EndoEconomics Winter 2019 Issue

WINTER 2019

A journal dedicated to advancing GI ASCs and practices

12 Partnering for fruitful growth

1 endoeconomics WINTER 2019

6

SUCCESSION PLANNING

10

NEGOTIATING CONTRACTS

22

FATIGUE RISK MANAGEMENT

ASC DEVELOPMENT SERVICES

Building GI Surgery Centers of Excellence!

Feasibility Study Site Selection Facility Design Project Financing Vendor Negotiations Equipment Purchasing Construction Management Staff Recruitment and Training License and Certificate of Occupancy Medicare & Accreditation Surveys

TO LEARN MORE: info@endocenters.com

EDITORIAL STAFF

Carol Stopa Editor in Chief cstopa@endocenters.com

CONTENTS 6

Lori Trzcinski Managing Editor ltrzcinski@endocenters.com Publishing services are provided by GLC, 9855 Woods Drive, Skokie, IL 60077, (847) 205.3000, glcdelivers.com.

EndoEconomics™, a free quarterly publication, is published by Physicians Endoscopy, 2500 York Road, Suite 300, Jamison, PA 18929.

Advertisers assume liability and responsibility for all content (including text, illustrations and representations) of their advertisements published.

Printed in the U.S.A. Copyright © 2019 by Physicians Endoscopy All rights reserved All copyright for material appearing in EndoEconomics belongs to Physicians Endoscopy, and/or the individual contributor/ clients, and may not be reproduced without the written consent of Physicians Endoscopy.

Reproduction in whole or in part of the contents without express permission is prohibited.

To request reprints or the rights to reprint such as copying for general distribution, advertising, promotional purposes: Submit in writing by mail or send via email to info@endocenters.com.

8

Retirement ahead

LETTER

NOTEWORTHY

STRATEGIES

2

4

6

Message from the President

Center news, National Colorectal Cancer Awareness Month and more

The views expressed in this publication are not necessarily those of Physicians Endoscopy, EndoEconomics or the editorial staff.

POSTMASTER: Send address changes to: Physicians Endoscopy, Attn: EndoEconomics, 2500 York Road, Suite 300, Jamison, PA 18929.

While every effort has been made to ensure the accuracy of EndoEconomics contents, neither the editor nor staff can be held responsible for the accuracy of information herein, or any consequences arising from it.

WINTER 2019

Retirement ahead

8

In the driver’s seat

10 12

A fair deal

18

EXCELLENCE

INSIGHTS

12

16

Partnering for fruitful growth

MARKETING It’s you, not me

18 CLINICAL

Increasing ADR: The bottom line

ENDO OPPORTUNITIES 24

GI physician opportunities at partnered practices

22

CLINICAL Rest for the weary

Find out more at endocenters.com or find us on

1 endoeconomics WINTER 2019

letter

{Message from the President}

THE PATIENT IS READY FOR YOU Enabling physicians to provide high-quality, patient-focused service.

David Young, President, Physicians Endoscopy

WE MUST STRIVE TO REMAIN GROUNDED AND NEVER LOSE SIGHT OF OUR MOST IMPORTANT CUSTOMER: THE PATIENT.

2 endoeconomics WINTER 2019

IN MY PREVIOUS MESSAGE, I FOCUSED ON THE IMPORTANCE OF PHYSICIANS REMAINING INDEPENDENT AND THE VALUE INDEPENDENCE DELIVERS TO THE HEALTHCARE SYSTEM. Maintaining such independence does not come easily.

It requires physicians to spend significant time and energy focused on the challenging bureaucratic component of running their practices and ambulatory surgery centers (ASCs). This includes matters such as payer contracting, supply purchasing, financial management and revenue cycle performance.

But all this “busyness” can cause us to direct too much time and effort to the business and not enough time to what ultimately makes or breaks our success.

We must strive to remain grounded and never lose sight of our most important customer: the patient. Through all of the distractions and stresses, it is imperative that we maintain an understanding of what it is like to be in the shoes of patients and what we must do to meet their needs.

These needs go beyond ensuring safe procedures and successful outcomes, albeit they must remain the top priorities.

We must prioritize access by striving to maintain flexibility for patients to come to our practices and ASCs when it works best for them. We must be concerned with the overall experience in our organizations outside of treatment. When patients come to us with built-in expectations of our high-quality care, they anticipate

high-quality operations and services in support of that care.

We must also provide education in areas such as costs, value and quality.

Consider that patients are becoming savvier about the healthcare system and their treatment options and are increasingly in positions to make choices concerning their care. Our patients trust us to be the experts on healthcare in general, not just treatment. They are looking to their trusted caregivers to help them understand and navigate the complex healthcare system and explain what they need to know to make the best decisions for their short- and long-term well-being.

You can market to patients and attract them to your practice and ASC, but just getting them in the door—and even providing great treatment—may not be enough to keep them. We must win their hearts. If we do that, they will not only stay with us but also help spread the word of our superior services.

I’d like to conclude with a thought I had after speaking to a large group of primary care doctors and reflecting on interactions between patients and physicians. At the beginning of a usual encounter, patients are often told, “The doctor is ready for you.” Considering today’s changing healthcare dynamic, that approach is becoming antiquated. Rather, this interaction should see a doctor being told, “The patient is ready for you.” That’s a very different viewpoint on service, but one that I feel is relevant for all providers.

With all of the challenges that compete for your attention, you’ll never have to compete for ours.

Because your dedicated team deserves our dedicated focus.

The healthcare environment presents new challenges every day. That’s why we at Boston Scientific are committed to being your indispensable partner in optimizing practice efficiency and enhancing patient care.

We have a team dedicated to serving Ambulatory Surgical Centers and we’re focused on offering devices, solutions and support that matter to your business. So ask more of us – we’re ready.

ASC SOLUTIONS

GI Lab Optimization

Single-Use Devices

Community Wellness

©2018 Boston Scientific Corporation or its affiliates. All rights reserved.

ENDO-554108-AA June 2018

Infection Prevention

Scope Repair and Certified Pre-owned Equipment

GI Specialized Pathology

noteworthy

{News and events}

Physicians Endoscopy Partners with Two New GI Groups in VA and MD Gastroenterology Associates of Fredericksburg (GAF), located in Fredericksburg, VA, is a group of eight board-certified GI physicians. PE and GAF formalized their partnership on October 31st, 2018. GAF performs over 6,000 procedures in their two-room facility. The group’s overall strategic goal in partnering with PE is working together on a three-way joint venture with the hospital, PE’s recruitment services, access to PE’s premier GPO and help in developing a plan to meet the needs of all their patients. The physician leadership group includes Frank DeTrane, MD, Medical Director, Chetan Pai, MD, Peter Wong, MD, Dong Lee, MD, and Narayan Dharel, MD. GAF represents PE’s first group partnership in the Commonwealth of Virginia and PE’s 58th center.

The physician owners of Bethesda Endoscopy Center (BEC), located in Bethesda, MD, recently concluded an

COLORECTAL CANCER AWARENESS MONTH

acquisition partnership with PE on September 30th, 2018.

The 15 GI physicians represent multiple medical practices spread throughout the greater Washington, DC metro area.

BEC performs over 8,400 annual procedures in their threeroom licensed ambulatory surgery center (ASC). The group’s overall goal in partnering with PE is access to their premier billing and collections team and recruitment services, as well as working with a strategic partner to further impact and build upon the growth of their successful center.

Gary Roggin, MD, serves as the center’s Medical Director.

This ASC represents PE’s second center in Maryland and PE’s 59th partnered center.

To learn more about these centers, visit endocenters.com/partnered-centers

➌

Have You Started Planning?

Nearly 20 years ago, former President Bill Clinton officially dedicated the month of March as National Colorectal Cancer Awareness Month.

According to the American Cancer Society, more than 60 percent of colorectal cancer deaths could have been prevented with a screening colonoscopy.

As March approaches, here are ideas you can plan for:

➊ | Encourage those in the community to talk about the

➋

risks of colon cancer, and discuss the importance of getting a screening colonoscopy starting at age 45 for average-risk adults. Consider posting flyers in areas that will attract attention: doctors’ offices, local hospitals, banks, community centers, etc. | Use social media to get your message out. Posting articles and informative content on Twitter, LinkedIn

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➍

and Facebook from your center can be a means of sharing knowledge about how to prevent colon cancer and why people should be screened for it. | If you’d like to do something more than just spread the word, consider participating in a colon cancer awareness event. Friday, March 1st is “Dress in Blue Day.” Encourage staff and coworkers to show their support of those who have suffered or are suffering from colon cancer by wearing blue for the day.

If you would like to take part in an even bigger event, every year PE participates in “Get Your Rear in Gear, Philadelphia!” at the Please Touch Museum in Philadelphia, PA. GYRIG works in partnership with the Colon Cancer Coalition to increase awareness and screening of colon cancer across the country.

There are dozens of GYRIG races scheduled nationwide each year.

Visit coloncancercoalition.org to learn more about these family-friendly events. | Another way to help support National Colorectal Cancer Awareness Month is to offer free screenings.

Surgery centers across the country have developed robust charitable care programs with the mission of providing free colorectal care screening and surveillance to uninsured individuals. Insured patients could qualify for a free screening colonoscopy under their health insurance plan and may not even know it. Screening colonoscopies can save patients cash, and potentially their lives.

To share your planning stories with us, email info@endocenters.com

Send us your community stories. Email us at info@endocenters.com

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National ASC Month Celebration American Cancer Society Updates Colorectal Cancer Screening Guideline Supported by the Ambulatory Surgery Center Association As of May 30th, 2018, the American Cancer Society (ACS) has updated their recommended colorectal cancer screening guideline age from 50 to 45. The change was based on a major analysis led by ASC researchers showing a trend of increasing cases of colorectal cancer among younger adults. The ACS believes that lowering the recommended screening age will result in more lives saved from colorectal cancer. This screening age only applies to those who are at average risk, and does not apply to anyone who is at higher than average risk. If a patient has a family history of colorectal cancer, a personal history of colorectal cancer, a personal history of inflammatory bowel disease or any other histories, they should be screened more often and/or get specific tests. At this time, insurers are not required to cover the cost of colorectal screening before age 50, and likely don’t yet.

To learn more about the ACS or the updated colorectal cancer screening age, visit cancer.org

(ASCA), National ASC Month celebrates the high-quality care ambulatory surgery centers provide to patients across the country. ASCA encourages centers to participate in National ASC Month by inviting key decision-makers to tour their facility. Many Physicians Endoscopy-partnered centers had visits from district representatives. Assemblymember Victor M. Pichardo (NY-86) toured Mid-Bronx Endoscopy Center (Bronx, NY).

Assemblymember Harvey Epstein (NY-74) toured East Side Endoscopy and Pain Management Center (New York, NY). Congressman Lee Zeldin (NY-1) toured Advanced Surgery Center of Long Island (Port Jefferson Station, NY).

Finally, New York State Sen. Anthony Avella (NY-11) toured Queens Endoscopy Center (Fresh Meadows, NY). ASCA is the national membership association that represents ASCs and provides advocacy and resources to assist ASCs in everyday patient care.

For more information on National ASC Month, visit ascassociation.org/asca/govtadvocacy/grassrootsadvocacy/ nationalascmonth

GASTRO MANAGEMENT SERVICES Focus on clinical care, not administrative duties.

Revenue Cycle Finance Operations Leadership Human Resources Information Technology

TO LEARN MORE: info@pegastro.com

strategies

{Business strategy and the bottom line}

Retirement ahead With thoughtful and proactive planning, GI practices and centers can get ahead of the curve when it comes to a physician leader retiring.

By TJ Berdzik

GI practices and centers today face an industry with an aging provider pool and younger physicians that increasingly opt for salaried positions with hospital systems over private practice. For this reason, succession planning is an essential part of long-term strategic planning.

As a physician slows down and moves into retirement, it will undoubtedly have a negative impact on volume and revenue for both the practice and center if succession planning is not successfully undertaken. GI practices and centers can counter this by absorbing the volume of the retiring physician into the remaining physicians’ practice or by recruiting additional providers.

If the practice and center are to minimize the impact or potentially grow volume with a new generation of physicians, physician partners must get ahead of the curve through proactive planning for this transition.

Important Questions to Address When a physician partner in a center approaches retirement, a number of questions can arise that are difficult to answer for the center, the physician and any practice partners: > Who will take over the retiring physician’s patients?

6 endoeconomics WINTER 2019

> Does the practice need to hire a new physician and, if so, when? > If an additional physician is necessary, what attributes are wanted or needed in a physician? > Can the retiring physician work part-time to ease into retirement? > Can a physician stop performing center procedures and focus on the office? > How will the reduction of physician providers impact the group’s coverage responsibilities at the practice, center, hospital and outreach clinics? > How will the center maintain or replace the volume of a retiring physician? > What notification clauses do practice or center agreements have in place to prevent unexpected departures with little to no notice? > What are the expected staffing levels needed to support operations after a physician retirement? > Is there a potential for merging or buying out practices after a physician retires? > Is there a potential need for a joint venture with a hospital system?

Having a roadmap to specifically address these concerns is the purpose of succession planning.

Learn about succession planning resources Physicians Endoscopy offers to its centers: endocenters.com/contact-us

endocenters.com

Advance Planning

center and practice productivity, efficiency and clinical Succession planning is best handled with early, open and outcomes. honest discussions between physician partners and even A center and practice must thoughtfully identify the junior physicians. Advance planning allows a practice next generation of a physician leader. This is not a process and center to identify the best candidates that it wants that should be handled in a three-month time frame. and needs, as well as attract the candidates that will Simply choosing the most productive physician may help maintain stability of the business and fit within result in burdening one of the business’s most producthe culture of the practice and center. Ideally, physician tive members with administrative tasks that ultimately partner succession planning should be a roughly two-year impact their productivity. plan (see “Timeline to Succession�).

Physician recruitment can be a challenging, lengthy and Tools for a Successful Succession potentially costly endeavor. Establishing an organized and While succession planning can be an uncomfortable topic ideally multi-option strategy for seeking viable candidates for many practices and organizations, it is part of a normal can increase the effectiveness of physician recruitment. business life cycle. Open and honest conversations among Strategies should utilize the resources and network of a stakeholders well ahead of separation events can allow competent ambulatory surgery center (ASC) management for planning and even provide additional options for partner, industry trade publications, physician word of the physician to ease into retirement over time. By mouth, relationships with medical educational instituworking with a strong management partner or advisors, tions, competent medical staffing and recruitment firms, the center and practice leverage tools for planning, and hospital partners. recruitment and preparation for the succession event.

Once a successor is identified and recruited, the The ultimate goal is to practice and center will require time to train the new maintain stability of the physician. Younger physicians and hospitalists may need business for all stakeholdassistance and mentoring to adapt to the leaner, more ers as well as patients. efficient operations of ASCs. During the period between the hiring of a new physiADDITIONAL CONTRIBUTOR Bob Estes cian and the departure of a retiring physician, the practice is the Senior Vice President, Operations, at TJ BERDZIK is a Senior Financial Analyst and center should market the new physician to patients Physicians Endoscopy. He has 30 years of at Physicians Endoscopy (PE). He can be and primary care referral sources while announcing the broad-spectrum healthcare experience. He can reached at tberdzik@endocenters.com. be reached at bestes@endocenters.com. retirement of the departing physician to show a seamless transition of patient care.

An effective marketing strategy can be instrumental to the success of these Timeline to Succession Post-retirement transitions with a focus > Sell interests to other partners on stability.

6 months out > Potentially maintain a part-time When a strong physician > Bring new physician on board role, including office or centerleader retires, a center and > Send letters, emails or other only capacity practice also must consider communications announcing the void that goes beyond physician retirement the simple loss of patient 1 year out > Transition new physician volume. A strong physi>P repare for the tran> Market new physician to cian leader may play an sition, including referring primary care providers important role in melding introduction of the clinical and business largest sources 2 years out aspects of the practice or of referrals to >S tart recruitment center. A physician leader other practice based on desired can be a mentor to other physicians characteristics and physicians and facilitate > Adjust schedules and center needs consensus among phystaffing levels if retiring sician partners. Strong physician plans to slow leadership can help drive down prior to retirement improvements in both

7 endoeconomics WINTER 2019

strategies

{Business strategy and the bottom line}

In the driver’s seat PE helps centers take control of payer contracting by negotiating the best rates and collecting correct, complete payments from payers.

By Betsy Zimmerman

You take the time to schedule patients for their That’s why it’s imperative to take control of your payer procedures, perform the procedures, fill out the contracting. Improving payer contracting can help grow required documentation and submit them to your payers. your ASC’s bottom line through increased collections, higher Considering all the work put in, you reimbursement and cost savings from should receive accurate and timely decreased time and resources needed for payment. And yet this is often not the collections management.

Nearly case. The American Medical Association (AMA) estimates that nearly 20 percent Areas of Focus of claims filed with of claims filed with commercial health To gain better control of your payer commercial health insurers insurers are processed inaccurately, contracting, there are several fundamental are processed inaccurately leading to payment delays or even areas where your ASC should focus rejections.1 its efforts.

While payers have come under pressure First, develop a basic understanding of to reduce their error rate, incorrect and your payers. If you’ve been in business for a while and slow payments are still a significant challenge facing contracted with many different payers, you may have ambulatory surgery centers (ASCs). Depending on the lost track of your current payers and the status of your payer, your revenue could be significantly impacted contracts with them, including whether you have fully by poor payer practices. executed agreements. Without this knowledge, it can be

20 percent

8 endoeconomics WINTER 2019

Learn more about how we help our centers negotiate and manage contracts: endocenters.com/contact-us difficult to effectively monitor payments and detect when payments are wrong or late.

Once you have a basic understanding of your payers, become familiar with your contracts. Of utmost importance is knowing what you are actually getting paid for procedures compared to what you should be getting paid for procedures. Hopefully these figures are the same. If they are not, perform a root-cause analysis to identify the reason for any discrepancy.

One such cause could be contract language that keeps you from receiving full payments. For example, some contracts penalize using nonparticipating ancillary providers or multiple procedures. If such language exists, try to negotiate it out of your contracts or at least argue for a reduction in penalty size.

Effectively detecting penalties—which aren’t always accurately enforced—incorrect payments and missed payments requires a monitoring system. Billing software often includes features that can alert you to payment discrepancies or delays. If you lack such an option, a manual comparison between claims submitted and payments received can suffice. What matters is implementing processes for monitoring payments and taking action when an inconsistency is spotted.

In the case of slow payments, understand your rights.

Most states have some form of a prompt payment law, and many have strengthened these laws over the years. Know your state’s rules and how to use them to your advantage.

If your efforts pay off, you should see improvements in the accuracy and timeliness of your payments.

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Our objective is simple: work to obtain the highest market rates available. Before agreeing to new contracts, we review them for unfavorable language that can be revised to eliminate or at least mitigate any material impact on our centers’ bottom lines.

When negotiating contracts, we use scores from quality improvement benchmarking tools such as GIQuIC and patient satisfaction survey results to illustrate that our centers are of the highest quality. This reminds payers that we’re saving them and patients money while still providing superior services.

Our partnered centers are always informed about any payer contracting efforts on their behalf. We ensure ongoing communication occurs with their administrators and board. Once contracts are finalized, we circulate a summary that highlights the most critical points. Our large, in-house billing team verifies that our centers receive correct payments in a timely fashion. If a payment doesn’t match a contract, one of our tools alerts us so we can determine and address the cause. If a payer is slow to pay, we follow up aggressively and do not hesitate to reference applicable state laws that allow us to collect appropriate penalties.

These efforts add up to stronger collections and bottom lines for our partners, allowing them to invest more in the high-quality care they deliver to their patients.

REFERENCES 1

www.medscape.com/viewarticle/745041

Our Secrets to Success When Physicians Endoscopy (PE) partners with centers, payer contracting is an operational component that receives significant attention from our team. PE’s history and presence throughout the country has allowed us to develop ongoing relationships with payers, helping us ensure our partners’ contracting needs are effectively met.

For new ASCs that we build in partnership with physicians, we go into their marketplace and create payer contracts from scratch. For existing ASCs that bring us on as a partner, we obtain their existing contract copies, BETSY ZIMMERMANN is a Payer review rate schedules and Contracting Manager with Physicians renegotiate contracts. We Endoscopy (PE). She is responsible for rely on tools that forecast payer contract negotiation, reviewing additional revenue using contract language and reporting resulting real-time data based on revenue increases. She can be reached at each procedure performed bzimmermann@endocenters.com. by the practice or center.

Making Top Dollar Getting paid in full is important. But just as important is receiving top rates for your most frequently performed procedures. Here are some tips that will help ensure you receive the best rates possible: ➊ | When you negotiate contracts, don’t accept payers’

standard rates; instead push for an enhanced fee schedule. ➋ | For contracts that are evergreen, regularly review them as part of your process to ensure you are receiving market appropriate rates. ➌ | During negotiations, make the case that your high-volume procedures deserve higher reimbursement by explaining the substantial savings you are providing to payers (and patients) compared to other settings.

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strategies

{Business strategy and the bottom line}

A fair deal Six ways to help secure fair product and service contracts.

By Angie Wustner Cost management is essential for any surgery center or practice.

Unnecessary spending can affect all aspects of an organization’s operations, including delaying capital purchases and growth projects, limiting employee compensation and reducing distributions. It’s imperative for leadership to focus on what they invest in products and services.

Supply cost oversight and management isn’t easy considering how many products and services are required to run a highperforming organization.

Fortunately, there are ways leaders can increase the likelihood of securing the best possible contracts.

Let’s highlight six that have proven effective.

Build Close

1 Relationships with Vendors

Get to know the vendor representatives assigned to your account. Stronger, more personal relationships can open doors. You should be able to negotiate better contracts when such conversations are conducted in a cordial manner.

Questions about contracts and their terms are likely to

10 endoeconomics WINTER 2019

be answered in an expedient manner. Vendors may provide samples for trialing new products and deeper discounts on products.

To strengthen relationships, engage in face-to-face meetings.

Invite representatives to your center and/or meet them at conferences. For routine communications, schedule an occasional phone call rather than relying solely on electronic communications, which are typically less personal.

Support

2 Preferred Vendors You have many choices for vendors, which means there’s competition for your business. That puts your center at an advantage for negotiations by comparing different vendors’ proposals, often to help secure better contracts. This approach requires work, professionalism and consideration for established vendors. For those vendors that deliver great solutions and customer service at a fair price, there are benefits to showing your appreciation by working more closely with them.

As you develop positive rapport with these

companies, they may be more confident in providing enhanced discounts on your spend. Managing fewer vendors and contracts should prove easier. Your business may continue to benefit further as you grow closer with these vendors.

Leverage a Group

3 Purchasing

Organization An easy and effective way to secure fair contracts is to join a group purchasing organization (GPO). The Healthcare Supply Chain Association defines a GPO

Learn more about how we help our centers secure fair product and service contracts: endocenters.com/contact-us as an entity that helps healthcare providers “realize savings and efficiencies by aggregating purchasing volume and using that leverage to negotiate discounts with manufacturers, distributors and other vendors.” As a GPO member, you gain access to its contracts and the prices secured by the organization.

Not all vendors participate with GPOs. When you reach out to new vendors, inquire about their involvement with your GPO. If they participate, it will make negotiating easier because the agreement and pricing is already established. If

they do not participate, this does not preclude you from working with them. You will just need to negotiate your own contracts.

4

Understand Contract Terms

Before signing a new contract, understand its terms. Two of the most important concern autorenewals for services (e.g., linens, medical gases) and price increases.

Service contracts often include an auto-renewal clause that kicks in unless the vendor is informed in advance of a customer’s desire to terminate the

contract. Vendors will often require that you provide a predetermined number of days’ notice in advance of the renewal date. Miss that deadline and the contract renews. Try to negotiate for shorter contract terms and fewer days required for advance termination notice.

Service contracts also frequently include clauses allowing for price increases on an established (e.g., annual) basis. Make sure there is a clause requiring notification of such change in advance and push for the right to negotiate it.

5

Verify Invoices

Negotiating a fair contract isn’t all that matters in securing fair pricing. If you don’t ensure you are charged the right price for purchases, it won’t matter what you negotiated. That’s why it’s essential to review invoices for accuracy.

Performing such review for every purchase may not be feasible. Keep a close eye on your highly used items— perhaps the 10–15 products ordered consistently—and more expensive purchases.

As you routinely conduct this review, you will start to learn product prices, making the review process easier.

Monitoring invoices is also important for identifying holes in your contract.

Let’s say you have a contract for a box of 20 forceps.

You’re running a little low one week, so you order a box of 10 forceps. Unless this box is contracted, you may find yourself paying list price.

You want to avoid making

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this purchase of 10 forceps again or see about adding the box to your contract.

6

Lean on Your Partner

If your center has a partner like Physicians Endoscopy (PE), you should have access to resources to obtain fair product and service pricing. While PE typically doesn’t place orders for its centers, we help with contract negotiations, complete letters of commitment and work with a distributor to ensure aggressive pricing tiers and uniform pricing across all our centers. We have a close relationship with a GPO and make sure our centers take full advantage of its offerings.

In addition to placing their own orders, we want our centers to watch their invoices and make sure pricing is accurate. If they identify an irregularity, we help resolve the issue. By working closely together, the PE team helps secure fair prices while maintaining the flexibility for centers to use the products and services that deliver the best care possible.

ANGIE WUSTNER is the Operations and Purchasing Manager at Physicians Endoscopy (PE) and has been with the company for 14 years. She works extensively with their GPO and vendors to provide contracts and supply pricing that offer savings to PE-partnered facilities.

She can be reached at awustner@ endocenters.com.

11 endoeconomics WINTER 2019

excellence

{Success stories}

Partnering for fruitful growth Hospital leaders discuss how working with PE has helped them succeed as the healthcare industry transitions.

As the healthcare industry shifts and puts more importance on value-based care, population health and greater transparency, partnering with an industry leader like Physicians Endoscopy (PE) provides hospitals with multiple benefits. When a hospital needs an ambulatory surgery center (ASC), PE offers the expertise and strategies to build a successful venture.

Three hospital leaders—President and CEO of Peninsula Regional Medical Center Steven Leonard, President of Abington Jefferson Health Meg McGoldrick and Director of University Hospitals Digestive Health Institute John Dumot, DO—spoke to PE Senior Vice President of Business Development and Marketing Carol Stopa.

They shared how their organizations are preparing for the changes in healthcare and how they are benefiting from partnerships with PE.

Carol Stopa (CS): How has your hospital been preparing for healthcare’s transformation?

Steven Leonard (SL): The healthcare industry is undergoing a major transition based on how care is delivered. Maryland is at the forefront of this change. Under the new all-payer model, Maryland hospitals are responsible for controlling the total cost of care. Peninsula Regional is

12 endoeconomics WINTER 2019

STEVEN LEONARD is the President and CEO of Peninsula Regional Medical Center in Salisbury, Maryland. He is a Fellow of the American College of Healthcare Executives.

He is a Certified Six Sigma Black Belt by the American Society for Quality.

MEG MCGOLDRICK is the President of Abington Jefferson Health in Philadelphia, Pennsylvania.

She is a Fellow of the American College of Healthcare Executives, a Malcolm Baldrige Executive Fellow and Chair of the Board of Mid-Atlantic Alliance for Performance Excellence.

JOHN DUMOT, DO, is the Director of the Digestive Health Institute, University Hospitals, in Cleveland, Ohio.

He is a Professor of Medicine at Case Western Reserve University School of Medicine. He is board-certified by the American Board of Internal Medicine in gastroenterology.

well positioned to succeed under these new paradigms of value-based care and population health.

This new era of healthcare is a journey.

We must continue to maintain the best hospital care and partner with our communities to help citizens understand how to best manage their pre-existing conditions, improve their overall health and bend the cost curve. We must coach people on how to stay healthy, provide the appropriate care in the appropriate setting and connect them to the services and information they need to get healthier.

Our journey started in 2010 with an intentional focus on ambulatory services, including clinical and professional services delivered in a more cost-effective location.

Our ambulatory pavilions in Maryland and Delaware are a step toward this transformation, and we are excited to partner with PE to bring quality healthcare to our beach communities.

Meg McGoldrick (MM): Abington Hospital began a journey to scale in 2007. We determined that as a standalone hospital, we would not be able to remain competitive given all of the market forces. We acquired a local community hospital and then acquired a second hospital in 2008. We decided to pivot strategically and merge with a large academically based hospital health system to continue to scale and

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THIS NEW ERA OF HEALTHCARE IS A JOURNEY. WE MUST CONTINUE TO MAINTAIN THE BEST HOSPITAL CARE AND PARTNER WITH OUR COMMUNITIES TO HELP CITIZENS UNDERSTAND HOW TO BEST MANAGE THEIR PRE-EXISTING CONDITIONS, IMPROVE THEIR OVERALL HEALTH AND BEND THE COST CURVE.

Illustration by Michael Morgenstern

–Steven Leonard

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excellence

{Success stories}

improve our negotiating position in a very competitive market.

appropriate setting while bending the total cost of care and delivering exceptional quality. Our mission to improve the health of the communities we serve is more relevant today than it has ever been. Services once only offered in the hospital setting, when clinically appropriate, are better delivered closer to home in an ambulatory setting.

Dr. John Dumot (JD): University Hospitals is doubling down on our value assessments. We have reduced the cost of care by looking into our utilization of staffing and are working with multiple vendors to find the best prices for disposables and implantable devices. The competition among vendors is healthy.

CS: How important is it for your hospital to create an ambulatory footprint within your extended market?

CS: Does your hospital have a formal strategy for your GI service line, and have reimbursement trends toward value-based care and pricing transparency impacted this strategy?

MM: Our goal is to achieve an 80 percent colorectal screening rate across the system, and we currently are developing that strategy. To that end, it is imperative that we have properly situated endoscopic facilities in close proximity, so that patients can access these vital services as conveniently as possible.

We are also in the process of standardizing the care for common conditions so that they fall in line with best-practice approaches. Our ultimate goal is a specialty medical home model where all services relevant to this complex patient population are provided within a single location. We are doing all of this with a critical eye focused on the emerging importance of value-based care and price transparency.

JD: In the past, we had a hospital-based endoscopy program, but our future now includes ambulatory centers focused only on routine endoscopy. This will save our patients and insurers a significant amount of money in the long run. The leadership of University Hospitals has taken the long view and will be ready to address our care model as it moves toward population health with shared risks.

SL: Our GI service line is consolidated within our overall strategic plan and ambulatory initiatives. Peninsula Regional aims to provide the appropriate care in the

14 endoeconomics WINTER 2019

MM: Our focus is on expanding our ambulatory services with conveniently located facilities throughout our service area that will provide clinical and physician services.

We remain committed to serving our patients within their community.

HISTORICALLY, WE HAVE DEVELOPED OUR OWN HOSPITAL-BASED INPATIENT AND OUTPATIENT SERVICES. AS WE LOOK TO DRIVE DOWN OUR COSTS, WE HAVE TURNED TO STRATEGIC PARTNERS TO HELP US GROW OUR MARKET SHARE. –Meg McGoldrick

JD: A move out of the hospital environment brings significant challenges but is worth it in the long run. We know a high-quality endoscopy does not need to be high cost. The hospital will always be utilized for high-risk procedures and high-risk patients, but the trend is to do routine exams in smaller, more efficient units closer to where patients live.

SL: This is one of our top priorities.

Providing an ambulatory campus in areas of need has been identified as critical to our success. We have opened two fullservice health pavilions and are expanding additional services off our hospital campus, making them much easier for people to access. We continue to seek innovative strategic initiatives to deliver the highest quality services while looking for opportunities to lower the total cost of care.

CS: Each of your hospitals is currently working with PE to help you develop a GI center. While many hospitals attempt this on their own, why did you decide to utilize a corporate partner?

MM: Historically, we have developed our own hospital-based inpatient and outpatient services. As we look to drive down our costs, we have turned to strategic partners to help us grow our market share.

endocenters.com

Their expertise provides cost-competitive services and helps physicians focus on quality, safety and optimal efficiency.

JD: We are currently working on two new centers simultaneously. Each project has its unique characteristics, and PE was sensitive to these differences and allowed us to develop similar but different solutions for each center.

well as future recruitment opportunities.

We are finding many new graduates are not looking to set up their own practices but rather are looking for employment or equity models. Having a freestanding ambulatory-based center allows for flexibility, whether that means employment or ownership structures. PE helps us maintain this strategic advantage in the new world of healthcare.

SL: Partnering with PE gives us the necessary expertise in a fast-paced ambulatory world. By working with a skilled clinical operator like PE, we are able to achieve our goals.

CS: How do you see your GI physicians— both independent and employed— fitting into your GI strategy and your new centers?

CAROL STOPA is Senior Vice President of Business Development and Marketing for Physicians Endoscopy (PE). She has more than 18 years’ experience in acquisitions, de novo and hospital/ system joint ventures. She can be reached at cstopa@endocenters.com.

MM: We have been fortunate over the years to enjoy a highly collaborative partnership with our GI physicians, and they serve an integral role in strategic development. We schedule quarterly strategy meetings that I participate in with GI physician leadership, administrators, hospital financial staff and legal advisors, so we can better serve the digestive health needs of our community. Transparent communication is the essential fulcrum of our joint strategic initiatives.

JD: Currently we only have employed gastroenterologists, but we face the same challenges as every organization: recruitment, retention and compensation. With PE, we are going to be much more successful than going at it alone. It is hard to imagine that a large healthcare system would not be able to move into the dedicated ambulatory endoscopy center business model quickly and efficiently, but that was our case. We benefited from PE’s experience and current business practices as we worked through the regulatory issues involved with a dedicated endoscopy center.

SL: The new center allows for a variety of options when working with our employed and independent gastroenterologists as

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insights

{Marketing strategies and tips}

It’s you, not me Make patients the focus of your marketing efforts.

By Paula Rosenberg Frey, BSN, MS In the retail world, consumers have become accustomed to finding more products that align with their needs and tastes. For everything from spaghetti sauce to blue jeans to pain relievers, consumers face an array of choices that give the illusion of customization. “Ah,” says the consumer, “they made this product just for me.”

Traditionally, healthcare marketing did not operate in the same way as retail.

Healthcare marketing models born in the early 1980s focused on facilities and physicians, putting service providers and service lines in the spotlight. Physician practice marketing became more relevant as large physician practices formed and joint ventures and hospital ownership

PUTTING THE CONSUMER FIRST IN MARKETING IS A WIN-WIN FOR ALL INVOLVED.

16 endoeconomics WINTER 2019

endocenters.com

became more prevalent. All this combined to present a top-down approach to consumer communications.

We, the healthcare professionals, know what is best for you, the consumer.

While that is certainly true of the one-on-one doctor/ patient service relationship, that kind of marketing message no longer resonates with consumers who feel more empowered to make their own healthcare decisions and provider choices. Hospital rankings, detailed service descriptions and selling the hospital/practice are no longer the most effective way to reach potential patients.

Higher unsubscribe rates on marketing emails and lower rates of engagement are all signs that marketing focused on the “me”—the practice or the center—is not the best approach to engage hyper-connected consumers.

Instead, messages focused on the “you”—the consumer—should provide information about the facility and physicians, but through the lens of patient success stories. When consumers learn that Jane or Joe in their community received top-flight medical care, superior service and an excellent personal experience, they will be

Riding the Wave

Savvy healthcare marketers are adjusting their outreach by meeting consumers where they live, so to speak. Several factors have fueled the shift toward consumer-first marketing.

Healthcare consumerism. Almost more than any other type of purchasing behavior, consumers can now refer to dozens of resources for health information (some better than others) that tell them what they might expect in terms of treatment. Because of this, they want a provider who can offer the services they have researched. For many people, the limitations forced on them by health insurers have made selecting the best provider available through their plan a critical decision point.

Growth of lifestyle marketing. To a certain extent, good healthcare is seen as an element of an aspirational lifestyle. Smart messaging can appeal to consumers’ need to do well for themselves and their families.

More competition. In larger urban and suburban markets where there are competing hospitals and ambulatory surgical centers, patients prefer to go to a facility they are familiar with. Building familiarity through your marketing messages becomes even more critical.

much more likely to turn to you for their medical needs.

This approach is consumer-first marketing. It is built upon empathy, respect, integrity and a certain amount of trust in consumers’ ability to choose wisely when presented with well-crafted content that draws a clearer, more relatable picture of what the practice or center can do for them.

Making It Work If your current marketing is not customer-focused, there are several steps you can take to revise your strategy.

First, look at your current patient population. Find out where your referrals are coming from and what types of patients they represent. Craft your marketing message with these specific demographics in mind.

Highlight patient stories. If you ask patients who have had a successful experience to offer a testimonial, they might be happy to lend their name to your marketing efforts. (Be sure to have them sign a release indicating their willingness to be featured in marketing materials.)

As much as possible, feature patient photos rather than those of physicians. Better yet, include photos of the patient and physician together, reinforcing the personal relationship that matters sometimes as much as the procedure’s outcome itself.

The form these messages take can be tailored for the channels you leverage. Written testimonials can be used in traditional outlets such as local newspaper ads or in direct marketing tactics such as postcard mailers or emails that provide follow-up screening reminders or offer an incentive for referring a friend. Patient video testimonials can be used on your social media outlets or your website.

If you or a partner is comfortable in front of a crowd, offer a free physician lecture in your office or a local public facility such as a library, park district space or hospital education center.

Content that educates your patients rather than sells your services is a great way to build a relationship, and gives listeners a sense of ownership over their care.

Putting the consumer PAULA ROSENBERG FREY is Senior first in marketing is a Vice President, Marketing and Client Strategy, at GLC, a marketing commuwin-win for all involved. nications agency. She holds a BSN in Consumers have a better Nursing and an MS in Health Systems experience and relationship Management. Having worked at a healthwith you, your practice care system before GLC, she also has and the center. And if extensive physician practice marketing done well, you will experience. She can be reached at see improvements in pfrey@glcdelivers.com. your results.

17 endoeconomics WINTER 2019

insights

{Clinical updates}

Increasing ADR:

The bottom line The financial impact of efforts to increase adenoma detection rate during colonoscopy.

By Timothy M. Wallace and Michael B. Wallace, MD

18 endoeconomics WINTER 2019

Colonoscopy is the most effective method for prevention of colorectal cancer (CRC).1 More than 15 million colonoscopies are performed in the United States yearly.2 It is widely recognized that there is variable quality in colonoscopy as measured by the adenoma detection rate (ADR). High ADR strongly correlates with lower risks of CRC3, resulting in increasing pressure to optimize ADR. Multiple methods increase ADR including educational interventions, high-definition colonoscopies, and specific techniques such as double examination of the right colon, adequate bowel preparation, surface washing and inspection behind folds and flexures.4 Multiple devices, such as specialized caps5,6 have also been shown to increase ADR. Despite proven benefits, many of these measures have not been widely adopted.

A significant impediment to improving quality and ADR is the associated cost, which can include retraining, higher-resolution endoscopes, chromoendoscopy and specialized caps, all of which are not reimbursed.

The cost, however, may be indirectly offset by financial gains associated with improving ADR.

endocenters.com

One of the most studied techniques for increasing ADR is the use of chromoendoscopy, specifically the application of blue dyes, such as indigo carmine or methylene blue (MB).7 Despite its effectiveness in inflammatory bowel disease, chromoendoscopy has until recently not been widely shown to increase ADR. A new chromoendoscopy drug—currently under FDA review—has been developed in a controlled release tablet form, which is taken by mouth along with the bowel preparation. This agent, MB MMX (Aries Pharmaceuticals Inc.), is prescribed along with the bowel preparation.

A large randomized multicenter international clinical trial showed a significantly higher ADR (56.3 vs. 47.8) compared to the current standard of care. (Repici A et al, manuscript submitted.)

In addition to the established clinical benefit of increasing ADR, there are both economic costs and benefits to the practice to consider when choosing methods to increase ADR. Increasing ADR improves practice revenue by converting the procedure from a standard screening/ surveillance colonoscopy to a colonoscopy with polypectomy. It increases pathology revenue and the proportion of patients returning for surveillance examinations.

Less tangible benefits include improved reputation and

referrals, lower litigation risk for interval cancers and enhanced insurance contracting. These benefits are offset by the costs of the devices and agents, although there is variability in the amount and who bears these costs. For example, a single-use cap is an unreimbursed cost to the practice, whereas a prescribed drug (bowel prep) is a pharmaceutical cost to the patient and/or insurance provider.

Capital equipment is an amortized cost to the practice.

We used simulation modeling based on current Centers for Medicare & Medicaid Services reimbursements8 to determine the financial impact that an increased ADR would have on both hospital outpatient departments (HOPDs) and ASCs over a 10-year period.

Methods In our base case scenario, we assumed a 10 percent increase in ADR based on studies demonstrating similar impacts.9 We estimated the increase in the number of patients seen over a 10-year period comparing baseline ADR and an increase of 10 percent. These patients were then classified as high-risk (seen every three years) or intermediate-risk (seen every five years), depending on the number and type of polyps found during their procedure. We took into consideration whether the procedure

insights

{Clinical updates}

was a standard screening and if polypectomy was performed. We evaluated reimbursement for both HOPD and ASC for high-risk screens, low-risk screens, colonoscopies with polypectomy and the pathology interpretations of the polyps, as well as any physician payments. Costs for each disposable and capital equipment device were estimated from corporate and published websites.8,10-13 We estimated the potential impact that improving reputation would have on the number of colonoscopy referrals and the total reimbursements. These data were based on typical colonoscopy volumes and a conservative 1 and 2 percent increase in volume. Finally, we assessed how higher

ADR could potentially lower malpractice costs. We used published median gastrointestinal physician malpractice cost of approximately $100,000 per year.13 We conservatively assumed that an increased ADR could potentially lower malpractice costs by 1, 2 or 5 percent, and also compared a five-physician practice to a 10-physician practice.

Results Overall, we found that a 10 percent increase in ADR would yield a 12.68 percent increase in the number of colonoscopies that would return for adenoma surveillance.

In financial terms, this corresponds to a 16.95 percent

TABLE 2

Financial Impact of Increasing ADR by 10% on Volume and Revenue From Colonoscopy Baseline ADR

Increased ADR

N (# colonoscopies)

1,000

1,000

% ADR

0.32

0.32

3 or more ADR

0.05

0.09

# Returning Every 10 years

680

580

# Returning Every 5 years

270

330

# Returning Every 3 years

50

90

1,420

1,600

Hospital Outpatient Department (HOPD Reimbursement Amount Over 10 Years From Low-risk Screens ($)

$586,588.40

$500,325.40

HOPD Reimbursement Amount Over 10 Years From High-Risk Screens ($)

$362,006.40

$517,152.00

HOPD Reimbursement Amount Over 10 Years From Polyp Removals ($)

$366,736.00

$481,341.00

HOPD Reimbursement Amount Over 10 Years From Pathology Interpretations ($)

$276,022.40

$362,279.40

$1,591,353.20

$1,861,097.80

ASC Reimbursement Amount Over 10 Years From Low-risk Screens ($)

$378,243.20

$322,619.20

ASC Reimbursement Amount Over 10 Years From High-risk Screens ($)

$233,322.60

$333,318.00

ASC Reimbursement Amount Over 10 Years From Polyp Removals ($)

$237,747.20

$312,043.20

ASC Reimbursement Amount Over 10 Years From Pathology Interpretations ($)

$237,961.60

$312,324.60

$1,087,274.60

$1,280,305.00

Total Colonoscopies/10 years

TABLE 1

Estimated revenue from increasing reputation and referrals for colonoscopy associated with higher adenoma detection rate.

HOPD and ASC Total Reimbursements Over 10 Years w/ Reputation Increase Colonoscopy Volume

HOPD

ASC

No Change

$1,861,097.80

$1,280,305.00

1% Increase

$1,879,708.78

$1,293,108.05

2% Increase

$1,898,319.76

$1,305,911.10

Abbreviations: ASC, ambulatory surgery center; HOPD, hospital outpatient department.

20 endoeconomics WINTER 2019

Total HOPD Reimbursements From Colonoscopies Over 10 years ($)

Total ASC Reimbursements From Colonoscopies Over 10 years ($)

% Change

12.68%

16.95%

17.75%

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increase in revenue for HOPD procedures and a 17.75 percent increase in revenue for ASC colonoscopies. Per 1,000 colonoscopies, this increase corresponds to a gain in revenue of $193,031 to $260,744 (see “Financial Impact of Increasing ADR by 10% on Volume and Revenue From Colonoscopy”).

Although it is more difficult to estimate the value of reputation, a conservative assumption of a 1 to 2 percent increase in colonoscopy referrals due to high-quality reputation data resulted in similar increases in total reimbursements (visit endocenters.com/increasing-adr for the full chart).

Reductions in malpractice costs are also difficult to estimate. However, a conservative assumption of 1 to 5 percent would net a $25,000 to $50,000 reduction in expense for five- to 10-person practices.

We also assessed the cost of drugs, devices and educational improvements to increase ADR (visit endocenters. com/increasing-adr for the full chart). Currently, there are capital equipment (high-definition) endoscopes, which improve ADR; single-use devices such as specialized caps; and quality improvement education. Each of these items would be considered costs to the practice. Prescribed drugs, such as MB MMX, would increase ADR and represent a cost to the patient/insurer rather than the practice.

Discussion The primary goal of increasing ADR is to reduce CRC incidence and death, but in this study, we demonstrate the favorable financial impact of interventions to increase ADR. Methods currently used to increase ADR include disposable devices, such as Endocuff (Arc Medical Corp.).

These devices cost approximately $25–30 each. Capital equipment such as high-definition colonoscopes can also help increase ADR.14 One of the benefits to practices of using prescribed drugs to increase ADR is the cost falls on the patient or insurance companies rather than the practice. This study suggests undertaking measures to increase ADR provides mutual and aligned benefits to both the patient and the practice.

A limitation of our study is that it is primarily applicable to a fee-for-service model. In the United States and in non-single-payer health systems, increased procedures improve revenue, whereas in closed settings increased procedures actually increase costs. While the clinical benefits of improving ADR should outweigh other incentives, alignment of benefits to patients and financial benefits to practices can provide complementary incentives to improve quality of colonoscopy services. Overall, results suggest that the financial costs of increasing ADR using commonly available tools are offset by equal or greater financial gains, thus removing the financial disincentives to improving quality.

REFERENCES auber AG, Winawer SJ, O’Brien MJ, Lansdorp-Vogelaar I, van Ballegooijen M, Z Hankey BF, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012;366(8): 687-96.

2 Seeff LC, Richards TB, Shapiro JA, Nadel MR, Manninen DL, Given LS, et al. How many endoscopies are performed for colorectal cancer screening? Results from CDC’s survey of endoscopic capacity. Gastroenterology. 2004;127(6): 1670-7.

3 Corley DA, Levin TR, Doubeni CA. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370(26): 2541.

4 Wallace MB, Crook JE, Thomas CS, Staggs E, Parker L, Rex DK. Effect of an endoscopic quality improvement program on adenoma detection rates: A multicenter cluster-randomized controlled trial in a clinical practice setting (EQUIP-3).

Gastrointest Endosc. 2016.

5 van Doorn S, van der Vlugt M, Depla A, Wientjes C, Mallant-Hent R, Siersema P, et al. Adenoma detection with Endocuff colonoscopy versus conventional colonoscopy: a multicentre randomised controlled trial. Gut. 2017;66(3): 438-45.

6 Dik VK, Gralnek IM, Segol O, Suissa A, Belderbos TD, Moons LM, et al. Multicenter, randomized, tandem evaluation of EndoRings colonoscopy—results of the CLEVER study. Endoscopy. 2015;47(12): 1151-8.

7 Omata F, Ohde S, Deshpande GA, Kobayashi D, Masuda K, Fukui T. Imageenhanced, chromo, and cap-assisted colonoscopy for improving adenoma/neoplasia detection rate: a systematic review and meta-analysis. Scand J Gastroenterol.

2014;49(2): 222-37.

8 Centers for Medicare & Medicaid Services. License for Use of Current Procedural Terminology, Fourth Edition (“CPT®”). 2017.

9 Coe SG, Crook JE, Diehl NN, Wallace MB. An endoscopic quality improvement program improves detection of colorectal adenomas. Am J Gastroenterol.

2013;108(2): 219-26; quiz 27.

10 Colorado Secretary of State. Department of Labor and Employment. Division of Workers’ Compensation. Workers’ compensation rules of procedure with treatment guidelines. 2011.

11 ASGE Technology Committee, Konda V, Chauhan SS, Abu Dayyeh BK, Hwang JH, Komanduri S, et al. Endoscopes and devices to improve colon polyp detection.

Gastrointest Endosc. 2015;81(5): 1122-9.

12 ASGE Technology Committee, Manfredi MA, Abu Dayyeh BK, Bhat YM, Chauhan SS, Gottlieb KT, et al. Electronic chromoendoscopy. Gastrointest Endosc.

2015;81(2): 249-61.

13 Jena AB, Seabury S, Lakdawalla D, Chandra A. Malpractice risk according to physician specialty. N Engl J Med. 2011;365(7): 629-36.

14 Buchner AM, Shahid MW, Heckman MG, McNeil RB, Cleveland P, Gill KR, et al. High-definition colonoscopy detects colorectal polyps at a higher rate than standard white-light colonoscopy. Clin Gastroenterol Hepatol.

2010;8(4): 364-70.

1

MICHAEL B. WALLACE, MD, MPH, is a Professor of Medicine and Director of Digestive Disease Research at Mayo Clinic in Jacksonville, Florida. He is the current Editor in Chief of Gastrointestinal Endoscopy and President of the Florida Gastroenterologic Society.

Disclosure: Michael B. Wallace, MD, has previously received consulting income and research support from Cosmo Pharmaceuticals, and research support from Olympus Corp, Fujifilm Corp, Boston Scientific and Medtronic. He is a consultant to Lumendi, Virgo and GI Supply.

TIMOTHY M. WALLACE has a BA in finance/business from Florida State University.

21 endoeconomics WINTER 2019

insights

{Human resources and personnel issues}

Rest for the weary Understanding the importance of fatigue risk management.

By Erin Lawler It would be reasonable, if not expected, for a passenger to feel reluctant about boarding a plane with a flight crew that had just completed a long flight, is fatigued after having worked a very long shift or is sleep-deprived from moonlighting flying for another airline prior to this departure. Yet, similar conditions are all too common within the healthcare environment and patients are often unaware that the provider making a diagnosis, administering medications or performing a procedure may be sleep-deprived or fatigued.

Different factors can impact fatigue, including time of day and relationship to circadian rhythms of wakefulness (times of wakefulness vulnerability include 2–6 a.m., 2–5 p.m. and 12–2 a.m.); time awake and amount of sleep one has had (the longer one is awake and/or the more reduced quality of sleep one has, the greater risk for fatigue) and time on task (longer periods on task, particularly monotonous tasks, can increase risk of fatigue).1 Particularly vulnerable to fatigue are healthcare workers who rotate shift

22 endoeconomics WINTER 2019

work, which can interfere with circadian rhythms; fill shifts that are primarily made up of rote tasks or those that require high vigilance; and work extended shift schedules that interfere with how much uninterrupted sleep they are able to acquire.2,3,4 Fatigue resulting from an inadequate amount of sleep or insufficient quality of sleep has cognitive, psychomotor and behavioral impact. Noted impairments include reduced situational awareness, vigilance, attention, concentration, problem solving and judgment; slower information processing and reaction time; reduced coordination and motor skills; increased irritability, lack of empathy and motivation; and impaired communication.2,3,5,6 Impairment from fatigue can, in turn, increase healthcare worker risks (e.g., increased occupational injuries such as needlesticks) and patient safety risks (e.g., medication errors).

Data from voluntarily reported sentinel events to The Joint Commission’s Office of Quality and Patient Safety between 2013 and August 2018 reveal that

51 sentinel events were reported in which healthcare worker fatigue has been cited as a contributing factor, including wrongsite surgeries, unintended retention of foreign objects, medication errors and delays in treatment.

The dangers of fatigue and sleep deprivation are well documented, and yet healthcare lags in adopting fatigue-reducing and fatigue-protecting strategies. Barriers to this are both institutional and individual-based, including staff shortages that require longer shifts, a normalized culture of “fatigue is part of practice,” a lack of understanding or appreciation of the risks of fatigue, limited awareness to one’s own vulnerability to fatigue, lack of health-promoting activities and self-care, and concern for maintaining continuity of care.

Don’t Sleep on Safety Fatigue risk management is a dual responsibility of not only the organization but the individual healthcare worker. To promote safety for the healthcare worker and, ultimately, the patient, organizations should implement fatigue risk-management systems

that target cognitive, physical and social components of fatigue.

Using human factors science and sociotechnical models as a framework may help ensure countermeasures are holistic and systems-based, incorporating strategies focused on the people, work processes, tools and technology, environment and organizational levels and interactions among them.

Example countermeasures to help reduce fatigue and protect against fatigued healthcare workers include:4,5,7,8,9,10,11,12 > Promoting professional accountability around self-care, sleep hygiene and fatigue reduction > Training staff on self-care and sleep hygiene as well as recognizing warning signs and effects of fatigue/sleep deprivation > Implementing an anonymous reporting system and empowering staff to report near-misses and incidents > Implementing policies supportive of sleep hygiene (including environments for restorative breaks and naps) and safe-staffing strategies

endocenters.com

that limit how long one can work > Supporting team training and tools for increasing shared situational awareness, task monitoring, active communication and mutual support > Endorsing a safe climate to speak up about personal factors—such as feeling fatigued—without retribution and developing a contingency plan should a worker need to be replaced > Endorsing robust handoff practices to account for continuity of care > Including technologies, environments and work processes that are error-tolerant, allowing an error to be caught prior to harming a patient or worker The dangers of fatigue persist in healthcare and reach beyond cognitive and physical effects to include social construct, attitude and culture consequences.

Healthcare organizations should continue pursuing strategies that promote safe working conditions and processes associated with fatigue to reduce potential risks to workers, patients and the overall healthcare system.

ahrq.gov/primers/primer/37/fatiguesleep-deprivation-and-patient-safety 3 Caruso, C. (2014). Negative impacts of shiftwork and long work hours.

Rehabil Nurs. 2014 ; 39(1): 16–25.

4 The Joint Commission (2012).

Improving patient and worker safety: Opportunities for Synergy, Collaboration and Innovation. From improving patient and worker safety long document. Oakbrook Terrace, IL. 5 The Joint Commission (2011). Health care worker fatigue and patient safety.

Sentinel Event Alert Issue 48. December 2011. Addendum May 2018.

6 Antill, S. (2016). Shift work’s impact on patient safety. ONS Connect. May 31(5):38-9.

7 Rogers, A.E., Hwang, W.T., Scott, L.D., Aiken, L.H., & Dinges, D.F. (2004). The working hours of hospital staff nurses and patient safety. Health Affairs, 2004; 23(4):202-212.

8 Scott, L.D., Rogers, A.E., Hwang, W.T., & Zhang, Y. (2006). Effects of critical care nurses’ work hours on vigilance and patients’ safety. Am J Crit Care.

Jan;15(1):30-7.

9 American Association of Nurse Anesthetists. (2015). Patient safety: Fatigue, sleep, and work schedule effects. Park Ridge, IL. 10 American College of Obstetricians and Gynecologists. (2018). Fatigue and patient safety. ACOG Committee Opinion No. 730. Obstet Gynecol 2018;131:e78–81.

11 Smith-Miller, C. A., Shaw-Kokot, J., Curro, B., & Jones, C.B. (2014). An integrative review: Fatigue among nurses in acute care settings. JONA (44:9): 487-494.

12 Samra, H.A., & Smith, B.A. (2015).

The Effect of Staff Nurses’ Shift Length and Fatigue on Patient Safety and Nurses’ Health. Adv Neonatal Care. Oct;15(5):311.

ERIN LAWLER is the Human Factors Engineer in The Joint Commission’s Office of Quality and Patient Safety in the Division of Healthcare Improvement.

She provides knowledge and expertise in human factors and ergonomics related to healthcare.

REFERENCES National Institute for Occupational Safety and Health. NIOSH training for nurses on shift work and long work hours, WB2408 and PART 2 WB2409.

(2017). Retrieved from https://www. cdc.gov/niosh/work-hour-trainingfor-nurses/.

2 Agency for Healthcare Research and Quality. (2018). Patient Safety Primer: Fatigue, Sleep Deprivation, and Patient Safety. Retrieved from https://psnet.

1

23 endoeconomics WINTER 2019

endo opportunities

West Mesa, AZ Central Arizona Medical Associates Seeking a full-time gastroenterologist. Physician can expect to step into a busy practice while replacing a retiring partner. Anticipate a short track to practice partnership and ASC ownership. Practice operates out of a single office and covers one hospital. Outpatient endoscopy performed at a physician-owned, two-room ASC. Enjoy sunshine and a great lifestyle in the metro Phoenix area.

Scottsdale, AZ Digestive Health Specialists Arizona Full-time gastroenterologist with partnership potential needed for small practice of four MDs, NP and PA. Outpatient-based with low inpatient volume and only one hospital round. No ERCP or EUS training needed. Physician office includes an infusion center, pathology lab and state-of-the-art endoscopy center, all within the same building.

Bellingham, WA NW Gastroenterology & Endoscopy Physician needed to join a nine-person single-specialty practice.

Freestanding AEC and pathology lab, EUS optional, ERCP optional.

Outstanding benefits package offered. Progressive coastal community offers ocean and lake recreation, skiing, and miles of hiking and biking trails. Small college town atmosphere with proximity to Seattle and Vancouver, Canada, and a great place to raise a family.

Northern & Central, CA SecureMD Board-certified gastroenterologists needed for mobile endoscopy practice in Northern CA (Sacramento/Stockton/Tracy) and Central CA (Fresno/Tulare/San Luis Obispo). Flexible schedules allow you to work as many as 2–3 days per week or as few as 1–2 days per month.

24 endoeconomics WINTER 2019

Midwest Bloomington-Normal, IL Digestive Disease Consultants Reputed single-specialty practice for more than 30 years seeks physician. Multiple revenue sources including endoscopy center, strong support from local hospital and guaranteed salary for two years. Low turnover and high retention rate.

Rochester, MI Troy Gastroenterology Two gastroenterologists skilled in general endoscopy and ERCP needed for private practice with two state-of-the-art, AAAHCaccredited ASCs. Competitive base salary with productivity incentive, retirement plan, discretionary allowance, insurance and eligibility for member status after two years.

South Gastonia, NC Carolina Digestive Diseases Seeking a BE/BC gastroenterologist to expand coverage in community of Gastonia, NC. Physician can expect to step into a busy practice while replacing a retiring partner. Anticipate a short track to practice partnership and ASC ownership. Practice operates out of a single office and covers one hospital. Outpatient endoscopy is performed at a two-room ASC.

Submit your CV online at endocenters.com/recruiting/ Northeast New York, NY Gastroenterology on Gramercy Park Seeking a gastroenterologist to join two-physician private group.

Expect to step into a busy practice while replacing a retiring partner. Opportunity offers a primarily outpatient experience with a reasonable call burden. Candidate will have ownership opportunity in affiliated endoscopic ambulatory surgery center.

North Bergen, NJ Advanced Center for Endoscopy GI physician needed to join a single-specialty, nine-physician GI center. The center can help the physician drive patient volume through the ASC, allowing the physician to increase procedure volume in the environment that is more convenient. Ideally located in North Bergen, the “gold coast” of Northern New Jersey, with a spectacular view of the NYC skyline.

Lumberton, NJ Gastroenterology Consultants of South Jersey Seeking full- or part-time gastroenterologist to join a privately owned, seven-physician practice. Well-established practice of 25 years, located among several growing communities in Southern New Jersey. We offer a 1:7 call schedule and an opportunity to perform ERCP/EUS (not required). Affiliated with Burlington County Endoscopy Center, a three-room ASC that is physician-owned and operated.

Central, NJ Garden State Digestive Disease Specialists, LLC Seeking full-time BC/BE gastroenterologist to join threephysician practice. The job offers an excellent salary, competitive benefits package, reasonable call schedule (which includes other gastroenterology colleagues in the rotation) and an opportunity for full partnership track in 2–3 years. EUS/ERCP training preferred.

Jenkintown, PA Gastrointestinal Associates, Inc. Seventeen-physician practice is seeking a board-certified gastroenterologist preferably with an investment in IBD or advanced therapeutic training. Full-time position with shared clinical and administrative responsibilities. The job offers a competitive salary and benefits that include bonus potential and partnership track.

Limerick, PA Endoscopy Associates of Valley Forge Board Certified. US Gastroenterology Fellowship. ERCP or EUS trained preferred. Full time, rotating call dispersed evenly with three other physicians. One hospital with endo suite, hospital is within 15 minutes driving distance of center. GI center has three procedure rooms. GI practice is in the same building as the GI center. Located one hour outside of Philadelphia.

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PRSRT STD US POSTAGE

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2500 York Road, Suite 300 Jamison, PA 18929

PERMIT NO 29 MADISON WI

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