A Journal Dedicated to Economic Issues Impacting GI ASCs and Practices
Physician Practice Consolidation Trends Page 5
Accreditation Survey Secrets Page 15
DHPA Gives Voice to GI Practices Page 20
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FALL/WINTER 2017 ISSUE
EndoEconomics by Physicians Endoscopy
Editorial Staff Carol Stopa Editor in Chief firstname.lastname@example.org
Lori Trzcinski Managing Editor email@example.com EndoEconomics™, a free quarterly publication, is published by Physicians Endoscopy, 2500 York Road, Suite 300, Jamison, PA 18929. 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. Periodical postage paid at Merrill, WI. 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. Advertisers assume liability and responsibility for all content (including text, illustrations, and representations) of their advertisements published. Printed in the U.S.A. Copyright © 2017 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 the Physicians Endoscopy. Reproduction in whole or in part of the contents without expressed permission is prohibitied. To request reprints or the rights to reprintsuch as copying for general distribution, advertising, promotional purposes--should be submitted in writing by mail or sent via email to firstname.lastname@example.org.
Content 4 Message from the President 5 Gastroenterology Practice Consolidation: Q&A with Drs. James Weber and Michael Weinstein 8 Saving Lives Through Genetic Testing: Carnegie Hill’s Lynch Syndrome Program 11 A Newcomer’s Perspective: Q&A with PE’s New Chief Strategy Officer 13 The New Landscape for ASCs Seeking to Provide Free or Discounted Patient Transportation 15 Accreditation Surveys: Secrets for Your Big Win 18 Owning Anesthesia Makes Sense and Cents 20 DHPA Gives Voice to Independent Gastroenterology Practices 22 Independent Physicians Successfully Lead Effort to Modernize NJ Self-Referral Laws 23 Physician Recruitment: Finding Success in an Ultra-Competitive Environment 25 10 Free Marketing Tools for Any Size Team 27 A New Era of Transparency: Prepare for the Inevitable 29 One Cannot Serve from an Empty Vessel: The Importance of Self-Care for Practicing Physicians
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31 Front & Center 33 Current GI Opportunities FAL L /WI NTE R 2 0 1 7 EndoEconomics
the President This issue focuses on the recent but ongoing resurgence of physician practice management (PPM). Following the 1990s when notable firms such as Phycor and MedBARRY TANNER Partners crashed President and CEO, and burned, little Physicians Endoscopy was heard of PPMs. While the industry never disappeared, Sheridan, TeamHealth, Mednax, NAPA, Envision, and several others continued on a steady course of growth, demonstrating substantive benefits to those physicians who joined the movement. Until recently, a majority of the PPMs seemed to be related to specialties that are mostly hospital-based including emergency medicine, anesthesia, and radiology. Now PPM sponsors have expanded their focus to dental, dermatology, pain management, ENT, and even gastroenterology. The trend makes sense. There are many costs and limitations of running a small independent practice. Physicians, faced with the challenges of remaining independent, are confronted with real questions – Can I continue to successfully run my small practice in a manner that I am accustomed? What are my alternatives? Two general thought trends are very much in play. First, small GI practices lack the needed financial resources and diverse expertise (e.g., IT, reimbursement, data management, etc.) that will play a vital role as we move closer to value-based care and reimbursement and more broadly to population health management. Second, more millennial generation physicians coming out of GI fellowship are less enamored with the rigors of managing an independent practice. These two trends, coupled with a graying population of GI physicians, are paving the way for either practice consolidation or hospital employment as alternatives. Now let’s turn to what is happening today. First, GI practice aggregation is taking place. Physicians are talking about and taking pro-
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active steps to explore practice consolidation. While there are some notable success stories I can point to (TDDC, Capital Digestive, IGG to name a few), there are only a small number of such stories relative to all GI practices. Consolidation is necessary for larger markets, and the advantages of practice aggregation, in light of today’s healthcare environment, outweigh the disadvantages. Practice aggregation is not easy. Most physicians I have had the pleasure of knowing for many years are fiercely independent and selfstarters, attributes worth preserving for the future of healthcare. Aggregation also requires sacrifice of some autonomy and a healthy measure of compromise, leadership, co-dependency, and a willingness to conform to standardized administrative functions (EHR, contracting, collections, HR, and patient outreach) for the good of the practice. The successful groups I mentioned have all demonstrated these characteristics. It wasn’t easy and probably quite painful at times. They share a common theme; each grew organically without any third-party help. While consultants, legal, and financial advisors were undoubtedly involved, they did not seek substantial outside capital investment. These practices became successful over a period of many years, and each physician in some way provided the growth capital through some form of personal sacrifice. Today, many GI practices are seeking to follow this model and catch-up to their colleagues. Enter private equity. As mentioned earlier, private equity firms have realized tremendous success in providing the rocket fuel (e.g., capital), the diverse business expertise, and the mentoring necessary for successful aggregation in other specialties. Several of these firms see gastroenterology as a specialty ripe for consolidation, and you may already have received solicitation from one of these firms to explore potential transactions. I am often asked – Do I need to engage with private equity to successfully consolidate practices in my region? The answer is no. Physicians are wholly capable of merging on their
own and maintaining maximum control over every aspect of their practice and support infrastructure that is vital to long-term success. Private equity, however, can be a viable alternative. Engaging with the right firm can provide the accelerant capital necessary for achieving more rapid growth and success. It also can provide for one or more satisfying liquidity events, in particular for those who took the risk to become founding partners. On the flip side, these firms have a limited life. They raise capital from investors, and it’s their job to deliver returns on invested capital within a five- to seven-year period. Physicians Endoscopy, publisher of this journal, is private equity backed. We are extraordinarily proud of the successes we’ve achieved over 20 years with the advantage of five different private equity partners. Due to the tremendous support from our current partner, Kelso, I am pleased to announce Physicians Endoscopy has formed a new division called PE Gastro Management. PE Gastro will endeavor to facilitate practice consolidation and provide the full spectrum of administrative management services necessary for the on-going success of any large modern GI practice. At PE, we have successfully and proudly provided services to our partnered ASCs for many years. Recently, we expanded our service offerings to partnered ASCs to include practice management, and we have been extremely pleased with the results. We are now taking it to the next step by facilitating GI practice consolidation in much the same way as any practice might experience if they chose to work directly with a private equity firm. But, there is one major difference – PE is and has been a dedicated partner to the GI specialty for nearly 20 years. We can function as a private equity partner because we have a strong private equity partner; however, PE does not have a limited life, and we intend to remain dedicated to helping GI physicians remain strong, independent, and successful over the long-term. Our private equity partner will inevitably change, but PE will continue to be the stable, growing and consistent vehicle who supports the GI specialty and watches over the interests of our partnered physicians. Please enjoy this edition of EndoEconomics.
Gastroenterology Practice Consolidation: Q&A with Drs. James Weber and Michael Weinstein
By Scott Fraser, President, PE Gastro
As president of PE Gastro, a new division of Physicians Endoscopy, I have the opportunity to work with a team of healthcare management professionals focused on the administrative side of private practice gastroenterology. My 20-plus years in the GI space has provided a unique opportunity to partner with many leading gastroenterologists and witness firsthand about what has made their respective groups thrive in this ever-changing healthcare environment. Although there are many top private gastroenterology groups around the country, two physicians who stand out for their leadership and vision for the future of gastroenterology are Drs. James Weber and Michael Weinstein. Dr. Weber is the president and chief executive officer of Texas Digestive Disease Consultants (TDDC). He formed TDDC in 1995 by bringing together a dozen doctors from several different groups in the Dallas area. Over the next 15 years, the super group grew close to 40 doctors. It was in 2010 when
TDDC began to pursue a Te x a s - w i d e expansion initiative. SCOTT FRASER TDDC is now comprised of over 120 physicians, making it the largest gastroenterology group in the country. Dr. Weinstein is president and chief executive officer of Capital Digestive Care. From 1985 to 2005, he helped grow a single gastroenterology group based in the Washington, D.C., metropolitan area to about 15 physicians. In 2006, Dr. Weinstein witnessed increased consolidation in healthcare and other industries and began meeting with other large groups in the region to explore partnerships. In early 2009, he helped lead the merger of seven practices into a single group — Capital Digestive Care — with nearly 50 physicians. Since then, the super group has grown to around 60 physicians, with about 15 non-
JAMES WEBER, MD
MICHAEL WEINSTEIN, MD
physician providers. Capital Digestive Care is now the largest private practice gastroenterology group in the MidAtlantic and Northeastern states. Drs. Weber and Weinstein share their thoughts in response to four questions on consolidation. Answers have been edited for length and clarity. Q: What do you see as the primary factors driving consolidation in gastroenterology groups? Jim Weber (JW): It’s a response to the changing healthcare environment. There have been many changes that can make it difficult for a small group to survive. One of the most significant challenges is the increase in consolidation throughout healthcare. Not only are other groups consolidating, but
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hospitals, accountable care organizations (ACOs) and payers are also merging. When payers consolidate, they often have less interest in pursuing contracts with smaller practices and tend to focus heavily on larger group providers.
is the bundling of care. Groups need to coordinate physicians, facilities, pathology, anesthesia, infusions — all of the components needed to manage risk, which can only be performed well in larger groups at scale.
Other factors include practices of all sizes increasingly finding themselves the target of acquisition efforts. Physicians coming out of training are looking at a vastly different landscape than I did in 1992 when I started my own practice. Today’s younger physicians are more interested in being employed than ever before, as recent data from AMA’s “Physician Practice Benchmark Survey” highlighted1.
Finally, there’s the capital needed to build a central infrastructure. Raising significant amounts of money is very challenging for small groups.
There are also increased regulatory requirements, such as the need for electronic medical records and data reporting. Come up short in these areas, and you may face penalties. Small practices are often finding themselves struggling to meet these requirements. It becomes almost imperative that smaller practices do something in order to compete. Michael Weinstein (MW): What drove our consolidation was the desire for a central infrastructure, the pursuit of ancillary services, and the benefit of negotiating payer contracts as a larger entity. This was true a decade ago and even more so today. In addition, information technology (IT) systems have become more important in driving consolidation because the cost of IT is likely out of reach for anyone but a big group. A really good IT solution is expensive, and a bad IT solution is even more costly. A newer factor is the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). We’re looking at a valuebased payment system in the future. That necessitates the ability to measure outcomes and comfortably take risks, which can be difficult for small groups. Part of the value-based payment system 1
Q: What challenges should physicians expect when forming a consolidated group? MW: Culture, culture, culture. Merging different cultures is rarely easy. The organization of some small groups, where you have senior partners, lesser associate partners and older partners, can cause problems because of the financial relationships between physicians. Physicians are often loyal to older staff, some of whom may not be particularly effective anymore. How do you get rid of legacy staff? Then there’s the question of what you do with extra space. If you want to merge, you would like to do away with space that will no longer be necessary with a central infrastructure. There’s the saying, “Everyone loves progress but nobody likes change.” Everyone loves the idea of more efficiency, better contracts, and new ancillary revenue — as long as they don’t have to change what they’re doing. To achieve benefits, there must be change. JW: I speak with a lot of practices about how to build a super group. What is always fascinating is they think I did this overnight. They ask for a magic formula, but I’ve been working at it for 25 years. The challenges typically center around the history of these groups. Some have
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been competing with each other for years. There are often substantial differences in how they practice, view each other, the EMR systems in use, preferred vendors, insurance providers, different hospital affiliations, different personalities — the list goes on. Doctors’ egos can get in the way, but what I have found is doctors typically buy into the idea of consolidation quickly. They know they will still see patients the way they want to. It’s management who is more likely to push back. You might have a manager who looks at his group as his baby and is suddenly faced with being told what to do and how to do it. When managers feel threatened, they often try to dissuade their doctors. Another big challenge is money. How will it be split? Is the larger group really going to make more money or will it cost more money? Creating a super group requires a lot of time, energy, and dedicated leadership. If you’re not fully committed to the idea, I recommend you find someone who is to lead this effort for your group.
Q: What are the immediate, midrange, and long-term benefits of consolidating into a super group? JW: You immediately become bigger and usually feel stronger and safer. You might finally feel confident that the hospital can’t take you over or the insurance company once ignoring you will actually speak to you about a contract. You may also experience a sense of relief that the group you were once fighting for consults, referrals, or patients is no longer competition. You may sense immediate satisfaction that you have a voice at the table.
The mid-range benefits come from using the larger size and strength to your advantage. You can now negotiate on behalf of all of the physicians for the best contracts possible. You usually have better visibility and coverage, so people are more likely to know about you. That may lead to more opportunities, not only with payers but patients, pharmaceutical companies, and other businesses. In terms of long-range benefits, you can start building efficiencies, standardize processes, work on protocols, and create care pathways. You may choose to bring more expertise inhouse, such as human resources or hiring a chief financial officer. You can also start to think outside of the box. What about alternative payment mechanisms? Could you bundle something or take on patient populations? Could you start taking the steps you will need to survive when fee-forservice is no longer a viable option? You can look at becoming vertically and horizontally integrated, and determine how to best serve your communities. You can build ancillaries, internal structures, and ultimately a robust business. MW: Almost immediately, you can save money on overhead costs by merging up administrative functions, particularly billing and collections. You can become really efficient with such functions because you can choose to keep your best staff and have them become experts in specific segments of the process. You can also achieve immediate savings in areas such as office staffing, malpractice rates, and health insurance. A little down the road, you can pursue negotiating better payor contracts. That’s also a good time to explore building potential ancillary revenues. These are patient benefit services that will generate revenue for the group
while lowering the cost of care. Examples include ambulatory surgery centers, pathology laboratories, infusion centers, and anesthesia services. You typically need size to make those ancillary services work. Moving along, it will become easier to attract employees and new associates. A bigger organization can offer better benefits. Physician associates typically rank larger groups higher, which will make it easier to recruit. In terms of IT, there is an immediate benefit in using a shared practice management system that the merged group will need from the get go. There is the question of when to decide on the super group’s electronic medical records (EMR) system. We did not try to tackle a uniform EMR on day one. Physicians have a great deal of attachment to the systems they are using. It’s a huge benefit to get on a uniform system, but it may take a year or more to identify one that makes everyone happy.
ernment and healthcare are changing, it’s becoming much more challenging and expensive to run a small practice. I think it has become very compelling for groups to consolidate. Maybe in a small town, a group of one becomes a group of two and that’s the consolidation. In a city like Dallas, you better be in a group of 50 if you want a seat at the table. MW: There are only a few, large metropolitan areas where we have not seen significant consolidation. New York stands out. It’s an incredibly fragmented gastroenterology market. You see that to some extent in Philadelphia. In almost every other metropolitan area, we have seen substantial physician mergers. I think we will continue to see consolidation as well as continued increases in physician employment. Whoever does not consolidate will end up employed. I anticipate within ten years it will be uncommon to find gastroenterology groups of less than five.
In the longer term, you’re looking at further centralized changes. You essentially take away functions from the offices and centralize them, such as a call center, human resources, employee training, and employee hiring.
Q: In the coming years, do you anticipate seeing an increase in consolidation? JW: I can’t see how there won’t be more in the future. We see consolidation in everything. I often liken it to when our country was young, and everyone had their own shop or farm. Now we have Walmart and huge consolidated farming industries. It’s difficult to open a five-and-dime store or small farm and survive on that income anymore. That’s looking like the case for healthcare. We were just one of the industries to move later in that direction. With the way the govFAL L /WI NTE R 2 0 1 7 EndoEconomics
Saving Lives Through Genetic Testing:
Carnegie Hill Endoscopy’s Lynch Syndrome Program
By Rob Kurtz
Gastroenterologist Blair Lewis, MD, saw an opportunity to make a difference in his patients’ lives. Several years ago, he realized that many patients had genetic syndromes that were going unrecognized and undiagnosed, both unnecessarily. Such syndromes include Lynch syndrome. Also called hereditary nonpolyposis colorectal cancer, Lynch syndrome is an inherited disorder that increases the risk of many types of cancer, particularly cancers of the colon and rectum. “In the ‘old’ days, if patients believed they had a family history of cancer or something unusual was found on pathology, they would receive a referral to a geneticist,” says Dr. Lewis. “Patients would be expected to go for a consult, provide a detailed family history, and then undergo genetic testing. Most patients would not follow through due to the complexity of the experience and a desire to avoid another doctor’s visit.” But genetic testing has come a long way, he says. “It has become simply a blood draw. Most insurance companies will provide coverage with the right documentation.” Dr. Lewis decided to try to incorporate genetic testing into his New York practice, but quickly learned that his effort was coming up short.
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“A geneticist provided by a molecular diagnostic company came into my office and spent a day with me while I was doing consultations,” he says. “I learned that the way I was taking family history to identify people at risk for genetic cancers was not correct. I was not asking the right questions or looking at the family history correctly. I was educated quite a bit that day.”
BLAIR LEWIS, MD
As Dr. Lewis became efficient at identifying people with a greater risk for genetic cancers, he became determined to help more people. The means to do so was right under his feet.
Executing a Vision Dr. Lewis is the founder of Carnegie Hill Endoscopy (CHE), a 15,000-square-foot endoscopy center in Manhattan, N.Y. CHE, an affiliate of Physicians Endoscopy (PE) and Mount Sinai Medical Center, has more than 20 doctors performing about 15,000 endoscopic procedures annually. “It seemed only logical, with the development of genetic testing and greater movement into the world of genetic
medicine, that we implement genetic testing into our endoscopy suite,” Dr. Lewis says. “If we were going to be in charge of trying to prevent people from getting colon cancer, we felt this had to be part of our armamentarium.”
“This company has been kind enough to essentially provide geneticists ‘on call’ who we can reach out to when we have questions,” he says. “And we have had questions. After all, we are not trained in genetics.”
“We are in the business of trying to prevent colon cancer,” Dr. Lewis says. “This is a way to obtain and provide very worthwhile information to our patients that will also help us provide high-quality care.”
CHE’s physicians envisioned the process as follows: When patients came to CHE for their screening exam, a nurse would take their family histories and determine whether or not they were at risk for genetic cancers. With patient approval, the nurse would perform the blood draw at the same time when IVs were placed prior to procedures.
Fruits of Labor
Ms. Chaisson adds, “PE is proud of CHE’s commitment to advancing patient care. It was impressive to see how they embraced the importance of the program and do what was necessary to implement it effectively.”
This may sound easy in concept, but Dr. Lewis acknowledges that turning CHE’s vision into a viable program took a great deal of work. “There are a bunch of steps that needed to be done. We needed to develop the criteria that would determine who should receive the test. We had to teach our nurses how to explain the process and its purpose to patients, take the family history, what criteria to look for, and how to obtain patient consent.”
“We will now monitor these four patients much more closely because they are at such a high-risk of developing colorectal cancer,” Dr. Lewis says. “We will have them come back for screenings on a two-year interval. Thanks to the test, we can provide more aggressive monitoring and have identified some of them as being at higher risk for other cancers (e.g., ovarian, breast, pancreatic) for which they should receive screening.”
There was also the matter of what to do if a blood test comes back positive. “If the blood test comes back showing the patient has Lynch syndrome, you know exactly what to do based on national guidelines,” Dr. Lewis says. “There is the possibility that the test comes back with results showing a gene with ‘unknown significance’ or a slightly increased risk of cancer that is not necessarily associated with full Lynch syndrome. Now the doctor must determine how to guide the patient.”
Teresa Chaisson, PE’s director of clinical support, says the test provides significant, far-reaching benefits. “This is not only education and empowerment for the patient, but it has a cascade effect for family members and generations to come. Once you have the Lynch syndrome diagnosis out there, as scary as that might be, then you have options. To not have the information is even scarier.”
These unknowns are why genetic support is critical, he says. The same molecular diagnostic company that provided the geneticist to Dr. Lewis supported his efforts to build the CHE program.
After a great deal of planning and preparation, CHE launched its program at the end of April 2017. Over the next several weeks, 111 patients met the criteria for genetic testing and agreed to participate. Out of those patients, four came back testing positive for Lynch syndrome.
For patients who met the criteria but were found not have the gene, they receive some reassurance. While they may not be at normal risk of developing colon cancer, they are not at a very high risk. Since these patients receive the test because of a family history of colon cancer, they remain at a five-year screening interval.
Embracing to Model Dr. Lewis believes CHE is the first endoscopy center to apply genetic testing on a system-wide basis. He understands why physicians may hesitate to add this service to their practice or center. “We are typically curmudgeonly people,” he says. “Many of us don’t embrace change well, especially when that change involves something unfamiliar.” Another barrier he foresees for physicians is time. “Everyone is busy doing cases. This does take time because you will need to explain the testing to patients and get a consent signed. Some of the process staff can do, some of it physicians will need to do, including discussing results with patients and any next steps. There is also the time it will take to learn about the genes, risks, and guidelines, and some of which is evolving.” In watching CHE build the program, Ms. Chaisson says a full commitment is necessary for success. “This is not a light project to take on. It needs to be carefully managed, and that is something CHE is doing really well. Once you learn a positive result, it is a gamechanging experience for a patient. The commitment to following through should not be taken lightheartedly.”
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Despite the challenges, Dr. Lewis says the time it took for CHE to establish and now run the program was well worth it. “The program has gone better than we anticipated. It has become a part of our process. We expect the program to continue to grow. I hope other endoscopy centers embrace this concept and it eventually becomes a standard of care.”
Blair S. Lewis, MD, FACP, FACG, FASGE, is a board-certified gastroenterologist in private practice in New York City. He is a clinical professor of medicine at the Mount Sinai School of Medicine and one of the medical directors of Carnegie Hill Endoscopy, an ambulatory endoscopy center he founded.
AliveAndKickn: Raising Awareness of Lynch Syndrome David Dubin loves soccer, or the “beautiful game” as he calls it. While long a fan of the sport, its role in his life became more significant in his late 20s. That’s when, in 1997, he was diagnosed with colon cancer. Ten years later, he was diagnosed with a secondary colon cancer and kidney cancer. “Soccer was a therapeutic component of my life as I was going through numerous treatments and surgeries,” he says.
Dubin was not surprised to learn he had colorectal cancer as every male member of the Dubin family for the past three generations has had colon cancer. What provided even greater clarity as to why members of his family had such a high rate was what he learned when diagnosed the second time: Dubin had Lynch syndrome. Lynch syndrome is an inherited disorder that increases the risk of cancer, particularly of the colon and rectum. “It has the potential to wipe out multiple members of someone’s family,” Dubin says. Over the years, Dubin has drawn strength from playing soccer. The sport also served as inspiration for the name of a blog he started in 2007. It was called “AliveAndKickn.” The blog grew into a non-profit organization focused on raising awareness about Lynch syndrome and colorectal cancer, with the AliveAndKickn name taking on greater meaning for Dubin. “It’s evolved into a way of life — a message and a sense of attitude towards a very difficult subject,” he says. About a year and a half ago, AliveAndKickn took on its greatest undertaking with the launching of the HEROIC Registry, which allows patients to contribute medical information and their experiences living with Lynch syndrome and its associated cancers. “We’re trying to get Lynch syndrome patients — both survivors and previvors — into the fold,” Dubin says. “It’s been estimated that 95% of people are unaware they have Lynch syndrome. Hopefully, the registry helps reduce that number, and we can really work to be ahead of the curve instead of waiting for the curve to hit us in the face.” This objective has great meaning to Dubin, who has three sons. “AliveAndKickn has evolved into a conversation around our children,” he says. To help further AliveAndKickn’s mission, Dubin calls on physicians to step up. “Find the time to have conversations with patients about genetics,” he says. “Statistically, it’s warranted. If they could take an extra few minutes to talk about family histories and undergoing genetic testing, that would be a huge boon to what we are working to accomplish.” Patients can also play a big part, Dubin says. “Become your own advocate. See if you have a family history of cancer. Other signs could be people in your family who have passed away at an early age due to cancer or something undiagnosed. If you have an ‘ah-ha’ moment about a potential increased risk, undergo genetic testing. It has the potential to be a difference maker in the lives of so many people.”
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A Newcomer’s Perspective:
Q&A with Roy Bejarano, PE’s New Chief Strategy Officer
In April 2017, Physicians Endoscopy (PE) welcomed Roy Bejarano as the company’s new Chief Strategy Officer. He joins PE after serving as President of a New York-based ambulatory surgery center management and development company since 2011 and co-founding the company in 2010. In this wide-ranging interview, Bejarano discusses his new responsibilities, what attracted him to the position and working for PE, and how he views PE’s position in the ASC industry.
Q: As the new Chief Strategy Officer for PE, what does your role entail? Roy Bejarano (RB): My role is still evolving, and that is one aspect of my position that I am most excited about: working with such a high-quality management team at PE that has provided me with the time and access to explore all that is possible. At this early stage, I can say I am primarily focused on two key areas. First, I am bringing as much of the PE value proposition to the surgery centers that were under the management of my previous company and are now purchasing services from PE. From providing liquidity options to enhanced revenues to cost reductions, we are ultimately working to improve the performance of the newly added ASCs wherever possible. Second, I am focused on bringing all of PE’s affiliated centers — in New York and the rest of the country — the creative, strategic growth opportunities that may now be available given the added knowledge and resources we have created
by combining my former company and its centers with PE and their centers. These new opportunities have arisen through the blending of our experience and the unique task of managing the evolution of 24 centers in one state, all while we are in the ROY BEJARANO process of adding to this number. Examples of such strategic opportunities would include the following: • ASC associate hires; • practice and patient absorption from retiring physicians; • forming agreements with self-insured employers; • improving the integration of ancillary revenue streams, such as anesthesia; • ASC-to-ASC mergers and consolidations; and • working with payors and referral sources, including management services organizations, to explore growth and alternative payment and cost-reduction models that will directly benefit our ASCs. To date, the majority of ASCs have relied on either the status quo or recruiting established physicians to join their center. My experience has shown me that as centers and the marketplace matures, we, along with our partner ASCs, will increasingly need to consider a wider menu of strategic solutions. These solutions exist, but require championing, education and ultimately execution and management.
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Q: How has your background effectively prepared you for this position? RB: My seven-year history in the New York ASC marketplace, centered around building my former company that provided services to close to 150 gastroenterologists across 16 centers, has allowed me to really appreciate the strategic opportunities that have emerged from PE’s unique scale and experience in this marketplace. Between PE and assets from my former company, we have gathered significant local market knowledge and access to a comprehensive menu of solutions that would not exist without this type of presence. It’s similar to running a controlled laboratory where you get to witness a number of experimental initiatives that demonstrate high to medium to low impact. Using that empirical knowledge, you can strongly recommend the best steps for ASCs to take, both in New York and elsewhere in the country. Beyond this history, my role as an entrepreneur, and former investment banker of 12 years working in corporate development, management consulting, and private equity, all help when it comes to analyzing business opportunities and determining whether they make sense.
Q: What attracted you to the opportunity of working for PE? RB: This was several years in the making, dating back to when I first reached out to PE’s leadership to discuss PE as a potential strategic partner to my former company. The key attractions were my knowledge of PE’s CEO, Barry Tanner, and seeing his team’s approach to building and managing centers, with a primary focus on long-term physician partnership versus some of the other models I’ve witnessed that are more short- term in nature. The PE model, which focuses on hands-on management in partnership with physicians, was highly complementary to what I grew up with in the industry. 12 |
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What also drew me to PE was the company’s development of extensive in-house expertise in key areas, such as payor negotiations, accounting, IT, marketing, and procurement — all areas that I knew our centers would appreciate. Ultimately, the belief and now realization that PE would support my desire to explore cutting-edge, creative, and strategic opportunities that would benefit ASCs, and that PE’s company focus stems from an unwavering commitment to ASC performance excellence on behalf of their physician partners, was too compelling an opportunity to pass on.
Q: As someone with a long history of working with surgery centers, how would you describe PE’s position in the industry? RB: It’s unique. There is no other management company of scale exclusively focused on GI from soup to nuts. PE successfully builds new endoscopic surgery centers and acquires existing endoscopy centers, incorporating their professional management services. There is no one else with 19 years of experience perfecting this service offering. And there is no one else that I have seen with the strength in management born from so many years of continuity among the management team. I would offer that with every passing year, our unique focus and access to resources will further increase the expertise gap between PE and other management companies.
Q: What do you think makes PE such an appealing partner to physicians? RB: I feel it’s a combination of so many things. Here are three of the key factors: • proven track record of bringing operational excellence across so many categories, such as IT, revenue cycle management, payor contracting, human resources, finance and clinical expertise; • retaining the heritage and culture of viewing physicians as true partners
and the primary value generators in each of our ASCs; and • having the resources, scale, breadth, and experience to put the best solutions to work for each ASC as a means to fuel performance in an often complicated and challenging space.
Q: How do you think PE’s services help support endoscopy centers and their affiliated practices in their efforts to be market leaders and achieve long-term growth and success? RB: It’s a combination of striving for operational excellence with a relentless pursuit of finding new solutions to tackle difficult problems, such as retiring physicians, limited growth opportunities, and struggling private practice performance. These objectives achieve a significant, short-term impact that becomes increasingly pronounced over time.
Q: For endoscopy centers weighing whether to bring in a partner, why do you think they should put PE on their list of considerations? RB: For existing centers that either have a different management partner or are willing to consider one for the first time, I would say that PE offers improved operational performance and immediate access to longer-term growth and risk mitigating strategic initiatives while leaving sufficient flexibility and room for continued physician leadership. It’s quite a compelling offer. Mr. Bejarano joined the Company in April 2017 and serves as Chief Strategy Officer where he primarily focuses on PE’s New York ASC market. In his previous role, Mr. Bejarano served as President of Frontier Healthcare, where he acted as the strategic advisor during Frontier’s founding and was directly responsible for all operations as well as strategic development. Mr. Bejarano was an active member of the Entrepreneurs’ Organization (EO), New York Chapter, as well as an active board member and senior consultant to the Chabad House Bowery. Mr. Bejarano graduated with an MBA from Columbia School of Business. He also provides over 12 years of investment banking, private equity, corporate development, strategic consulting, and asset management experience.
The New Landscape for ASCs Seeking to
Provide Free or Discounted Patient Transportation
By Amber Walsh and Melissa Szabad, McGuireWoods LLP What do you do when a patient’s primary obstacle to receiving treatment at your ASC is the ability to arrive at the ASC safely and on time? In response to this persistent dilemma, many ASCs offer patients some form of free or low-cost transportation. But the provision of free or low-cost transportation services to patients implicates the Medicare Civil Monetary Penalties Statute (CMP Statute), the Medicare and Medicaid Anti-Kickback Statute (Federal Anti-Kickback Statute) and may implicate similar state laws. In December 2016, the Department of Health and Human Services’ Office of Inspector General (OIG) published a final rule that establishes a new “safe harbor” — the “Transportation Safe Harbor” — outlining circumstances in which free or low-cost local transportation would be exempt from liability under the Federal Anti-Kickback Statute. The new Transportation Safe Harbor provides assurances to ASCs that they can offer free and low-cost transportation without running afoul of these laws as long as they meet the safe harbor requirements. We provide a brief history of this issue, describe the specific elements of the Transportation Safe Harbor and discuss additional considerations for ASCs interested in implementation of free or discounted transportation policies.
A Brief History Prior to the adoption of the new safe harbor, offering free or low-cost local transportation services posed a greater risk
for providers in terms of potential liability under federal law. Historically, regulators warned of a risk of impermissible beneficiary inducement if patients — desiring to reduce their costs associated with such transport — were (i) aware that the provider provided such transport, or believed that such transport was only available if they chose to receive services at that provider’s facility, and then (ii) chose to receive care at the provider’s facility rather than at another location, particularly if those patients lived closer to another facility or outside of a provider’s typical service area.
However, over the past decade, the OIG had also provided guidance and specific recommendations through various advisory opinions. In its advisory opinions, the OIG provided parameters which, if followed, in the OIG’s opinion, reduced the key risks associated with local transportation services and protected beneficiaries and federal health care programs from the potential for fraud and abuse. The Transportation Safe Harbor incorporates many of the parameters of the advisory opinions. Now, ASCs can look to one set of requirements (at least at the federal level) in the Transportation Safe Harbor in structuring their policies govFAL L /WI NTE R 2 0 1 7 EndoEconomics
erning free or low-cost local patient transportation.
New Safe Harbor Requirements As is the case with all safe harbors to the Federal Anti-Kickback Statute, Transportation Safe Harbor requirements must be met and maintained during the course of providing free or low-cost transportation services in order for an ASC to enjoy immunity under the CMP Statute and Federal Anti-Kickback Statute. Specifically, under the Transportation Safe Harbor, the provision of free or discounted transportation will not be considered a violation if the following eight conditions are met: 1. The ASC creates a policy for the provision of free and discounted transportation and applies the policy uniformly and consistently to all patients. 2. The determination to provide free or discounted transportation is not made in a manner related to the past or anticipated volume or value of federal health care program business. 3. The free or discounted local transportation services are not air, luxury or ambulance-level transportation. 4. The ASC does not publicly market or advertise the free or discounted local transportation services, no marketing of health care items and services occurs during the course of the transportation or at any time by drivers who provide the transportation, and drivers or others arranging for the transportation are not paid on a per-beneficiarytransported basis. 5. The ASC makes the free or discounted transportation available only to established patients of the ASC. 6. The ASC makes the transportation available within 25 miles of the ASC (or within 50 miles if the patient resides in a rural area). 14 |
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7. The free or discounted transportation is provided for the purpose of the patient obtaining medically necessary items and services. 8. The ASC bears the costs of the free or discounted local transportation services and does not shift the burden of these costs onto any federal health care program, other payers, or individuals. Note that these elements apply to free or discounted transportation other than shuttle services. The Transportation Safe Harbor provides separate rules for shuttle services. Essentially, shuttle services must comply with all of the requirements described above, except that (a) shuttle services need not be operated in accordance with a policy that is applied uniformly and consistently, although implementation of such a policy may be advisable from a risk perspective, and (b) shuttle services need not be limited to established patients or for the sole purpose of obtaining medically necessary items and services (for example, employees and/or family members may utilize the shuttles). To receive protection under the Transportation Safe Harbor, the shuttle service must be local and will qualify if there are no more than 25 miles between any stop and the ASC (or 50 miles in rural areas).
Two Additional Considerations It is important to note that providing free or discounted transportation in a method that differs from the Transportation Safe Harbor does not necessarily make the transportation offering violative of the CMP Statute or Federal Anti-Kickback Statute. However, with implementation of the Transportation Safe Harbor, the OIG has signaled even more strongly to the industry about the parameters of transportation programs that it finds to have minimal risk of abuse. Therefore, ASCs that choose to vary from the Transportation Safe Harbor requirements are
taking risk of serious examination by the OIG of the intention behind the free/discounted transportation and the program being deemed an inappropriate inducement. By contrast, one cautionary note is that state laws may contain anti-kickback or anti-patient inducement laws that may be even more restrictive than federal laws or may also cover commercial patients. These laws may contain a similar safe harbor to the federal safe harbor. It is important that ASCs understand the laws of their own states and incorporate any state law considerations in their policies on free or discounted transportation.
Conclusion The take-home message for ASCs is that because the OIG has been expanding providers’ ability to offer free or discounted local transportation for patients over the past decade, establishing such a program is now a lower-risk proposition than it has been in the past. The OIG has recognized that such programs, when properly studied, can successfully address issues of patient safety and need without posing significant compliance issues for providers. Amber McGraw Walsh is a partner at McGuire Woods Law Firm in Chicago, Ill. She is the chair of the firm’s healthcare department. Named to “Illinois Rising Stars,” Healthcare, Super Lawyers, by Thomson Reuters, Amber focuses on corporate healthcare transactional work and regulatory matters. Her experience includes representation of various types of healthcare providers including hospitals, health systems, dialysis facilities, multiand single-specialty medical practices, specialty hospitals, ambulatory surgery centers and a variety of healthcare industry entrepreneurs in sales and acquisitions, joint ventures, general corporate matters, contracting, securities and regulatory matters. For more information, Amber may be reached at email@example.com. Melissa Szabad is a partner at McGuire Woods Law Firm in Chicago, Ill. Her practice focuses on healthcare corporate and regulatory matters. She advises various types of healthcare providers, including ambulatory surgery centers, ambulatory surgery center chains, and hospitals and health systems. Her experience includes counseling clients on general corporate matters, anti-kickback and Stark issues, self-referral, corporate practice of medicine and fee-splitting prohibitions, HIPAA, certificate of need, licensure requirements, and state and federal securities matters. For more information, Melissa may be reached at mszabad@ mcguirewoods.com.
Accreditation Surveys: Secrets for Your Big Win
“How you run the race — your planning, preparation, practice, and performance — counts for everything. Winning or losing is a by-product, and aftereffect, of that effort.” — John Wooden, 10-time winning NCAA national championship coach, UCLA basketball
The strategies for winning in sports are the same for business — or in this case, a successful accreditation survey. In both business and sports, you must know the rules, create a game plan, and bring in a strong leadership team. Helen Lowenwirth, MBA, CASC, administrator at East Side Endoscopy & Pain Management Center (ESNY) in Manhattan, New York, scored big on her most recent surprise CMS (Centers for Medicare & Medicaid Services) accreditation survey. She and her Physicians Endoscopy (PE) team share some of their secrets for survey success. Physicians Endoscopy has been a long term affiliate of the center providing ongoing administrative services and operational oversight.
East Side’s Backstory “You never know when they’re coming. We waited for months, and every Monday if they didn’t show by 11 a.m., I knew we had another week,” remembers Helen. “When
they walked through the door that busy Monday morning in May, it was go time. I’m proud to say we were ready, and the team did great!” she says, “And we finished almost every case on the schedule that day!” But it wasn’t easy getting there. HELEN LOWENWIRTH, MBA, CASC Helen says it took time to wrap her head around the accreditation process for ASCs, which is more stringent in New York, with both city and state oversight. “I came from a large radiology center where compliance focused more on equipment,” she says. “The different level of oversight involving people and procedures was overwhelming at first. There was so much to learn, but it got easier after a few cycles.”
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When asked about her secrets for success, Helen cites a very dedicated staff and support from Physicians Endoscopy. “PE helped me get organized and gave me the tools to succeed. They stood by me every step of the way, yet allowed me to figure out what worked best for us,” she adds. Mary Ann Gellenbeck, senior vice president of implementation services at PE, and Ann Sariego, PE’s vice president of operations, credit Helen’s leadership and her focus on doing the right things for the right reasons. Mary Ann says, “We can give anyone the guidelines and teach them processes and procedures. It’s ultimately up to the onsite leaders to manage compliance and create a culture where safe, high quality care matters most.”
Pro Tip: Lead with quality, and the rest follows. When you’re continuously focused on reducing risk and improving patient safety, everything takes care of itself.
Strategies for Survey Success Know the Rules (and Share Them) Helen regularly engages and educates the Center’s physicians and staff about the regulatory standards. She also talks about how ESNY’s processes and procedures meet them. “I hold meetings to ensure the team is well-versed in the rules, and we always talk about why we do what we do,” Helen says. “This empowers the staff to speak up and hold each other to the highest standard of care,” Helen adds. Helen also shares what it means to win. “When they see value in what we do, the team is motivated to work together and do their very best, every time,” she says.
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Designate Experts and Special Teams Pro Tip: Survey rules and regulations are tough to meet — and can change. Be sure to check with your accrediting agency for the latest standards and implement them well before your expected visit.
Create a Game Plan Helen’s winning game plan involves organization, standardization and followthrough. “I really don’t know how you succeed without obsessive organizational skills and attention to the tiniest details,” Helen says, pointing to her penchant for lists and spreadsheets. “I have a weekly, monthly, quarterly and yearly schedule to review defined goals and tasks. I set time to follow-up, or gently ‘nag’ people until a task is complete,” she adds. Helen also standardizes documentation, such as credentialing and personnel forms, and uses binders for everything. She reports, “This makes it easy for anyone to see how to do something and where it goes, so we’re not spending time tracking it down later.” ESNY’s “Blue Book” is especially important to the team. “This ‘bible’ has nearly everything we need to run the business, including licenses and certifications, NPI numbers, payroll information, fee schedules and past survey results,” Helen says. “I leave it easily accessible. If anything happens while I’m away, it’s all there.”
Pro Tip: Organize and regularly update the information you know the surveyors need. It sets the tone for a calm, confident experience.
Helen appoints subject matter experts (SMEs) to manage accreditation readiness and lead committees based on performance elements, such as infection control, OSHA safety, credentialing and education. But it does not end there. Helen gives her team the tools to do their job well. “The staff are busy. I set up processes and create checklists and spreadsheets to help them stay organized,” Helen says. “We work together to establish goals, and I schedule time to followup on their progress. We also share everything, from knowledge, experiences and accomplishments, to even the shortcomings and things we need to do better.” Helen is also serious about committee meetings and board meetings. “This is the time we discuss opportunities for improvement and make policy decisions. If we don’t meet regularly, we’re not addressing the most pressing issues involving patient care,” she adds.
Pro Tip: When hiring, seek SMEs who are committed to quality and process improvement, so you’re all working for the same goals.
Practice and Train for the Win PE performs annual mock surveys to test ESNY’s readiness. “We use this opportunity to not only highlight our weaknesses, but also celebrate improvements made over the year,” Helen says. Helen also conducts her own drills and regularly asks her frontline staff to describe what they’re doing to prepare for questions from surveyors. When
needed, she brings in vendors for training sessions and demonstrations during staff meetings. “Staff involvement is key. Regular practice builds confidence and ensures compliance to our standard of care, which is especially important for new hires,” Helen says. She adds, “I can rest knowing we’re all consistently providing safe, quality care for our patients.”
Pro Tip: Consider a third party for formal readiness reviews. A fresh take can help you identify opportunities you might overlook while you’re in the trenches.
Keep your Eye on the Next Big Win “You can relax the day after the survey, but that’s the only time,” laughs Helen. “The next day, I assess areas that need improvement and start following up all over again.” Helen continues, “At the core, it’s really all about following the rules, doing what we know we should do, and not taking shortcuts. This means we’re giving our patients what they deserve: The best care possible.”
Pro Tip: Survey readiness is a constant. When the whole team works together, you will always win.
For more information about how to prepare, visit your accrediting agency’s website. You can also become a member of your state’s Ambulatory Surgery Center Association for access to the latest state regulations and standards, educational resources and tools for continuous compliance and improvements for all aspects of the business. Visit http://ascassociation.org to find your state. Helen M. Lowenwirth, MBA, CASC, is the administrator at East Side Endoscopy & Pain Management Center (ESNY) in Manhattan, New York. She has 27 years’ experience in directly managing operations in Article 28 facilities and private practices, including revenue generation, clinical oversight and compliance, credentialing, marketing and human resources. In 2014, Helen obtained her CASC (Certified Administrator of Surgery Center) certification and was named to the Becker’s ASC Review list of “100 ASC Administrators to Know.” For more information visit http://esecgi.com.
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Makes Sense and Cents
By Bergein (Gene) F. Overholt, MD
As gastroenterologists face downward pressure on reimbursements, the need for ancillary revenues is an important topic in facilities and practices around the country. CMS cut diagnostic colonoscopy reimbursement by approximately 12% in 20161. In 2018 another decrease is scheduled. The widespread impact of reimbursement cuts has led â€” or may soon lead â€” to practice-level layoffs, further mergers between groups to share costs, seeking alternative salarybased employment, and even early retirements. As expected, physicians strive to offset their professional and facility fee reductions. Incorporating ancillary revenue streams into the practice is one option that is increasingly important. However, it is important to recognize before adopting any ancillary revenue stream, a primary goal of the practice should be aiming ancillary services at improving the quality and efficiency of patient services. Revenue, although important, is secondary to quality and efficiency. Incorporating anesthesia services is an important ancillary opportunity for the practice. For those practices with an ASC, providing anesthesia services meets the goal of improving quality of care and efficiency for patients while also producing an additional revenue stream for the
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practice. The revenue stream not only helps offset reimbursement reductions, but it also builds financial and equity value in the practice and positions it for the possibility of monetizing with a partner in the future.
BERGEIN F. OVERHOLT, MD
Bringing anesthesia in-house is smart. Anesthetics, techniques, skills of anesthesia professionals, and the monitoring of anesthesia have all improved significantly over the past 15 years. Propofol has now become the anesthetic of choice for the outpatient gastroenterology setting. In 2001, only 11% of screening colonoscopies were sedated by an anesthesia professional. Today that is closer to 55% (percentage can vary based on geography)2. This trend will continue to increase as more procedures are performed in the outpatient setting, as lower costs drive more procedures to the outpatient setting, and patient preferences favor a more convenient outpatient setting.
Legal Clarity Recent qui tam cases have caused confusion among healthcare attorneys and physicians researching anesthesia. The
question being asked: “Can gastroenterologists legally own their anesthesia?” is right, but there is confusion with the answer. Most often the practice decision depends on legal counsel, but as the saying goes, ask ten attorneys, and you will get ten different answers. In contrast, when a decision comes from the ruling government legal body — the Office of the Inspector General (OIG) — there is no gray area. Opinions are either dismissed and deemed compliant or not. The reality is that every unsealed OIG opinion regarding the company model has been dismissed. The company model is one where an anesthesia entity operates separately outside the GI practice but provides services to the ASC. However, as in any new venture, if setting out to start anesthesia in your ASC, I would recommend getting several opinions or perhaps even better, bring in attorneys and consultants who have set up GI anesthesia entities before to benefit from their experience in compliance and operational issues.
Structuring for the Future There are different avenues to arrive at the same destination when it comes to structuring GI anesthesia entities. The best example I can provide is the one that has worked for myself and my partners for the last fifteen years. Create a separate company owned by the practice (or ASC) so that it allows all partners to benefit from owning anesthesia. As new partners come and old partners retire, have bylaws in place allowing physicians to buy in and be bought out as time requires. Hire anesthesia providers (CRNAs or anesthesiologists), and a billing/collections team. Contracting with insurance com-
panies, while laborious, is crucial, as well as participation in Medicare and state-specific government plans.
cially in five or ten years? What are contingencies for bundling or anesthesia reimbursement cuts?
Whether you are in the planning phase of owning anesthesia or your group has benefited from ownership for years, there will likely come a time when you will want to monetize your intangible assets by bringing on a business partner.
Hard questions should be asked early. And check references!
If you are building your anesthesia program from the ground up, you might want to find a partner who will take a small ownership fee up front and then purchase their agreed upon ownership based upon earning multiples after the first or second year of operation. You will receive value in 3 ways: (1) the expertise of the partner in setting up the entity; (2) the benefit from their billing/ collections operations from day one; (3) the benefit of a transaction paid out at a multiple of earnings taxed as longterm capital gains3. When looking to sell, make sure that a future partner will bring something to the table beyond just a check on the date of the transaction. An important future point to consider is that CMS is changing the anesthesia landscape. Effective January 1, 2018, CMS will reduce all lower endoscopy procedures by one base unit from five to four and has hinted at an even further reduction for all screening colonoscopies. With these and further changes likely coming to anesthesia, one consideration is to sell sooner and maximize your ROI. But choose whom you sell to carefully. Lastly, when exploring a sale of your anesthesia business, thoroughly ask questions such as: What is your track record with current and past partners? Where do you expect us to be finan-
Final Thoughts Establishing an anesthesia service in your ASC offers many advantages for patients, physicians, and the practice. Obtaining expert advice before and during the anesthesia start-up is essential. Planning from the beginning to allow for new physicians and retirements is critical. All physicians who have or will have anesthesia services in their ASC should build in a process in which an outside entity can buy into the anesthesia operation, allowing for physicians to capitalize, if desired, on the value of the entity they have established. Sources: 1
Becker’s ASC Review. “How Medicare colonoscopy reimbursement cuts could impact GI in 2016 and beyond.” 24 November 2015. Becker’s GI & Endoscopy. http://www.beckersasc.com/gastroenterology-andendoscopy/how-medicare-colonoscopy-reimbursement-cuts-could-impact-gi-in-2016-beyond.html 2
John J. Vargo, Paul J. Niklewski, J. Lucas Williams, James F. Martin, Douglas O. Faigel. “Patient safety during sedation by anesthesia professionals during routine upper endoscopy and colonoscopy: an analysis of 1.38 million procedures.” Gastrointestinal Endoscopy January 2017: 101-108. 3
Kreger, J. (2017, July 19) CRH Anesthesia
Dr. Overholt is a graduate of the University of Tennessee Medical School. He did his internship, residency and gastroenterology fellowship at University Hospital in Ann Arbor, MI, and additional gastroenterology fellowship training at New York HospitalCornell Medical Center. He co-founded Gastrointestinal Associates (GIA) in Knoxville, TN, in 1971 and served as its president from 1971-2107. His efforts led his group in the development of the first licensed and accredited endoscopic ambulatory surgery center in the USA.
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A Unified Voice
DHPA Gives Voice to
Independent Gastroenterology Practices
It’s amazing what can happen over a simple cup of coffee. In August 2013, a bill was introduced in Congress calling for the elimination of the in-office ancillary service exception. If passed into law, it would have greatly impacted those independent gastroenterology practices which had integrated pathology into their services. “A casual conversation at a Washington, D.C., Starbucks in February 2014 hatched an idea of combining independent practices to raise funds to fight against that bill,” recalls Fred Rosenberg, MD, board-certified gastroenterologist at Illinois Gastroenterology Group. Eleven practices joined in that initial effort, leading to the formation of the Digestive Health Physicians Association (DHPA). The organization quickly grew to 40 practices within one year. “With that increase in size, we had sufficient resources to commission a study of pathology utilization in gastroenterology,” says Dr. Rosenberg, who also currently serves as DHPA’s president and chairman of the board. “The data demonstrated that the growth in pathology services was higher at hospital-based practices than independent practices.” We submitted those findings as part of our response to the bill.” Ultimately, the bill was defeated. “That experience brought us together,” Dr. Rosenberg says. “We realized that working together, we could accomplish much more than we could individually.” 20 |
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Fast forward to September 2017, and DHPA is now comprised of 75 member practices in 36 states. “We have around 1,700 physicians, which represents half of independent practicing gastroenterologists and nearly one in five of all practicing gastroenterologists,” Dr. Rosenberg says. Each practice, regardless of size, has membership on DHPA’s governing board. The board has in-person meetings twice a year, one of which is held in D.C. In addition to the board meeting, DHPA physician board members, in small groups, also spend a day and a half speaking with members of Congress. “This is a wonderful opportunity to spend time with legislators and their staff who work on healthcare policy,” Dr. Rosenberg says. “We are able to inform and educate them about the issues that are important to our practices and patients. Our current topics include removing barriers and improving access to colonoscopy and modernizing the Stark Law as we transition away from fee-for-service to value-based care. At our 2016 D.C. meeting, DHPA physicians visited 106 congressional offices, which we’ve been told is the largest, single-day outreach of any single-specialty society.” Another meeting is held outside of D.C. each year, bringing together the physician board members and their practice administrators. “We feel that part of what we can share with each other are those experiences, lessons learned and best practices from each individual practice,” Dr. Rosenberg says. “Providing the opportunity to share those stories in person helps disseminate that information very quickly.”
Efforts on All Levels For its first few years, DHPA was essentially “playing defense,” Dr. Rosenberg says. “We were looking at how policies would impact our independent practices and how we could protect ourselves from changes that affected our practices and the patients we care for. As we have grown, we’ve started to identify opportunities ‘to play offense.’” The association is actively supporting proposals submitted to the Physician-Focused Payment Model Technical Advisory Committee (PTAC) for advanced Medicare alternative payment models (APMs). “I’m happy to report that the first proposal approved by PTAC was from an independent gastroenterology practice,” Dr. Rosenberg says. “The proposed APM would improve treatment for patients with inflammatory bowel disease and could also significantly affect the treatment of other chronic diseases and conditions. DHPA supported that proposal and the development of another proposal concerning a comprehensive colonoscopy advanced payment model.”
prepare for that contingency. This is one example of cross-pollinating — something we are trying to do more and more.” DHPA has also supported efforts in New Jersey and Maryland concerning each of those state’s version of the Stark Law. “Wherever we can help out, we do,” Dr. Rosenberg says.
Another Voice for Gastroenterologists While Dr. Rosenberg hopes DHPA will continue to grow and thrive, he emphasizes that the association will always work closely with the gastroenterology tri-societies: American College of Gastroenterology (ACG), American Gastroenterological Association (AGA) and American Society for Gastrointestinal Endoscopy (ASGE). “The tri-societies perform vital functions we all need,” he says. “I believe everyone in DHPA belongs to one or more of the three societies, and we encourage them to continue to do so. Members of the DHPA executive committee also have leadership roles in the trisocieties.”
DHPA has focused most of its efforts on issues at the federal level, but has also supported policy advocacy at the state level. “We may not have the bandwidth to be present in every state for every issue, but we can put practices together and provide resources to fight for state and regional issues,” Dr. Rosenberg says. For example, last year, Connecticut imposed a tax on ambulatory surgery centers. Oregon member practices recently discovered they were under the same threat. “We had been working with our member practices in Connecticut to push back on the tax,” Dr. Rosenberg says. “The Oregon practices were able to tap into the resources already created for the Connecticut groups to help them
In fact, DHPA and AGA are jointly hosting a conference in D.C. on Oct. 6, 2017, called “Partners in Value 2017” (http://piv.gastro.org). “We must work together,” Dr. Rosenberg says. “Our goal is to promote integrated care in the independent gastroenterology setting. We must find the most cost-efficient, highquality ways to distribute healthcare for the benefit of patients and physicians.” He continues, “There is an African proverb which I like to quote: ‘If you want to go fast, go alone. If you want to go far, go together.’” Learn more about DHPA at www.dhpassociation.org. Follow DHPA on Twitter at @DHPAnews.
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Independent Physicians Successfully Lead Effort to Modernize NJ Self-Referral Laws For the past several years, the federal government has shifted its position toward allowing physicians to legally engage in self-referrals if they are participating in an alternative payment model. This movement began in 2011 when the Centers for Medicare & Medicaid Services was authorized to waive the federal Stark self-referral law for participation in Medicare Shared Savings Programs. “With the advent of the Affordable Care Act, the federal government has set its sights on moving towards a different payment model for physicians,” says Robert Gialanella, MD, president and chief executive officer of New Jersey’s Allied Digestive Health, an independent, integrated practice. “By 2018, it wanted 50% of Medicare payments to be in a non-fee-for-service environment. This would be accomplished through the creation of and participation in new value-based alternative payment models that mandate the sharing of information and manpower between independent entities.” “This may sound great for physicians interested in engaging in value-based alternative payment models, but for physicians in New Jersey, there was just one rather significant barrier: The state is one of several in the United States with very strict self-referral laws,” Dr. Gialanella says. When independent gastroenterologists in New Jersey found conflicts between the Stark law and New Jersey’s self-referral law (the “Codey Law”) that had the potential to harm patient care and practice viability, they took action. In the summer of 2016, Dr. Gialanella says he became very involved with the New Jersey Patient Care and Access Coalition (NJPCAC), which promotes and represents the interests of physicians in the state. Along with NJPCAC’s lawyer and lobbyist, Dr. Gialanella met with Sen. Richard Codey (D-Essex), for whom the Codey Law is named, members of the New Jersey Legislature, and the chairman of the state’s department of health to propose legislation to modify the Codey Law. “We hoped to modernize the law,” Dr. Gialanella says. “We wanted to exempt physicians in New Jersey from self-referral laws if we engaged in alternative payment models.” 22 |
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These efforts were backed by the Digestive Health Physicians Association (DHPA), a national trade association which advocates on behalf of independent gastroenterological practices. “It is very powerful to have a national organization of likeminded physicians come together to support initiatives,” says Charles Accurso, MD, from Digestive Healthcare Center in Hillsborough, N.J. “The organization is a valuable addition in the armamentarium to help private practice gastroenterologists lobby for better patient care and develop consensus on how to provide better care at a lower cost in a value-based environment.” “DHPA provided us with a grant to support our efforts,” adds Dr. Gialanella. “They also provided very strong legislative backing. With our team, we engaged legislators directly to explain that we needed them to help us and our patients navigate these challenging times in healthcare.” The message hit home, and the legislation was embraced by members of the New Jersey Legislature. It passed both the senate and assembly unanimously, and was signed into law by the governor on July 13, 2017. “New Jersey is just the second state in the country to modify its self-referral laws,” Dr. Gialanella says. “We’ve modified them in a very impactful way. They don’t only affect government programs like Medicare and Medicaid, but also private payors. Anyone who pays for medicine in the state has to abide by the new laws.” “Physicians are now in a better position to work in valuebased care without running afoul of New Jersey's selfreferral laws,” Dr. Accurso says. “It was a major development as it makes New Jersey one of the first states to revamp and rewrite the law to allow for the new payment systems under MACRA and for value-based contracting.” Changing the law has “opened a whole new era of medicine” for physicians, Dr. Gialanella says. “We can share data analytics and patient navigators with other practices not necessarily part of a single group. As long as the payment model meets the Triple Aim of better patient care, population health management, and lower costs, the department of health will support those alternative payment models and treatment modalities.”
sicians nationally, with about 450 candidates coming out of training every year. Ninety-four (94) percent of GI physicians are board certified. Twenty-nine (29) percent of GI physicians are international medical graduates. Nearly sixty (60) percent of GI physicians are over the age of 55.
Finding Success in an Ultra-Competitive Environment
In particularly high demand today are physicians who perform endoscopic ultrasound (EUS) and endoscopic retrograde cholangio-pancreatography (ERCP) procedures. There are only roughly 700 GI physicians who are fellowship trained in both EUS and ERCP. The other GI physicians who perform these procedures were proctored by a colleague trained in EUS and ERCP. On average, only 50 candidates who perform both procedures are coming out of fellowship each year. Most of these candidates prefer to perform both procedures, while a majority of facilities only presently offer one or the other. Another important statistic to know about today’s GI physicians: starting compensation (excluding factors such as loan repayment, relocation expenses, and a sign-on bonus) is between $480,000–$550,000.
Setting Yourself Up for Success By Rob Landstad, Partner & Senior Consultant, Goldfish Medical Staffing Finding it more difficult to recruit physicians these days? If so, take solace in the fact that you’re not alone. Thanks to an aging patient population and shortage of physicians, demand for new physicians entering the workforce is sky high. And that’s not ROB LANDSTAD likely to change anytime soon. In 2014, 14.5% (46.3 million) of the U.S. population was aged 65 or older. That is projected to reach 23.5% (98 million) by 2060.1 A recent study conducted for the Association of American Medical Colleges by IHS Market projects a physician shortage between 40,800 and 104,900 doctors by 2030.2 For organizations looking to sustain or grow their GI physician workforce, they must develop an aggressive recruitment strategy taking numerous factors into consideration.
Who are Today’s Gastroenterologists? To effectively identify which GI physician candidates your organization will target for recruitment, it is first helpful to gain a general understanding of the current and incoming workforce. According to the American Medical Association3, there are approximately 16,000 GI phy-
While recruitment competition is fierce, it is still advisable to develop a list of what you feel are your ideal candidate parameters. With that in hand, focus your efforts on recruiting physicians who meet those parameters rather than casting a much larger net. You may need to remain flexible if the “perfect” candidate(s) does not come along, but you will want the physicians who you add to possess as many of those qualities as possible. To increase your likelihood of recruitment success, be prepared with the information candidates are likely to expect from you. Most will ask for information including procedural volumes, a relative value units (RVU) spreadsheet with conversion factors, breakdown of payor mixes, potential patient out-migration, and bonus potential. You will also want to take into consideration information that may be pertinent to a specific candidate. If a candidate has children, make sure you have information on local schools readily available. If a candidate would relocate with a partner who would need to find a new job in the area, do some research on possible places of future employment. Develop a predetermined market competitive compensation package. Make sure to factor in any sign-on bonus/loan repayment offering, continuing medical education allocation, relocation support, benefits and potential partnership track. Outline all of these details in contract form. It is wise to let go of legacy compensation plans and recognize the benefit
IHS Markit, The Complexities of Physician Supply and Demand 2017 Update: Projections from 2015 to 2030. https://goo.gl/3dQRve
AMA is the source for the raw physician data; statistics, tables or tabulations as prepared by Goldfish Medical Staffing using AMA Masterfile data. FAL L /WI NTE R 2 0 1 7 EndoEconomics
of profit sharing and reduction of overhead brought on by introducing a new colleague or partner. In all likelihood, physicians are envisioning their time with you in decades rather than years. This makes it all the more important that you effectively communicate the mission and current and future vision of the group to the potential new recruit. Work to establish expediency throughout the recruitment process. My experience has shown that those groups which establish a point person as a unified voice of the group greatly increase the likelihood of landing a successful recruit. It is for this very reason that rural facilities will often times out-recruit their urban counterparts simply because of their ability to move a candidate through a pre-determined process with direct access to either the decision-makers or those who influence the decisionmaking process. Expediency through the recruitment process solidifies the candidate’s perception of the hiring entity’s level of urgency, hence motivating candidates to move up their decisionmaking timeframe. There is also tremendous value in working to get in front of individuals in fellowship programs well in advance of them becoming candidates. Work closely with the programs in your area and others you feel may produce the types of physicians you hope to add in the future. Participate in job and career fairs. Establish rapport and credibility with program directors by offering to provide students with education. Share monthly updates of job opportunities. Consider whether offering referral incentives would be a worthwhile investment. True grass roots recruitment of fellowship physicians occurs 2-3 years prior to graduation.
Model for Excellence For every seven candidates targeted for recruitment, most organizations will successfully add one, maybe two. There are exceptions to this rule, and 24 |
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that includes Bronson Healthcare in Michigan. I’ve had the good fortune of working with Bronson and John Jones Jr., senior vice president of Bronson’s 400-plus physician group, for about 16 years. During this period, Bronson has managed to achieve closer to a two-candidate, one-successful-addition ratio. Jones, one of the most competent executives I have encountered in my career, uses many of the tactics described above and others to increase Bronson’s number of physician placements, including those for the Kalamazoo Endo Center. Once candidates agree to come to Michigan for a visit, a critical component to success becomes the work of current physicians. “We get our physicians actively involved in the recruitment process with the candidates,” Jones says. “Our partners emphasize our patient-driven, patient-centric focus. They tell candidates how call works, how processes within the practice works and the vision for the practice. This is also a helpful experience for our current physicians as it provides an opportunity to get to know their possible future partners.” Current physicians also spend time talking about the area where candidates would practice. “We show off the communities of our healthcare system,” Jones says. “They receive tremendous support by local philanthropists. We have a strong public education system. More money is being allocated toward major community projects.” He continues, “We make sure candidates know that Bronson received the Malcolm Baldrige National Quality Award in 2005 and about our ownership stake in the Western Michigan University Homer Stryker M.D. School of Medicine. There’s a lot that living and working here has to offer — the area sells itself. It’s up to us to ensure candidates come away from their visit with us knowing all of these details.”
There is also ample time set aside to discuss matters such as compensation. “Candidates have a good idea of compensation when they come here, but then we really get into the details and benefits. We don’t want them leaving here with critical questions unanswered. We keep working at our recruitment efforts, trying to do whatever is necessary to get people here and keep them for a long time.”
The Work Never Stops Whenever you are fortunate to add a physician, feel free to breathe a sigh of relief and satisfaction. You’ve earned it. Recruitment requires a great deal of time and effort, and you are likely to have more failed attempts than successes. That’s par for the course. So take a moment to celebrate. But don’t dwell for long. Retaining physicians is a whole new battle, and the effort needed to do so begins right away. To establish a strong foundation for retention success, develop and maintain a clearly defined list of new hire expectations. This may include expected patient encounters (pending available patient volumes), number of surgical procedures, quarterly financial evaluations, work schedule, employee review schedule, potential business development opportunities, community outreach, speaking engagements and scholarly papers. Every physician is different. That’s why successful recruitment and retention will require you to become a chameleon, constantly adapting to accommodate the needs and wishes of an individual physician. If you’re unable to do so effectively, physicians will notice, and you can be certain other organizations are just waiting to fill that void in their lives. Rob Landstad is a partner and senior consultant for Goldfish Medical Staffing, a national physician recruiting firm. Rob has spent the last 17 years working with healthcare organizations to improve provider recruitment and retention, focusing on how to connect with candidates and be as effective as possible in the recruitment process. For more information, contact Rob at firstname.lastname@example.org.
your homepage, and the total number of organic leads that engaged with your page. There is a lot to learn from this program that can be used to benefit any marketing campaign. 2. MailChimp (https://mailchimp.com/)
10 Free Marketing Tools
for Any Size Team
By Meredith Jayne When managing a marketing program, sometimes it’s hard to determine what would be a good use of precious resources. A lot of available programs that are designed to make a marketing campaign easier are expensive and hard to navigate unless you have a MEREDITH JAYNE degree. Explore ten of the best free marketing tools that any marketing newbie can use. These can be useful in delivering more information about your practice and surgery center and ultimately increasing your patient customers. 1. Facebook Audience Insights (https://www.facebook. com/business/news/audience-insights) Most businesses have a Facebook profile because it is a simply managed program that is widely used by over 214 million people in the US alone. One facet of Facebook is Facebook Insights, a great tool for market and content research. Track likes, post reach, page visits, video, and use this information to deliver messages that matter to your patients. Audience Insights tracks trends in the aggregate information about purchase behavior, demographics, and engagement of current and potential customers. Track how many people your post was served to, how many times your page tabs were viewed, glean information about your target audience, etc. Check out the “Overview” tab. This tab keeps a week-long log of Page Likes, Post Reach, and Engagement. It denotes the total and new likes for your page, as well as the total number of unpaid or paid searches that landed patients on
Email makes it easier to deliver an organic message that viewers feel relates directly to them individually. It cultivates a more intimate interaction between business and customer. It also allows the opportunity for nurturing leads directly. MailChimp is an effective email marketing program that enables the user to send out e-campaigns to a predetermined list of people. Using their formatting for personalized releases, MailChimp makes it easy to see what’s successful, and what to work on more in the future. There are hundreds of templates for any occasion, as well as numerous design options, and professional help along the way. Automate marketing communication by setting up pre-built emails to release while the day-to-day tasks of a business are handled on the front end. MailChimp makes it easy to monitor how campaigns are performing, all while sending you customized tips for campaign performance improvement. 3. Shopify Online Logo Maker (https://www.shopify.com/ tools/logo-maker) A logo is arguably one of the most important components to a business’ success. When patients can associate an image with an experience, it makes it easier for them to recommend and return. Sometimes, though, creating a logo can be a frustrating, arduous, even expensive process when trying to explain what you want to a logo design company who has little time to spend on your business. Introducing Shopify Online Logo Maker. Shopify’s logo maker has a library filled with various icons, fonts, designs, and ideas that will allow you to create a vision of a logo that expresses your business’ identity. Save time and money, and represent your brand through a logo that you can create with no prior training or design skills. Use Shopify to test out virtually endless design options until you have an image that speaks to your business’ mission. 4. Survey Monkey (https://surveymonkey.com/) Survey Monkey is the world’s #1 online survey software. Whether your goal is to do a simple poll on a recent event or post or more in-depth market research, Survey Monkey is the one-stop, easily maneuvered program that will help you accomplish your goals. Survey Monkey makes it easy to design a survey using their templates and standard questions. They help reach patients digitally via email, mobile, web, social media, etc. Share insights with your team, come up with new ideas, and act on them with survey results. Capture the voices of your audience and let them know you care about their opinions. 5. Buffer (https://buffer.com/) Buffer is a marketing administration tool that modernizes social media interactions by posting from several platforms at once. Create a post, and let Buffer publish it to Facebook, Twitter, FAL L /WI NTE R 2 0 1 7 EndoEconomics
LinkedIn, etc. Streamline any marketing campaign by composing and scheduling posts far in advance, and focus on everyday tasks while they periodically release on the predetermined dates. The Buffer website boasts that their program is “…The best way to drive traffic, increase fan engagement, and save time on social media.” With social media becoming an ever-growing field that the upcoming generations feel increasingly comfortable with, Buffer is an ideal way to expand a social presence for any business. Learn how to build your brand, create drip campaigns, and determine the success of your posts. 6. Pablo by Buffer (https://pablo.buffer.com/) Built to work hand-in-hand with Buffer is Pablo by Buffer. Pablo is equipped with over 600,000 images that make it easy to create an aesthetically appealing post. In the program, you select one of the supplied images, or upload your own, and are then able to use a host of social image tools. This feature includes text overlay, filters, logo placement, adjust facets of the size, and download/share. Create eye-catching media to accompany your marketing and reel in viewers. The forever free plan at Buffer lets you connect a profile from each network (one from Facebook, one from Twitter, etc.) and to schedule ahead ten posts each. Buffer and Pablo working together are the best way to drive traffic, increase fan engagement and save time on social media, while also presenting clear, visually appealing, professional content. For an upcoming event, post an announcement, send a reminder, and send followup updates post-event. Here at PE, we are impressed with the straightforward instructions and user-friendly setup on which both programs operate. 7. Google Analytics (https://www. google.com/analytics) Many businesses utilize Google in some capacity, such as research, email, or even sometimes as a way to upload media onto their website. Google Analytics is a fantastic free tool that tracks 26 |
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traffic on your website with ease. Once the one-time tracking code is placed on the back-end of your website, check the engaged reading time or find realtime statistics about who uses your site in-the-moment, among many other tools. This program gives you a better understanding of your digital customers, which means you can evaluate the performance of your content and make adjustments as to where you can make improvements on your site. These reports are a shareable, ever-evolving, and ever-updated mass of useful data.
links on your website’s domain as well as on keywords and competitors. If search engines can’t access a website’s content or find the site at all, then they cannot drive traffic to them. Even though social media presence is pertinent, when patients try to figure out where to go for a service or product, typically their first step is to do a Google search. Visit moz. com and complete one easy step to determine where you stand from a search engine perspective.
8. Charlie (https://charlieapp.com/)
Working from the same database as Open Site Explorer is Moz Local. A common problem for small or new businesses is the consistency with showing up in search engines. Simply enter your website’s domain location, then Moz will push your listing to all data aggregators (Google, Bing, Apple Maps, Four Square, Super Pages, etc.). Moz Local audits this information for free, and you can then fix the issue yourself. Once they have ensured the local listings are correct, consistent, and visible across the web, search engines will be able to find your information, so new and current customers can easily find you. The paid version of the tool even researches and remedies the discrepancies for you!
Charlie is a CRM (Customer Relationship Management) tool that helps you keep track of and manage current and future customers’ information. This program helps businesses connect with clients and get to know them digitally. Give Charlie access to your calendar, and it provides you a full content-driven run-down of the social media profiles, interests, big news, etc. of anyone on an upcoming calendar invite or email contact. This convenient program gives you a competitive edge by finding out important personal details that you otherwise may overlook. Charlie sends you the data automatically, so you don’t have to worry about forgetting! According to their website, Charlie saves an average of 57 Google searches before each meeting by combing through 100s of sources and consolidating it into a one-pager. Or opt for the paid version “Charlie Enterprise” and automate your lead and sales research using Salesforce. 9. Open Site Explorer (https://moz. com/researchtools/ose/) Open Site Explorer (OSE) is a perfect tool for monitoring and understanding your link profile. Enter the URL for your site or a competitor’s, and view results revealing the ranking potential in search engines, as well as spam score, link opportunities, and top pages to maximize link building. OSE checks how many inbound links you have, when they were created, and from what sources. The tool also has the capability to report on all
10. Moz Local (https://moz.com/local/ overview)
Take advantage of these ten tools, and promote your business to a whole new level. Your marketing campaign can be a source of income, so it’s important to foster a positive image, and these programs will help you do so! Instead of spending money on resources that may not work, you now have the freedom to try several different methods and find out what works for your situation. Meredith Jayne is the Marketing Coordinator at Physicians Endoscopy. Ms. Jayne assists with the corporate and center marketing initiatives of PE and its affiliated centers. Ms. Jayne earned a B.A. in Marketing and Communication from La Salle University. For more information, she can be reached at email@example.com. Opinion Disclaimer: The views and statements expressed in this article are not necessarily an endorsement for the use of any of these programs. These views and opinions do not represent those of Meredith Jayne, Physicians Endoscopy, and/or any/ all contributors to this publication.
answered, receiving explanations of preparation for procedures such as a colonoscopy, and the methods of obtaining informed consent are all significant points of contact with the patient which contribute to the experience and overall opinion of the care furnished by the provider. Many of these touch points — as well as others — also apply to the patient experience at endoscopy centers.
A New Era of Transparency:
Prepare for the Inevitable
By James W. Saxton, Esq. and Darlene K. King, Esq. We are entering a new era of increased transparency in healthcare delivery. Advertising and promotional campaigns market healthcare practices and facilities with descriptions such as “best center,” “top patient satisfaction,” and “exceptional quality.” JAMES W. SAXTON However, these promotions often fail to offer objective statistics to support the claims. The reality is that narrow networks, accountable care organizations, virtual integrated clinical networks, as well as payors and the public will be looking for true data and not subjective proclamations. DARLENE K. KING For a GI office, actionable data will include the patient’s impression of the process for scheduling an appointment, the setting of the facility, and the ease of working through the visit. Interactions with office staff, ease in obtaining information and having questions
Experience is ultimately linked to engagement. While it certainly is not news, patient engagement has taken on an extraordinary new importance. In fact, one of the reasons the patient experience has become so important is because it is thought to be the gateway to patient engagement. Payors, networks, and customers will want to know the level of “engagement” of GI patients. Engagement means that patients understand their disease, the need for medications and various treatment modalities and lifestyle changes recommended to improve their health. Patient engagement is one of the most important concepts on the horizon. A few additional observations about engagement drive home its importance. Engagement has been shown to lower the cost of care, create efficiencies and enhance the experience, and is thought to be one of the cornerstones of population health.1 Accountable care organizations or clinically integrated networks endeavor to “sell” their provider network as “best in class” in areas that are important to patients (e.g., patient engagement and experience). Now they need the data to prove it.
Engagement Reduces Liability Risk Patient engagement also has the effect of considerably lowering the potential of a medical liability claim.2 This represents a noteworthy economic issue. The financial impact is not just limited to the possibility that your premium may rise because of a claim, but it is imperative to factor in the cost of potentially losing one or more of the gastroenterologists from your practice or center for several weeks due to a trial. Further, the underestimated emotional and physical toll of a lawsuit that stretches over years, win or lose, significantly impacts doctors and their families. After lawsuits, doctors often react differently to patients and consider more carefully the patients they see and the procedures they perform. Some struggle with confidence, begin to practice defensive medicine, and even consider the question of whether they should continue to practice
1 For example: Hibbard, Judith and Jessica Greene. What the Evidence Shows About Patient Activation: Better Health Outcomes and Care Experiences; Fewer
Data on Costs. Health Affairs 32:2 (2013) 207-214; Doyle C, Lennox L, Bell D, A systematic review of evidence on the links between patient experience and clinical safety and effectiveness, BMJ Open 2013;3:e001570. doi: 10.1136/bmjopen-2012-001570. 2
See Hickson, GB, Jenkins DA. Identifying and addressing communication failures as a means of reducing unnecessary malpractice claims. NC Med J 2007; 68(5):362-364. FAL L /WI NTE R 2 0 1 7 EndoEconomics
medicine. These are real and underappreciated “costs.” When a patient is truly engaged and understands and acknowledges the risk of receiving treatment or undergoing a procedure, the patient is less likely to seek legal counsel and pursue a lawsuit when an incident occurs. Consider the value of carefully reviewing the consent form with a patient. If an unfortunate complication occurs, you are able to circle the discussion back to the consent form. The patient may recall that a perforation, for example, was a complication they were told about and acknowledged in writing. They will have received a copy of the informed consent document which clearly lays out that they acknowledged the risk. Family members and friends who encourage a trip to a lawyer can be reminded of and shown the document in which the risk was acknowledged, perhaps dampening the enthusiasm to pursue a lawsuit. If the patient contacts an attorney, that attorney is likely to obtain and review the medical record, which would contain the informed consent form. The attorney would also likely ask whether the patient signed any type of informed consent form. It will be quite discouraging to the lawyer to see a well-drafted and signed form. If the attorney believes it will be difficult to convince a medical professional liability insurer to settle or convince a jury for a win in the courtroom, they will probably pass — it is that simple. Remember, 45%, which is in some cases an attorney’s contingent fee amount, of zero is a very small number. It’s even smaller when you subtract expenses.
Measuring Clinical Indicators Delivers Numerous Benefits In order to reduce liability risk even further, consider measuring clinical indicators, such as those related to safety, quality, and effectiveness. Behavior as28 |
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sociated with those indicators is related to reducing adverse events, which could turn into lawsuits. Those indicators are also important to the payor community. Use a measurement tool to gather data that compares your performance against peers. Doing so is vital to negotiating new, value-based contracts in the future. Such a tool can also serve as the platform for you to participate in continuous quality improvement. Focused measurement provides information on how to effectively deploy resources toward areas in which there is a need for improvement. This information is particularly effective and efficient in multisite practices and centers. Gastroenterologists do not want “fixes” for areas in which they are already excelling. The issue is in truly understanding how one is performing against well-accepted benchmarks.
Getting Started The good news is that developing a program through which you can monitor and measure the patient experience and engagement, and those clinical indicators tied to them, is not necessarily difficult. There are several good measurement tools in the marketplace, some of which are not expensive or difficult to incorporate into a practice and center. The first step should be for your leadership to make such an effort a critical and cultural component of your organization. To help ensure a successful measurement program, you must
not only measure data but examine it closely and react to it. You will want to work to make sure a patient experience you believe is truly “five star” and “best in class” has data to support these claims. It is what you do not know that can raise red flags and detract from your pursuit of excellence. Putting a spotlight on how well you compare to your peers is key to a successful practice and center in the future. Enhancing economics and reducing professional liability exposure creates an effective combination in the present environment. James W. Saxton, CEO of Saxton & Stump, has sustained an active health law and health care litigation practice for more than 30 years. Jim is a nationally known speaker on health care issues and has presented to many prominent health care organizations including the Society of American Gastrointestinal and Endoscopic Surgeons and American College of Surgeons. He advises companies on innovative risk mitigation issues. Darlene K. King, Chair of Saxton & Stump’s Risk Mitigation and Safety Group, concentrates her practice in the representation of hospitals, doctors and health care professionals in health care litigation. She guides health care clients with issues involving risk management, crisis management, patient care and liability exposure.
One Cannot Serve from an Empty Vessel:
The Importance of Self-Care for Practicing Physicians
By Susmitha Jasty, MD “Don’t settle for Happy-ish… Live with Joy, Confidence, and Freedom.” This promise — presented as the title of an Art of Living Foundation (AOLF) workshop — is what drew me to the event, my first conducted by AOLF. During this workshop, attendees explored a curriculum of SUSMITHA JASTY, MD yoga, breathing exercises, meditation, and practical wisdom, all crafted with the intention of unlocking the freedom within themselves. During my medical residency and fellowship in gastroenterology, I would work 36 hours straight in a busy inner-city hospital. It was the late 70s. I was new to the USA and carrying an enormous amount of stress. Building my private practice in the male-dominated field of gastroenterology during the 80s was not easy. On top of working in two hospitals and performing procedures, I was also raising two girls and caring for my extended family. I had no time for myself but accepted the overwhelming stress I carried as a small price to pay and a fact of life for a working female physician. I never challenged this so-called fact of life until a few years ago, when I was introduced to AOLF. I first experienced
the Sudarshan Kriya and the Sahaj Samadhi meditation in a multi-day AOLF workshop. Sudarshan Kriya incorporates specific natural rhythms of the breath which harmonize the body, mind, and emotions. This breathing technique is designed to eliminate stress, fatigue and negative emotions such as anger, frustration, and depression, leaving one calm, yet energized; focused, yet relaxed. Sahaj Samadhi is a meditation technique designed to alleviate the practitioner from stress-related problems, deeply relax the mind and rejuvenate the system. During that workshop, I learned more about the science of breath and the mind-body connection than in five years of medical school. This program changed my life. It challenged what I thought I knew about meditation, helped me find some peace in my hectic schedule, and taught me how to live in the present moment. Although my workload didn’t change, I noticed that I was able to more skillfully balance my personal and professional lives. My communication skills and interpersonal interactions improved. It became easier to connect with my patients on a deeper level. I became more efficient, more compassionate and an all-around better doctor. To my surprise, I even had colleagues approaching me, yearning to learn how I was still so full of enthusiasm and energy at the end of a busy day.
Application for Today’s Physicians Physicians practicing in the current healthcare environment are under an enormous amount of pressure and stress. According to the American Foundation for Suicide Prevention, 300-400 physicians die by suicide annually. That’s almost a doctor a day. As mentioned in the April 2016 issue of U.S. News & World Report, physicians have higher rates of depression, divorce, and substance addiction than the general population, and 50-70% of doctors suffer from “burnout syndrome”1. This chronic, unattended stress can lead to emotional exhaustion, depersonalization, and lack of personal achievement that can affect patient care. Over the years, I’ve seen health care professionals lose their sense of self and purpose due to the intense stress we face. Moreover, many of us are not able to identify the effect stress has on our own well-being, nor are we comfortable seeking help for it. The more invested I became in my own wellness, the more I felt compelled to help others who face the same stresses I do, using the time-tested techniques and tools I learned in the Art of Living Foundation course.
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Historically, physicians are caregivers, but we don’t always take good care of ourselves. When we invest in self-care, we typically become better role models for our patients and our families and experience less stress and burnout. When we overlook these priorities, we might become wealthier but may do so at the cost of our health and happiness.
for HCPs (Healthcare Professionals),” which introduces simple, yet powerful breathing and meditation techniques to physicians. We work closely with the NYU Langone Medical Institution and AOLF to help physicians and other healthcare professionals learn, through the program, to be free of stress, healthier and happier, earning 20 CME credits in the process.
According to AOLF, Dr. Sarita Patel, a physician and the Director of the Palliative Care & Pain Management service at Kingsbrook Jewish Medical Center in New York, said, “In today’s demanding, distracting world, the mind can be stuck in the past or in the future. But happiness is here in the present moment. It cannot be experienced when the mind is vacillating between regretting yesterday or worried about tomorrow. The Art of Living Foundation’s Living Well program is a great way to sharpen the skills for handling the tendencies of the mind.”
What is Living Well: Self Care?
I teamed up with Dr. Patel to develop the “Living Well: Self-Care Program
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The Living Well program is designed for medical doctors, nurses and other healthcare professionals seeking to build a proficient practice for self-care to enrich their quality of life. This program provides techniques and tools that help practitioners manage their emotions, reduce stress, anxiety, exhaustion and compassion fatigue. It is intended to empower practitioners to enhance their physical, mental, spiritual and social well-being upon completion of the program. The course is designed for physicians, medical students, residents, fellows, osteopath practitioners, nurses, nurse
practitioners, allied HCPs and complementary and alternative medical practitioners, offered in various locations throughout the year. In our experience, the participants who complete the course typically leave with an understanding of science of breath, mind body breath connection, how managing the mind can help bring awareness to and alleviate stress and burnout and optimization of sources of energy. Dr. Susmitha Jasty has been a practicing gastroenterologist in Brooklyn, New York, for more than 30 years. She earned her medical degree from Gandhi Medical College in Secunderabad, India. Dr. Jasty completed her residency in internal medicine (1978-1981) and served as chief resident in internal medicine at the Bronx Lebanon Hospital Center, N.Y., where she also received training and completed a fellowship in gastroenterology (1981-1983). Dr. Jasty is board certified in internal medicine and gastroenterology by the American Board of Internal Medicine. She currently serves as an instructor in the department of medicine at NYU Langone Medical Center. In addition to her academic activities, Dr. Jasty also volunteers as medical faculty for the Art of Living Foundation, an international, educational, non-profit, non-governmental organization that offers self-development seminars and various service projects globally.
Center • The Endoscopy Center at Bainbridge Chagrin Falls, OH (October 2007)
Community Initiatives Physicians Endoscopy and several of their affiliated centers have engaged in civic initiatives including fundraising activities, and various drives. PE is proud to be partnered with centers that are so invested in making a positive impact on their patients and their communities.
5 Years: • Carnegie Hill Endoscopy New York, NY (March 2012) • DHA Endoscopy Center Stoneham, MA (September 2012)
Advanced Endoscopy Center (AEC) AEC (Bronx, NY) will be the inflatable colon sponsor for the “Get Your Rear in Gear” Colon Cancer Awareness 5K run/walk on Sunday, October 22, 2017. The event takes place at Riverside Park in New York, NY, and will raise funds for New York City’s colon cancer prevention programs. It will also help fund a National Lynch Syndrome Registry through AliveAndKickn and The Genetic Alliance allowing genetic research, support for Lynch survivors and previvors, and other Lynch Syndrome awareness and education.
Physicians Endoscopy (PE) PE was excited to support the residents of the Doylestown, PA Housing Shelter by donating hundreds of mini toiletries and hygiene products for residents. PE also participated in the Robert Half Annual Suit Drive’s “Dress for Success,” where staff donated interviewappropriate attire for disadvantaged job seekers. The drive provided items such as men’s and women’s suits, dress shirts, blouses, ties, handbags, jewelry, shoes, and more. The philanthropic staff also participated in the “Liberty USO Project Einstein Drive” where dozens of backpacks were collected, as well as boxes full of required supplies for grades K-8. This drive supports the children of local military families in need.
Island Digestive Health Center (IDHC) IDHC (West Islip, NY) participated in the “Take Steps for Crohn’s & Colitis” run/walk. Fundraising through “Take Steps” gives participants the opportunity to directly impact vital treatment, research, and life-giving patient programs for the 1.6 million Americans who suffer from Crohn’s disease and ulcerative colitis. IDHC raised almost $2,500 and hopes to influence critical research projects, as well as groundbreaking patient programs like Camp Oasis through their efforts.
The Endoscopy Center of Robinwood, located in Hagerstown, MD, will celebrate their 15th anniversary in October by hosting an open house on October 23rd from 4-7PM. Senator Serafini, District 2, Washington County, and a local TV personality will be in attendance. The staff will provide guided tours, explain how procedures are performed, and educate guests about the facility. Goodie bags will be offered to the first 100 attendees, and light refreshments, as well as door prizes, will be offered. Congratulations to the following centers who have been long-time partners of Physicians Endoscopy. We are proud to have as them part of the PE family! 10 Years: • Advanced Endoscopy Center Bronx, NY (May 2007)
• Digestive Disease Endoscopy Center Normal, IL (August 2012) • Eastside Endoscopy Center Issaquah Issaquah, WA (February 2012) • Elgin Gastroenterology Endoscopy Center Elgin, IL (September 2012) • Endoscopy Center of Bucks County Newtown, PA (December 2012) • Hudson Valley Center for Digestive Health Cortlandt Manor, NY (July 2012) • The Endoscopy Center at Robinwood Hagerstown, MD (October 2002)
Important Dates & Events National ASC Week National ASC Week, held August 7-11, 2017, promotes awareness of how ASCs have transformed the outpatient experience. Hosting community events and educating key policy and decision-makers about the benefits of ASCs provided an excellent experience to build relationships with local representatives as well as prospective patients from the surrounding area. PE is proud of those centers that have taken full advantage of this opportunity. In celebration of National ASC Week, Hudson Valley Center for Digestive Health in Cortlandt Manor, NY, distributed patient education materials and giveaways for all scheduled patients for the week. Advanced Endoscopy Center, Bronx, NY, was honored to host Senator Gustavo Rivera, and Assemblyman Jeffrey Dinowitz to promote National ASC Week. “The Senator and
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Center MBA, MA (Michigan Endoscopy Center), Steve Housberg (Advanced Endoscopy Center), Helen Lowenwirth (East Side Endoscopy and Pain Management Center), Sarah Malaniak, CASC (Ambulatory Center for Endoscopy), Jean Neading, RN (Endoscopy Center at Bainbridge), Chad Querry, BSN, RN (Endoscopy Center of West Central Ohio), and Scott Williams (Carnegie Hill Endoscopy Center). Assemblyman toured the facility and spoke with staff and providers. They learned a great deal about ASCs as a means of delivering quality healthcare and some key initiatives AEC has been working on and promoting,” stated Steven Housberg, MHA, CASC, Administrator. Special thanks to Steven Housberg, Jennifer Tuttle, and the AEC staff for showcasing the center and educating the Senator, Assemblyman, and their Chiefs of Staff on the quality-focused and low-cost care provided by ASCs in the community and nationwide.
Another article by Becker’s ASC Review, “76 GI-Focused ASCs to Know” published June 1, 2017, featured 45 PE partnered centers. PE is excited to be in partnership with so many centers across the country that consistently provide high-quality care and exceptional service to patients. Accreditation Island Digestive Health Center, West Islip, NY, was recently awarded Joint Commission Accreditation. Advanced Endoscopy Center, Bronx, NY, was reaccredited by AAAHC. Individual Recognition Congratulations Dr. Brett Bernstein for being appointed the Chief of the Division of Gastroenterology at Mount Sinai Beth Israel, effective May 24, 2017. Dr. Bernstein is a leader in endoscopy quality initiatives and serves as the chief quality officer for Beth Israel ambulatory endoscopy services.
AliveAndKickn During their annual Blue Genes Bash event in New York City on Thursday, May 18th, AliveAndKickn founder Dave Dubin recognized Physicians Endoscopy as their first corporate sponsor and partner. The foundation has also recently partnered with Mount Sinai Hospital. AliveAndKickn works tirelessly to promote awareness to help improve the lives of individuals and families affected by Lynch Syndrome and associated cancers through research, education, and screening.
Awards & Recognition Becker’s ASC Review honored several PE center administrators in their article “163+ ASC Administrators to Know” published August 7th. Included on the list were Brien Fausone,
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Dr. Richard Moses of Philadelphia Gastroenterology Consultants was recently named President of the Pennsylvania Society of Gastroenterology (PSG) at their annual meeting September 8-10, 2017, held at the Nemacolin Woodlands Resort in Farmington, PA. PSG represents the interests of approximately 300 gastroenterologists, certified registered nurse practitioners, physician assistants, and nurses statewide. Visit www.pasg.org to learn more about exceptional member benefits. Sarah Malaniak of Ambulatory Center for Endoscopy in North Bergen, NJ, has been reelected to the Board of the New Jersey ASC Association. “Sarah continues to make a very significant impact on the ASC industry at the State and Federal level,” said Annie Sariego, VP Operations at Physicians Endoscopy.
Center Recognition South Broward Endoscopy (SBE) (Cooper City, FL) was selected as one of Modern Healthcare’s “Best Places to Work in Healthcare” for 2017. SBE received the award seven times in the past eight years. The recognition program lists workplaces throughout the healthcare industry that empower employees to provide patients and customers with the best possible care, products, and services. PE would like to congratulate our partnered centers who received the SPH Analytics APEX Award. • Hudson Valley Center for Digestive Health Cortlandt Manor, NY • South Broward Endoscopy Center Cooper City, FL • Endoscopy Center of Niagara Niagara Falls, NY • Laredo Digestive Health Center Laredo, TX The APEX Quality award was adopted as one of the most prestigious awards throughout the healthcare industry, with only 78 facilities nationwide recognized. This national distinction recognizes outstanding healthcare organizations that have demonstrated the highest levels of excellence in patient satisfaction and overall care over a 12-month period. Key Performance Indicators tied closely to clinical, operational, and interpersonal measures are paramount drivers in the overall evaluation process.
GI Opportunities Submit your CV online at www.endocenters.com/recruiting
Central New Jersey
Gastroenterology Consultants of Laredo – Laredo Digestive Health Center
Garden State Digestive Disease Specialists, LLC
The physicians of Gastroenterology Consultants of Laredo, a private gastroenterology group, are seeking a gastroenterologist to expand the practice. This candidate will have ownership opportunity in the affiliated endoscopic ambulatory surgery center. This two-room facility is located in Laredo, Texas in the Northtown Professional Plaza on McPherson Avenue. • • • • • • • • • •
Physician-owned and controlled center State-of-the-art endoscopic equipment Medicare licensed and AAAHC accredited Anesthesia services for patient comfort Physician efficiency and optimal patient quality of care Nursing staff has extensive experience in GI endoscopy An outstanding benefits package is offered Professionally operated and managed Group participates in research High population to GI Doctor ratio 60,000:1
Garden State Digestive Disease Specialists, LLC is seeing a BC/BE Gastroenterologist to join our three-physician practice in Central Jersey for a full-time position. The job offers an excellent salary, competitive benefits package, a 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 is preferred. We serve culturally rich and diverse communities; our patients reside primarily in the Union and Middlesex counties of Central Jersey. Our SurgiCenter is a state-of-the art endo center presently being expanded into a 3 room facility. We are affiliated with 4 local hospitals, 2 of which are teaching hospitals with residency programs. We are in the NYC metropolitan area, 45 minutes from Manhattan, conveniently located near an international airport, and in close proximity to many cultural centers and the Jersey Shore.
Lima, OH Gastro-Intestinal Associates, Inc.
Mesa, AZ Central Arizona Medical Associates
The physicians of Central Arizona Medical Associates (CAMA) are seeking a full-time Gastroenterologist to join their practice. 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 a single office and covers one hospital. Outpatient endoscopy is performed at a 2 room ASC with maximum efficiency and quality of care. Enjoy sunshine and a great lifestyle in the metro Phoenix area.
The physicians of Gastro-Intestinal Associates are seeking a BE/BC gastroenterologist to join our sixphysician, four-CNP single-specialty practice. Established in 1977, the practice has an outstanding reputation with the local Lima community. This is an opportunity to join a GI physicianowned 18,000 square foot combined office and three-room endoscopy center. The center, built in 2008, is AAAHC and ASGE certified. In the area are two local hospitals with state-of-the-art facilities. This opportunity offers: • 1:7 call rotation • First year salary guarantee • Outstanding earning potential • Professionally operated and managed
Consider submitting your CV even if you do not see a desired location currently listed and indicate where you would be interested in practicing. For more information visit:
Bellingham, WA NW Gastroenterology & Endoscopy
Exciting opportunity to join a nine-person single specialty GI practice in Bellingham, Washington. This 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. Great place to raise a family! This collegial group has a freestanding AEC and pathology lab. EUS optional, ERCP strongly preferred. Outstanding benefit package.
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GI Opportunities Submit your CV online at www.endocenters.com/recruiting
Rochester Hills, MI
Gastroenterology Consultants of South Jersey
The Center for Digestive Health (Troy Gastroenterology) is a well-established, highly respected private practice looking for two Gastroenterologists to join our growing practice. We have several offices across Metro Detroit with two state-of-the-art AAAHC accredited ambulatory surgery centers. We’re looking for an enthusiastic physician skilled in general endoscopy, ERCP.
Gastroenterology Consultants of South Jersey is a privately owned, seven-physician practice located in Lumberton, NJ. We are a well-established practice of 25 years located among several growing communities in Southern NJ.
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• Affiliated with Burlington County Endoscopy Center, a three room ASC which is physician owned and operated
Competitive base salary with productivity incentive Incentive bonus Retirement plan Discretionary allowance Eligibility for member status, after two years Insurance (malpractice, health, dental, vision, life, supplemental & dependent life, short & long-term disability)
• Located within 30 minutes of Philadelphia and within 1 hour of New York City
• We are seeking to add a full- or part-time gastroenterologist • We offer a 1:7 call schedule and an opportunity to perform ERCP/EUS (not required) • Partnership will be offered in both the practice and ASC
North Bergen, NJ An outstanding opportunity for a gastroenterologist!
Advanced Center for Endoscopy (ACE) has an immediate opportunity available for GI physicians looking for an outstanding ASC in which to perform procedures. Our single specialty, nine physician GI center is the perfect environment for you and your patients. Our center can help drive additional patient volume to you through the ASC, allowing you to increase your procedure volume in the environment that is more convenient. Our center can provide your patients a better outcome, and you will have satisfied and loyal patients. ACE is ideally located in North Bergen along the banks of the Hudson River—the “gold coast” of Northern NJ, with a spectacular view of the NYC skyline. This is an excellent opportunity for a motivated physician.
Northern CA Central CA
GI physicians: are you looking for flexibility and supplemental income? Our mobile endoscopy practice is seeking board-certified gastroenterologists in Northern CA (Sacramento/Stockton/Tracy) and Central CA (Fresno/Tulare/San Luis Obispo)! Flexible schedules allow you to work as many as 1-2 days per week or as few as 1-2 days per month. Position offers competitive pay.
New York, NY Gastroenterology of Gramercy Park
Gastonia, NC Gastroenterology on Gramercy Park, a two-physician private group, is seeking a gastroenterologist to expand the private practice. Physician can expect to step into a busy practice while replacing a retiring partner. The opportunity offers a primarily outpatient experience with a reasonable call burden. This candidate will have an ownership opportunity in the affiliated endoscopic ambulatory surgery center. This opportunity offers: • • • • • • • •
Physician-owned and controlled center State-of-the-art endoscopic equipment Medicare licensed and AAAHD accredited Anesthesia services for patient comfort Physician efficiency and optimal patient quality of care First year salary guarantee Retirement benefits Desirable location in downtown Manhattan
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Carolina Digestive Diseases
Four established gastroenterologists located in central North Carolina, are seeking a BE / BC gastroenterologist to join our physicians to expand the coverage in our community of Gastonia, NC. The physician candidate can expect to step into a busy practice while replacing a retiring partner. Anticipate a short track to practice partnership and ASC ownership. Practice currently operates out of a single office and covers one hospital. Outpatient endoscopy is performed at a 2 room ASC with maximum efficiency and quality of care. Located 2 hours to the Smoky Mountains and 4 hours to the Atlantic beaches. Enjoy sunshine and a great lifestyle in the metro Charlotte area.
2500 York Road, Suite 300 Jamison, PA 18929
EndoEconomics™ is a GI-dedicated quarterly journal, specifically focused on the current topics faced by the GI community and GI physician ow...
Published on Oct 1, 2017
EndoEconomics™ is a GI-dedicated quarterly journal, specifically focused on the current topics faced by the GI community and GI physician ow...