about our value proposition and we do different workshops to tease out why we’re different, how are we unique, what is special about our organization. But when we’re seeing two different organizations merge it’s an activity that can’t be overlooked for a few different reasons. On the other side of the merger if we haven’t done that pre-work, if we haven’t thought through, you know, what is the potential or what is the future anticipated value proposition, then we are potentially not managing perceptions well for patients, or staff members, or providers that maybe an entering employee, or even at a leadership level and so this is sort of one of those places that we want to all be singing out of the same hymn book. And it also offers opportunities to get some excitement because some of the opportunities from a value proposition standpoint that I’ve seen include for an organization obviously, it may be better contracting with a third party payer, it may be a higher level of technology as Ryan was just discussing, it could be more locations convenience for the patient, it could be a higher level of expertise. I work with a dermatology practice right now and they are potentially merging with a Mohs surgery practice. There’s an enormous value proposition in this for both the general dermatology practice and the Mohs surgery practice, and a new provider entering the equation who offers pediatric dermatology adds even more of a value proposition. Internally for the team members of that organization it’s really important for the team members in the general dermatology practice to understand that we are now going to have this additional service line, or two additional service lines, which offers enormous you know potential for our organization but it also provides these additional services which our patients will be able to access in a really smooth and unique way. So that’s a feel good for staff, it’s a real feel good for patients who often want a one-stop shopping. They want to come to one place, they want to have trust in an organization and not have to go to several different practices for things that could potentially happen with their chosen practice.

Other value propositions that we often talk about at an ownership level include risk mitigation, or uh proactively managing the marketplace that you are in. So back to that dermatology practice with a Mohs surgery practice, with all of the consolidation that is happening right now it can be a potential risk for a solo dermatology practice and a solo Mohs surgery practice. It can be a risk for the both of those organizations if they’re in that consolidating environment and they are a solo practice and so merging these two practices together in this particular region of the country that has more solo practices than merged means that they will have a built-in referral network. They will, you know, have more patients and better contracting, better risk mitigation. They’ll be able to offer staff more flexibility and scheduling, potentially more opportunities for remote workers, and you know that value proposition goes on and on, and retaining top talent can often mean something like you know having flex hours or being able toto work remotely. So utter clarity about your value proposition post-merger can be such an invaluable opportunity.

The sixth thing that I’d like to sort of talk about and touch on is the risk of losing, or the difficulty in retaining top talent, and this is something that you know has always been a part of practice management and we see great opportunity for retaining top talent during a merger if there’s good communication, and Ryan mentioned earlier, he mentioned communication I think three times in the short time that we were talking, and communication is what it’s all about with team members when we are potentially merging two organizations. So what does that look like, we very often will see small groups formed, and the merger task force, and it can be a merger task force in both organizations as well as a united task force post-merger, and those task force are comprised of representative from all areas of the organization.

We worked with a practice not too long ago and there was someone from the customer service department, from scheduling, clinical nurse supervisor, a physician MD, employee leaders of the practice at an administrative level, accountant, attorney, practice management consultant, this was a powerhouse team, but one of the most beautiful things about this task force team for this organization was great representation of all of the people that each one of these individuals represented. So retaining top talent was an absolute focus for everyone but we had different perspectives on what that looked like and what good would look like during the merger. So transparency, empathy, and excellent communication is a best practice that we endorse.

Glenn let me ask you a question, one of the things I’ve noticed among our accounts is I think that they’re in larger groups that perhaps have had experience with past mergers, I see a more I think mature or strategic approach to communication during these moments and surprisingly the smaller, more intimate mergers, two private practices coming together, three forming a group, where this is overlooked and what I’ve experienced recently with one of our clients was that they lost a very important member of their team for the lack of communication internally about what was happening and as I was reminiscing with the doctor at the moment and what we might have learned from that and you know my advice back was simply that in the absence of information people will invent their own stories about what’s happening, and mergers and acquisitions are incredibly stressful on teams, nobody knows what’s happening, everybody worries about job security, and this person just didn’t believe that they were safe in that environment and chose to leave to go to a place where they just simply wouldn’t have to deal with the turmoil associated with the merger. What’s your experience, your advice especially for smaller groups like private groups that are looking to come together, about how and when to start the conversation about the merger, and a frequency of updates that are important, you know that that are appropriate to keep staff in the loop?

Yeah that’s such a great question Ryan, and you know the first thing that I mentioned was mission, vision, values, right and so it’s such a critical piece for staff retention whether you’re considering a merger or not. So it comes into play when we are faced with some of the most difficult, or challenging, or complicated situations in the practice life and so this is absolutely a place that I would start there because, you know I actually talked to someone a couple hours ago in a practice and they were going through a lot, there was a lot of, I don’t want to use the word turmoil because it was positive, but there was a lot of moving pieces for a very complicated project. And what this person said to me was I leave work happier than when I arrived and it really resonated for me to the point that, you know, said time out let’s talk about this. And her answer really resonated because what she was committed to was the mission, she still believes in what this organization is all about and what they are attempting to do, she is aim on and so is every other individual in that organization. So you know, just by starting there and having passion around who you are, what you are, what you want to do, and being comfortable sharing that with the team, and I see you doing this Ryan, you are passionate about what you do and it infuses everything that you do, and when you bring a team into that passion and vision you have trust and commitment, and you’ve got to go into a complicated situation with trust. As Bruce Maller, you know Bruce who started BSM Consulting, he talks about having a tall stack of chips and if you’ve done a great job and you have a lot of chips then when times get tough and you have to cash in a couple of chips it’s still okay because you’ve got a tall stack of chips with your employees, or with an individual you’re working with, and those chips are trust and so I don’t know if that answers your question around cadence of communication, that’s going to change or be different for every organization. I can give you examples of what that has looked like in successful communication. I work with a solo practice as you said, that can be a challenging environment for communication, or not. This particular organization has been very transparent around interest in merging but not why they are interested in merging and that’s because the why is something that could be unsettling for the employee team, and it’s not a bad thing but it’s the timing of communicating that is going to be strategic because there’s no reason to cause any upset when that reason can be given and the solution given at the same time. It’s a you happy ending no matter how you look at it, but they are being very transparent everywhere they can in the most important things that will impact the employees, and the cadence of that aligns with the cadence of their typical communication, it ramped up a little bit as the merger you know task force were formed and then the communication was you know very, very frequent during a merger, and then post-merger it stays pretty intense communicating and helping teams learn better, and different communication post-merger, that’s a whole different area that can be a standalone webinar.

Excellent thank you.

Number seven, and this is something that I’m sure a lot of you are familiar with, is having a sacred cow or a unique process that is really difficult to shift. During a merger it’s important in the front end you know when we’re exploring culture, we’re exploring operations to not just understand what those differences are, but if we identify differences to understand how adaptable each team will be to change. Pointing out the areas that we’re alike is really important and minimizing the places that we’re different can be important, so the more that we can do that the better it is, I always think in terms of change being something that I would like a team to come to on their own and so we may we may know the change that we’d like to see happen but starting with why can be very helpful to help individuals or organizations actually implement change and guiding people towards the right decision about change means that sometimes it can become their idea and that flexibility and adaptability becomes a lot easier. So have it at the end of the day to merged practices need to embrace one common way of doing things from an operational level, from a patient management standpoint, from a branding and brand articulation standpoint, and learning who you are as an entity and understanding all of those value propositions that you will have as a merged entity means that we’re able to communicate those effectively to patients, among teams and be successful both during the merger and post-merger.

So let’s talk just a second about why mergers aren’t sometimes as successful starting with a cultural fit, lack of leadership, and you know from the standpoint of brand articulation and value proposition. All of those have to, we have to be on the same page at the highest leadership level and then you know all the way down the food chain in the larger organization. If there’s not alignment then we’re going to have some problems. Too much focus on the valuation and not as much needed focus sometimes on some of these other things we’re talking about, not focusing on key operational considerations can be a huge stumbling block, and we talked about that as well as lack of communication. And then the last that we haven’t really talked about is inaccurate or unrealistic revenue or expense projections in the pro forma and these can be mitigated by additional due diligence. Testing the theory, understanding market dynamics so none of these stumbling blocks are things that can’t be overcome with good planning, and focused intention.

So some of the best practices for successful mergers are alignment in these areas and I would challenge anyone that is considering a merger to go through the checklist that will provide and identify areas, do a sort of self-evaluation if you will, to understand where your weaknesses, and threats, and opportunities, and strengths are. a SWAT analysis can be very helpful as you contemplate a merger.

Thank you so much for allowing me to be a part of this webinar with you Ryan, it’s been such a pleasure and I believe we’ll have some Q&A at the end.

Absolutely and I’m going to switch over there and get my slide up on the screen for us to share, pardon me while I do exactly that. Glenn go ahead and disable the sharing on your side. While we’re doing that transition, for everybody that’s on the call with us today in the live session, what I want to invite you to do is if you had the questions that came to mind as you’re watching Glenn’s presentation just to remember to use the Q&A feature at the bottom of the screen. You might see me glance off to the side as we’re doing this next section here and we’ll be referencing my second monitor where I’m going to see your Q&A so we make sure we get those questions answered before we wrap up today. I’m going to, as Glenn and I talked about just the beginning a little bit, I’m going to focus on the other side of that merger acquisition where Etna Interactive more often gets involved. Very often when we’re brought in after a small group is formed or a large group has established some really ambitious revenue goals and is looking to reach and acquire new patients into the practice. So really what we’re going to be looking at are the challenges really for specific operational challenges that we’ve experienced firsthand with the large and mid-sized groups that we serve. Just a tiny bit about myself, I’ve been involved in marketing for the medical industry for about 23 years now, I’ve had Etna for just over 18. I’ve got a great group of people that are based out here in California but we work with clients all over North America and we pretty much do all things online marketing.

Now the first challenge, and I think this is the thing to ask yourself is, are you not in control of all of your local listings and social profiles, if you’re in that post-merger environment. While we see this I think with probably every new group client that we onboard I’m forced to think about one of our newest clients that’s joined us, they have about a half dozen locations, but just over 200 providers. They had actually had a series of mergers over the last five years and as we were bringing them on board our due diligence, our assessment actually, discovered that the oldest brand that was required that hadn’t existed for five years still had an extensive online presence with active listings on yelp, a google my business listing that conflicted with the new branded listing, that they didn’t have control of the online rating and review sites for the majority of their providers. So all of those Healthgrades, and RateMDs, and Vital listings for over 200 different providers were out there often receiving critical feedback from patients and they had no way to engage in that dialogue or even really be able to become aware as those reviews were appearing. You know and we have to acknowledge today that you know the yellow pages are, you know they’ve gone the way of the dinosaur, they’re largely extinct, although they still get delivered they more often not end up in the recycling bin and that today local results, and then as well those social profiles, they dominate search results right and we know that the majority of North Americans are turning to the internet first to guide their healthcare decisions.

So what you need to know if you’re maybe in that post-merger environment and you’re not sure, and if you’re not sure you can ask the question this way, you can go to your marketing leadership or to your agency partner and ask do we have a record of all of the places where our businesses, and our providers appear online, and the credentials to access and control those listings. And if the answer is no a couple things you need to appreciate, and it’s completely normal in those group profile group environments profiles do tend to proliferate especially if there’s been brand transitions over the years, or movements of providers in and out of the practice. But that inconsistency, unreliable naming conventions, a lack of a clear brand reference across your locations, all of those things directly impact how and how often you’re going to show up in local search and can actually reduce your market opportunity it will keep you hidden, inconsistencies can keep you hidden from patients actually finding you when you want to attract new business. It’s a difficult thing I think for some business leaders to accept but today patients may more often learn information about your clinics on properties that you can’t directly control so they’re less and less often actually making it to your website, and they’re getting things like your phone numbers, your hour of operation, which providers and procedures are available at which locations from sites like Google or Yelp.

So how do you get control of these things? Ultimately you need to catalog all of those existing profiles that are out there and make sure that you have the credentials to access and control them. When you do that assessment you’re likely to find that you have a disparity of ways that you talk about your business and you need to decide at a leadership level what do you expect your marketing team or the agency that you hire to control. Some large groups will say we’re really only going to focus on our locations, right, the physical presence because it’s just too much work to try to keep our hands around all of the listings that are out there on the internet about your providers, and that’s okay. Others will say no we need to have a better handle on our brand and what’s being said about our providers so we need to capture all of those things, and deciding what that strategy is how much you expect of your team is going to be important so they can do it well and be successful. Then we want to leverage whether it’s an internal team or the agency to go through what can be a very arduous process of regaining control, often we find that there are listings that were set up a decade ago, they were established by a nurse or a practice manager and nobody has any more the login and password that’s required to get in there and update the address, or the phone number, or your hours of operation, and as a result those listings are left to languish. Now there are processes in place to recover access to those things and you just need to make sure that everybody knows that it’s an expectation that you are going to control your listings.

So the second thing we have to think about here, and it’s a question to ask yourself is, are you overlooking online channels for crisis communications. You think uh, what possible means can I have for crisis communications, well COVID is a great example, but this actually first came up for us a number of years back we had a large multi-specialty surgical group that we worked with in the Northeast and as many of you on the call will know from the northeast snow days are a real thing they happen every couple of years, and the process, especially for groups that may run a contact center where some locations are closed and others are open and need to continue normal business operations but all communications are handled inside of a contact center, it can be debilitating for a larger group especially a multi-regional group to get clear messaging out about what’s happening at one or more locations when you don’t actually have either that control of the plan. So a couple things that you need to know, critical events we’ve seen this firsthand I know it’s a real thing, they can completely overwhelm a contact center if that’s how you’re going to run communications and it can take and it can exacerbate a problem where if just a select number of offices are dealing with a crisis or they’re dealing with it a certain way that event can actually prevent normal operations and seriously disrupt revenue in the rest of the network. So it’s important that you know and you have an infrastructure in place to support that and that simple things like adjustments to hours, alerts during COVID how important was this, that they either need to be broadcast not just on your local profiles like your google my business listing, it’s often the first place people are going to go I’m sure everybody on the call has done this during COVID check to see is my hairdresser open yet right, that vehicle, that medium is important today. Social media that we need to have a plan that gets messaging out there and either location specific alerts on the location pages of your website or a global alert if this is a crisis that’s affecting the whole of your network. So how do you master the situation what projects could you take on to do better at this the next time this comes up. Hopefully we don’t have a situation where we’re looking at a resurgence as we get into the fall of COVID and in select markets we might see rollback, but it is a real possibility so now is the time to take control of this. So document the protocol right, give your team a plan for success, something that they can fall back on because in the midst of the crisis this can actually be a real life saver. In addition to that you can deploy enhancements now that empower your team to quickly broadcast those location those updates on individual location pages are site-wide without the need necessary to interface with a web developer, a support team, so that you can more efficiently and more quickly get important notices out to the public.

So the third of the four things that I want to challenge you to think about today is, are you leaving online reputation specifically, to sort of take care of itself. Now the thing I want to acknowledge in the midst of joining practices together or even just running day to day a really large group, taking time or energy to focus on a reputation can seem like a distraction right, it can seem like a want rather than a need to do. The couple things I really need for leaders in group practices to understand is that reputation today, especially in the medical space is more important than it’s ever been and it is one of the major drivers for your long-term success. So what we know dating back as far as this report that was published in early 2018 based on data that came out of 2017, is that doctors were already third in review popularity after only dining establishment in hotels right so we were trained originally, we became accustomed to reviews, in the travel and leisure space but very quickly they become central to the way that we approach healthcare decisions. I’m forced to think about you know Glenn talked a moment ago about due diligence, and I’m forced to think about a large group that we worked with that whose diligence prior to us working together did not include examining the online reputations of the clinics that they were acquiring. What we saw as we looked at their performance data for the previous two years that the there was a direct correlation between those clinics who were financially underperforming and those clinics who came to the group with a bad online reputation because what many leaders need to understand is simply changing your brand, if the clinic is staying at the same address, it is very difficult to run away from a history of bad online reviews. Most of the major online review portals the, Yelps the Googles of the world, will transfer the business reviews on to a new brand as long as there’s continuity of the same service category at the same location. Right and so reviews like this, they’re never answering, they’re never communicating, I made my appointment but when I got there they never told me that they stopped accepting my insurance. Or worse a review like this that says, I haven’t even been into the office and I’d recommend you don’t go there because my customer service experience was so bad.

This is very much in keeping with a series of studies that we did we looked across a couple different industries. This is actually the specific chart for ophthalmology the data is slightly different but the order is exactly the same we found in dermatology and in plastic surgery, was that negative reviews most often were about common service concerns, poor communication, poor attitude, time management issues, feeling rushed in a consultation, or being forced to wait too long, and things like the outcome, things like the cost or the value of the services very, very rarely were coming up. What we know from studies more recently is that about 60% of health care decisions and this is U.S. data, I know we’ve got some Canadians on the call with us today, about 60% of healthcare decisions are directly linked to online reviews. So this stuff we knows matters, so what you need to know is that right now reviews that are deposited specifically on Google are going to offer the greatest benefit for your clinic because those reviews, especially when they’re positive reviews, are going to directly influence your visibility in Google local search. Those map search results which for many of our clients today can account for 54% or more of all of the reviews coming from the traffic coming from google back to their site.

Now how good do you need to be? Well the good news is you only need, maybe this is bad news for some of you, but you only need to be four stars or better for each location and physician. You don’t need to be perfect, consumers have I think fairly realistic expectations in some cases. Now they do value consumers recency of reviews above all else so this means that you have to have a program that encourages patients to continually deposit new reviews because old reviews aren’t seen as very trustworthy by patients who are about to have a new experience with your clinics.

So among those people that are actually reading reviews what’s important to note is that 97% of those that cohort are actually taking the time to study how an office replies. Many of you especially here in the United States where you have to be concerned about HIPAA, many who raise their hand and say I can’t reply because of HIPAA, that’s not true there are safe ways to reply in a HIPAA compliant manner you just have to be very mindful about how you engage in the public space. But what’s I think probably most salient in this is that you need to know that today, especially in a large group environment where scalability is a concern, that the majority of businesses are actually using software automation to help prompt patients to deposit those reviews. So if you’re focused on if you really want to try to take control of your online reputation for your physicians and your larger group brand you really need to focus on training for and closely monitoring, specifically phone and messaging skills, I know today it’s not just phone, people are communicating by email, they’re communicating by SMS, they’re in chat applications, you need to make sure that those skills are developed monitored and continuously improved. Wait times and rushed appointments, those are going to cause you to receive no matter what you do you’re going to get negative reviews if that’s a part of your operations so striving to overcome that is going to be important. Managing expectations is another thing that was a smaller contributor in our study, patients who didn’t know what was next or didn’t understand what aspects of the recovery would be like for surgical procedures, those were in fact regular drivers for complaints online. You need some kind of software in place that’s ultimately going to automate the monitoring and alert you when new reviews come up so you can address situations head on, and there’s as well software today that you should be considering or deploying that will automate the ask. We have seen that when the review request goes out in SMS you’re more likely to get a review deposited than when it goes out for example in an email, and then you’ve got some clear protocols in place to escalate patient concerns when they are appearing online and where you can see specific trends at the level of individual locations because in groups, different offices obviously are going to have different reputation profiles online.

Now the last question here and then we’ll move to that Q&A section is about missing any opportunities for automation. Right so in large groups I think very often, as Glenn pointed out, what we’re thinking about here is we’re joining together for often some kind of economy of scale and what we very often experience especially with the largest groups that we serve, those groups that are over 20 locations, we have groups that approach or exceed 100 different office locations is that you can end up with a kind of patchwork, and a patchwork that makes patient experiences very difficult. So what I think you need to understand, and I’ll think of actually right now a location that we serve in the Northeast, they brought together a large group of practices and each one had different practice management software, a different set of procedures that they offered because they had different devices and technology, they had different providers at different offices at different times, and because their procedures were different, different offices wanted to run different promotions inside of the same month. But most notably is their pair mix was a mess and they are still today working on normalizing pair mix which is incredibly difficult because they cross state lines. And when we studied the calls coming into the call center what we found is actually 60% of all the calls coming in were asking where do you accept my insurance. So in their particular case we were able to automate away the majority of those calls by developing marketing automation software that lets patient self-service, that lets them look up which payers are available at which office locations so they can pick where to go.

So what you need to know if you’re operating in any patchwork like that, first and foremost is that those inter-office differences, the providers, your procedures, your payers or promotions, they’re going to be a major source of inquiry coming in and if you’re operating a contact center where the main thing that you want your operators doing is booking new appointments, but the reality is that the majority of your labor cost is going into answering questions about which offices are supporting the fall Lasik promotion, or which offices accept my insurance, then you’re wasting a lot of money that doesn’t need to go that way. But more importantly it can drive complaints because if your call center operations are scaled to the number of appointments you need to book, but that you’re wasting a significant amount of time on other ancillary concerns that patients should be able to answer online for themselves, it’s going to drive wait times, poor communications, which will translate into complaints on those online rating sites. What we find that’s important for I think business leaders to understand is there’s great data out there, it’s actually Harvard Business Review published this one, that 81% of consumers would prefer to actually try to self-service to solve their own problems rather than contacting a live representative if we give them the tools.

So the challenge for you as a large group is to decide well where can I turn automation to my advantage. So a great way to identify this is audit both your inquiries, listen to recorded calls in the call center, use any software that you have available to track what was the primary reason for inquiries that were coming in, or look at your feedback forms that are coming in to identify those areas where self-service is really going to help your business to soar, and then deploy those automations that are going to save you time, save you significant cost, and ultimately improve patient experience, and it’s going to feed right back in to that loop with those online reviews that we talked about in your reputation to make that better.

Now, Glenn and I between us, I think we talked about 11 different areas where you might need to focus before and after the merger, Glenn if you want to come back in here and we’ll remind the audience that a couple of things, number one use that Q&A box if you’d like to pass us a couple of questions, we’ll be sure to get those answered before we wrap up here in just the next couple of minutes. But I want to remind everyone that, and Glenn I’m not sure what your experience is with this, but in most cases when I’m looking at group practices my perception is that they’re understaffed for the scale of the challenges very often that they need to overcome, and that pursuit of operational efficiency very often means that members of the team have even more on their back that they need to address. So today you know you might look to focus on taking on one or two things away not all 11 so don’t feel overwhelmed, but one or two things that you think are really operational imperatives that you can that you can tackle successfully.

So for my part if you want a copy of the presentation deck you can email me directly, if you’re interested in our newsletter you can go to that address there, but let’s just close out by taking a couple of questions. Glenn first question that’s coming in is about due diligence, in your experience what is most often missed or overlooked when practices, whether they’re either doing it themselves, or they’ve brought somebody in what have you seen that gets overlooked in that due diligence phase?

I think it typically is in the operational realm and it may be revenue cycle management, how revenue cycle management what that process looks like in one practice versus the other, and you pointed out you know all of those different practices it had a different way of doing things. But I would say operations is typically where enough due diligence was not done in advance, and then post-merger there’s a little bit of a scramble to figure out how we can create those consistencies.

Good, and this is a this is a question I think all it’s a fairly tactical question, I’ll take with this one, on how do you manage promotions at individual locations for large multi-location groups. So to answer your question back there’s a variety of different things that we do on the website level. We build the site in such a way where promotions can link to one or more of the practice locations so that we can display location specific deals, or offers, I think this most often comes up with our aesthetic clinics dermatology and plastic surgery practices, although we’ve seen this a little bit with our large ophthalmology groups that don’t offer Lasik at every one of their offices, and Lasik is prone more often to seasonal promotion, but where we can display a promotion on a centralized promotion page that lists where it can be redeemed and then each one of the associated locations get that same promotion automatically featured on its profile page. We can then take that information and go out to local profiles like Google My Business and actually put posts there on those listings that advertise that promotion at those individual locations. There’s more that we can do there but it’s largely focused on clear communication on the website and then things like segmented email lists, or specifically geographically targeted social media advertising. So it’s definitely doable if you’re in a place where you’re not making the same offer at every location and every time.

Glenn another question that’s coming in is looking specifically at challenging conversations about potential team consolidations, when’s the right time. So I think if interpret this question correctly what they’re asking is you know there’s a moment in time where you have to reveal to the world that a merger is happening because you’re going to start to see people in the office doing due diligence, you’re going to have to start that communication, and then I would imagine very often there’s a time gap between that and when the staff configuration begins to change. I’ve seen the mistake ‘oh everybody’s going to keep their job’ and then there’s a huge trust loss when that doesn’t actually happen. What’s your advice for practices that are trying to retain talent during the transition period, it’s a really difficult communication topic.

Yeah it can be, but it doesn’t always have to be so you know the transparency that we both have talked about and involvement. The more we can involve key individuals for a department, for a division, however you know large the organization is, but having a representative if it’s a large group, let’s say a manager, a manager representative if you’re merging lots of locations, so that the managers can understand does this mean that I’ll be managing multiple locations now and not one, and begin to answer some of the most pressing questions. So you know understanding what those questions are means that we are asking the right questions, and then we’re asking the question behind the question, and so it takes time, it takes focus, it takes a lot of empathy, but we’ve become pretty good at it through COVID having difficult conversations and you know dialing up empathy and meeting people where they are, and at the end of the day if we’ve done a great job in you know bringing them in as part of our mission and then you know getting investment in the new mission, then there’s increased trust so that’s what we’re always looking for is trust, and deserving that trust, earning that trust so that we can manage through together.

Excellent, well on behalf of my entire team I want to be sure to thank you and everybody at BSM for making your time available for the webinar today. As I mentioned at the beginning of the conversation that this session’s been recorded so if you want to play it back or share it with any colleagues you’re free to do so, it’ll take just a couple days we’ll get that out on Friday, and I think Glenn has been generous enough to offer her checklist up. We’ll include that checklist in the post so you can download that as well, Glenn thank you so much for joining me today.

Thank you so much, we love partnering with you Ryan, it’s a pleasure.

Excellent, good day everyone, take care and enjoy the rest of the week.

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