EndoEconomics Spring 2016

A Journal Dedicated to Economic Issues Impacting GI ASCs and Practices

SPRING 2016

This image is from the cover of the Summer 2010 issue of EndoEconomics. We are running

Survival Guide for Ancillary Income

it once again as a tribute to Dr. Monte Allen, a great man and partner to PE for many years.

(Part II)

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M E M O RI AM

Monte D. Allen, D.O. M AY

The GI Journal of:

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“Improving the landscape of healthcare one surgery center at a time.”

SPRING 2016 ISSUE EndoEconomics

by Physicians Endoscopy

Editorial Staff Carol Stopa Editor in Chief cstopa@endocenters.com

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Lori Trzcinski Managing Editor ltrzcinski@endocenters.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.

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Content 4 Message from the President 5 In Memoriam – Monte D. Allen, D.O.

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

6 Gastroenterology Practice 2016 and Beyond: Survival Guide for Ancillary Income (Part II)

Printed in the U.S.A.

11 Five Star Service – Excellence in GI

Copyright © 2016 by Physicians Endoscopy.

13 Medical Entrepreneurship in GI

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 info@endocenters.com.

16 What Every Physician Should Know From GI Roundtable 2016 19 Financing Terms and Tips in The Ever Changing Economy 21 Hemorrhoid Banding: The Implications of Introducing the Procedure to a GI Practice 24 Digital Strategy: Utilizing Your Greatest Marketing Tool (Part II) 28 Front and Center 30 Current GI Opportunities

Find out more at endocenters.com or find us on SPR I NG 2 0 1 6 EndoEconomics

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Message from

the President As we approach the mid-point in the year, I thought that it would be a good time to reflect upon the many changes in reimbursement that have oc- BARRY TANNER President and CEO, curred and are Physicians Endoscopy perhaps only now beginning to be felt by independent gastroenterologists nationwide. I would also like to spend some time talking about reimbursement changes that have yet to be felt but will be affecting gastroenterologists in the months and years ahead.

Beginning January 1, 2016, CMS began paying for incomplete colonoscopies submitted with modifier 53 at one-half the values of the inputs for the normal GI codes. Historically, the CPT manual defined an incomplete colonoscopy as a colonoscopy that does not evaluate the colon past the splenic flexure, and as such, an exam was submitted as CPT code 45378 with the 53 modifier.

Beginning in 2016, the definition of an incomplete colonoscopy was broadened to “a colonoscopy that does not evaluate the entire colon.” Also accompanying this change, there are now four possible codes that can be used to bill for an incomplete colonoscopy, again all with the 53 modifier – C-Stoma (CPT 44388); Diagnostic Colonoscopy (CPT 45378); Colorectal Cancer Screen, High-risk (CPT G0105); and Colorectal Cancer Screen Not High-risk (CPT G0121).

On the other hand, CMS professional fees for the performance of a variety of colonoscopy procedures were lowered beginning January 1, 2016, with some procedure reimbursements being reduced by 17% or more. In addition, CMS 4 |

EndoEconomics SPR ING 2016

lowered the Physician Fee Schedule for all professional services by 0.77% in 2016 primarily because CMS failed to achieve the targeted 1% reduction for misvalued codes in 2015 as mandated by legislative act.

While 2016 brought no changes to PQRS (Physician Quality Reporting System) measures for gastroenterology, it will be the final year of PQRS reporting neutrality in terms of reimbursement. Beginning in 2017, physicians who have failed to report PQRS measures for 2015 by the recently extended deadline of March 18, 2016, will be subject to a 2% negative adjustment to their CMS professional reimbursement beginning in 2017.

Also beginning in 2019, CMS will begin to adjust reimbursements for quality reporting and other factors pursuant to the Merit-Based Incentive Payment System and Alternative Payment Models as required by the Medicare Access and CHIP Reauthorization Act. On a more positive note, CMS updated ASC facility payments by 0.3% (national average) for 2016, once again using the much aligned Consumer Price Index. On the horizon, CMS is planning to negatively adjust the professional reimbursement for over one-hundred endoscopy codes to remove that portion of the professional reimbursement attributable to the physician administration of conscious or moderate sedation. CMS’s position is that the majority of GI procedures are now being performed with monitored anesthesia care (MAC), which is being separately billed and reimbursed to anesthesia professionals, and therefore reimbursement to the GI physician is duplicative. Going forward, CMS proposes that a new CPT code will be instituted to report sedation being administered by the endoscopist beginning in 2017. This new CPT code will have no monetary value in terms of

additional reimbursement; however, the code is expected to be reported along with the underlying procedure code. Anesthesia providers will continue to be reimbursed separately.

Finally, President Obama’s 2017 budget proposal includes an important potential change to the CMS reimbursement for screening colonoscopies. The proposed legislation entitled “Removing Barriers to Colorectal Cancer Screening Act” (HR 1220/S 624) has been incorporated into the proposed 2017 budget and seems to have bipartisan support. This important legislation, if enacted, would finally eliminate the surprise cost of coinsurance for Medicare beneficiaries who present for a screening colonoscopy but later learn after the procedure that polyps have been removed. Therefore, it is no longer a screening but a therapeutic procedure causing them to experience an unexpected out-of-pocket cost. This legislation would finally remove any surprise out-of-pocket cost for CMS beneficiaries who present for a screening once and for all.

The foregoing is not meant to be all inclusive but merely a summary of an everchanging reimbursement landscape for the GI service line. You can rest assured that the changes are not over and, in fact, the pace of change is likely to accelerate in the coming years. As specialists, gastroenterologists need to continue to strive for efficiencies and clear and transparent quality metrics—building strong partnerships and alliances, and to unite (where possible) into larger practice units that will better support access to needed resources, expertise, data, capital, and will promote the capture of economies of scale.

Please enjoy this edition of EndoEconomics.

“We are all devastated by the tragedy of his sudden illness and untimely demise. Dr. Allen was a friend of PE for almost ten years. It affects us like a death in a close knit family.”

BARRY TANNER, CEO, PHYSICIANS ENDOSCOPY

Monte D. Allen, D.O. M AY 2 6 , 1 9 5 8 – A P R I L 0 4 , 2 0 1 6

Physicians Endoscopy would like to dedicate this issue of EndoEconomics as we remember one of our long-time, truly great Physician partners who recently passed away in April 2016. Dr. Monte Allen was been part of the PE family since 2007 when we first met to develop a surgery center in Laredo, Texas, along with his partners Dr. Elsa Canales and Dr. Anthony Galan. During this time we also got to know Dr. Allen’s wife, Amy, who was always supportive of her husband’s desire to enhance and improve the Laredo medical community. The cover of EndoEconomics is from a 2010 issue highlighting the one year anniversary of Dr. Allen’s new endoscopy center — Laredo Digestive Health Center.

Dr. Allen’s compassionate spirit and love for people are evident in the culture developed at Laredo Digestive Health Center where staff have continually exceeded expectations in providing the highest quality of care and attention to detail in serving their patients. It’s a center where staff and clinicians are truly family.

Born in Fredericksburg, Texas, Dr. Allen also lived in Portales, New Mexico, Big Lake, Texas and Van Court, Texas during his youngest years. He attended the University of Texas at Arlington, receiving a Bachelor of Science Degree in Economics in 1982. After working several years as a computer systems analyst in Las Colinas, he returned to school to pursue a career in medicine.

Dr. Allen received his Doctor of Osteopathy degree from the Texas College of Osteopathic Medicine in Fort Worth in 1991; he then completed his internship and residency at the Osteopathic Medical Center of Texas. Desiring to specialize in the area of gastroenterology, Dr. Allen then completed a fellowship in gastroenterology at the Chicago Osteopathic Hospitals and Medical Centers in 1996.

Looking to return to Texas after completing his training, Dr. Allen was recruited to Laredo by the Laredo Medical Group and began his practice. He was joined in practice

by Dr. Elsa S. Canales in 2004, and together they created Gastroenterology Consultants of Laredo.

For almost 20 years, Dr. Allen served his patients in the Laredo area with unmatched dedication and compassion.

A true gentleman doctor, he was best known for his tender bedside manner, his heart of a teacher, and his genuine interest in each and every patient.

Despite his huge commitment to the practice of medicine, Dr. Allen’s most cherished role was that of husband and father. He married Amy Lynn Ritchie, formerly of Taft, Texas in 1991 and they have 3 children. Dr. Allen’s love of his family and all people was a reflection of the love of God, which he felt deeply. Physicians Endoscopy has surely lost a true friend while the GI community has lost a truly exceptional Physician.

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(Part II) Gastroenterology Practice 2016 and Beyond:

Survival Guide for Ancillary Income

Assembled, edited, introductions and conclusions provided by David Johnson, MD, MACG, FASGE, FACP Contributions by Harry Sarles Jr., MD, FACG; David Johnson, MD, MACG, FASGE, FACP; and Klaus Mergener, MD, PhD, MBA, FACG, FACP

HARRY SARLES JR., MD, FACG

With the “draconian� cuts imposed by the Centers for Medicare & Medicaid Services for endoscopic procedures effective 2016, gastroenterologists are presented with a significant challenge to fiscal stability and potentially the viability of their practice. In addition to the financial cuts, there are innumerable other factors, such as involvement or exclusion in accountable care organizations or networks, which may direct or exclude patient access to their practices with significant consequent effects.

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DAVID A. JOHNSON, MD, MACG, FASGE, FACP

KLAUS MERGENER, MD, PHD, MBA, FASGE

With this in mind, a group of nationally known, private practice experts developed this treatise to help guide their peers via their success in developing alternative revenue streams, which they have found highly successful in their practices.

In the first part of this two-part series, published in the winter 2016 issue of EndoEconomics, we had excellent guidance from Drs. Steve Morris, Reed Hogan and Jim Leavitt regarding opportunities for developing lines of

service revenue through anesthesia services, radiologic imaging and inhouse pharmacies. In this continuation, Drs. Harry Sarles, myself and Klaus Mergener discuss other opportunities for revenue streams by developing programmatic hemorrhoidal banding-, research- and pathology-related lines of service. This discussion is not meant to be applicable to every practice, but will hopefully encourage gastroenterologists to explore some options that may fit their practice. With challenging times upon us, gastroenterologists should

evaluate every option to leverage and potentially monetize the value of their practices.

Hemorrhoid Banding

By Harry Sarles Jr., MD, FACG Diversification is a strategically important concept that is paramount to the survival of today’s GI practices, and should be a part of a practice’s business plan. Reimbursements for the services of gastroenterologists have been declining since the 1980s. Successful practices have been diversifying since the 1990s by adding ambulatory surgery centers (ASC), pathology labs, anesthesia companies and infusion services, each of which has been very helpful to our practices. One of the newer service offerings being offered in GI practices is hemorrhoid treatment.

Though there are many treatment options available, hemorrhoid banding is now the preferred treatment for the nonsurgical management of symptomatic internal hemorrhoids. The procedure is known to be safe, effective and easily adaptable to the skill set of the gastroenterologist.1 Most GI fellowship programs do not spend a significant amount of time training us to care for anorectal problems, but a company such as CRH Medical (CRH O’Regan System) will provide this training through physician-tophysician procedural instruction at your office in order to help incorporate these procedures into your daily practice.

The addition of hemorrhoidal banding to my practice has allowed me to provide more comprehensive care to existing patients and attract new patients, ultimately allowing me to provide a higher quality of care as well as create a new revenue stream.

Most patients have three columns of hemorrhoids that require treatment, and we typically treat one column per session at two-week intervals in order to keep complications to a minimum. Symptomatic relief has

been reported in as high as 99% of patients, and the vast majority of the complications (1%) are easily cared for by the gastroenterologist.2 No patient prep is required; the procedure is easily performed in the office or ASC setting, and is well reimbursed, providing more benefit to your practice per hour than colonoscopy.3 Anoscopy has also become a routine part of my physical exam in the office for any patient complaining of anorectal issues. The anoscope has been shown to be superior to the flexible endoscope for examining the anorectum, and it is a quick, painless and inexpensive procedure that is easily performed in the office setting.4 While most patients will attribute any anorectal complaint to “hemorrhoids,” the use of anoscopy, along with a good anorectal examination, has allowed us to better identify the causes of the patients’ problems. They may include hemorrhoids but also other entities that need to be addressed in order to achieve optimal patient outcomes.

These techniques and treatment algorithms are presented alongside the hemorrhoid banding training provided

by CRH Medical.

The addition of nonsurgical hemorrhoid and anorectal care to my practice has provided great benefits to both my patients in my practice, and I recommend that all GIs consider doing the same.

Clinical Research

By David Johnson, MD, MACG, FASGE, FACP Although traditionally thought to be the purview of academic health centers, clinical trials to evaluate new drugs, tests and devices are being performed more and more in private medical practices or other healthcare organizations with little or no academic affiliation. A welldeveloped clinical trial program can improve the finances of a practice or healthcare facility by providing an

income stream not directly related to traditional patient care activities. Since this income stream comes through a contract with a for-profit company and not from a government program or healthcare insurance company, it provides a diversification for the revenue of the entity. So, is clinical research as part of a private medical practice something you should pursue? Here are seven points to consider, with some caveats.

1. Decide if you have the practice “culture” amenable to clinical research. Is there an intellectual interest in performing these studies? Since they may involve treatments or testing with randomization, the local investigator must be willing to have the patient treatment plan directed by the protocol, not the treating care provider.

2. Develop the necessary infrastructure. This involves having clinical coordinators as well as personnel dedicated to the regulatory monitoring and reporting process. This is not simply another collateral duty imposed on a member of your office staff. There are certifications of competency for clinical coordinators, and this is highly encouraged. Holding these credentials is very attractive to research organizations evaluating your site for potential clinical trial participation.

3. Understand the “rules.” The oversight of patient participation in a clinical trial has liability implications, rule of law implications and ethics concerns. The dedication to attention to developing the necessary infrastructure and culture of “attention to detail” is critical. This is not simply another collateral duty imposed on a member of your office staff.

Clinical competency and regulatory process understanding are essential for all involved in the program. Additionally, there is ever-increasing scrutiny placed on clinicians who assume the role of principle investigator (PI) in regard to conflicts of interest and oversight responsibilities monitoring progress of the study and patient safety.

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A new, additional responsibility is the FDA’s Physician Payments Sunshine Act which requires any sponsor of a clinical trial to post the income a PI receives on a publically accessible website even though much of that revenue will be used to support the infrastructure needed to run a clinical trial.

4. Develop a business case for your level of clinical trial involvement. It is also necessary to have the appropriate staff as well as certain equipment and space, all of which vary depending on the nature of the clinical trial. A mistake to avoid is to perform such activities by adding the new responsibilities of clinical trials to old responsibilities of clinical care. This practice is not a good formula for the business success of the new venture. You must do a great job and foster a great reputation among clinical research organizations and sponsoring companies when making your debut into clinical research.

Remember: Good news spreads slowly but bad new spreads quickly. A bad performance can knock you out of the business quickly. Do not overextend or overcommit.

5. Do not select all trials presented to you by sponsors. The target patients should be reflected by your practice setting. Selecting a trial for disease states that are naturally common to your patient population avoids unproductive recruiting searches.

6. Develop a database of patients with key disease states you anticipate will be areas of forthcoming trials.

In our practice, we have done this with hepatitis C, non-alcoholic liver disease and inflammatory bowel disease patients. When a sponsor comes, we can not only demonstrate the number of potential patients, but also have a means to rapidly recruit to studies, which frequently have competitive enrollments. Sites that are able to enroll more are frequently

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given this preference by the sponsors if enrollment by other sites lags.

7. Market your practice. Mention to pharmaceutical representatives that you are in this business and have them pass your name to their companies. In addition, promote your practice, patient population, expertise and experience to contract research organizations.

Do your due diligence The development of a clinical trials program can be personally, intellectually and financially rewarding if it is developed properly. You will not only provide your patients and community with care they may not otherwise receive, but you will also keep yourself on the leading edge of change and development in your field. If done well, a clinical trials program can provide a very meaningful alternate revenue stream to your standard practice. Just make sure you do it well.

Pathology Options

By Klaus Mergener, MD, PhD, MBA, FACG, FACP Busy endoscopy centers generate large numbers of biopsy and polypectomy specimens for histologic evaluation.

The tissue is initially fixed in formalin and then prepared for reading by embedding it in paraffin, cutting and mounting it onto slides and finally staining it with a variety of solutions.

This work is referred to as the “technical component” (TC) of the pathology service. Slides are then examined and interpreted by a pathologist.

This represents the “professional component” (PC) of the service.

Traditionally, GI practices have sent tissue specimens to an external laboratory at a local hospital or a national lab company for processing and interpretation. The external pathology company then generates

a report back to the practice and bills insurers and patients independently for both the TC and the PC. In recent years, many GI practices have explored the option of insourcing pathology services (either TC, PC or both) in order to better control quality and turnaround times, but also to capture additional revenue in an era of continued cost increases and reimbursement cuts. Others have engaged in a practice termed “client billing.”

The following review explains these different models and provides practical tips for interested GI practices to consider.

Insourcing the TC The TC of the pathology service (i.e., getting polyp tissue and biopsies ready for professional interpretation) can be performed as a semi-automated process in a 300-400 sq. ft. laboratory. Equipment required includes a processor, embedding center, microtome, stainer and cover-slipper. The initial financial investment is modest, and should always include obtaining the assistance of an experienced consultant to build the lab and help navigate the many legal and regulatory issues. Some payers now require accreditation of in-office pathology laboratories,5 and the related costs need to be factored into the overall expense of creating the lab.

Operational expenses will include rent, utilities, supplies, maintenance and repair costs as well as salary and benefits for one or more histopathology technicians. Building a small, de novo histopathology laboratory and getting it ready for operations can usually be accomplished with outlays of under $500,000.

The upfront investment necessary to build the lab will only make sense if a GI practice is large enough to generate

a sufficient enough number of tissue specimens to recoup its investment and reach profitability in a reasonable amount of time. As a general rule of thumb for determining the feasibility of TC insourcing, an annual volume of at least 5,000-6,000 specimens is desirable. These specimens must be available to be processed in the practice’s own laboratory (i.e., not tied to payer contracts that mandate processing of tissue by a specific external laboratory).

Insourcing the PC The pathologist interpreting the tissue specimens can be employed by the practice or work as an independent contractor. In a single-specialty GI practice, this work is highly focused (only involving GI specimens) and usually comes without any on-call requirements, making employment an attractive proposition to many pathologists. Issues such as backup staffing for vacations and absence due to illness need to be considered and favor larger volume practices, which may generate work for more than one pathologist.

An important regulatory issue to consider is the Medicare anti-markup rule and site-of-service requirement for the PC. In short, in order for the GI practice to bill Medicare for the PC and realize a profit from this service, pathologists need to perform at least 75% of their professional services for the GI practice or perform their work “in the office of the billing physician.”

A more detailed discussion of this important regulation is beyond the scope of this review and can be found elsewhere.6 Legal framework While the federal Stark law generally prohibits physicians from referring patients to entities with which they have a financial relationship, such referrals are permissible under certain

circumstances under the in-office ancillary services exception (IOASE) to the Stark law.7 Recent concerns about inappropriate overutilization of such self-referred services have led to a number of challenges to the IOASE on both a federal and a state level. However, proponents of in-office labs have argued that evidence for such inappropriate overuse is scant and contradicted by a recent study,8 and that the IOASE instead improves patient care and efficiencies by integrating necessary medical services in a single office. At the time of this writing, proposals to limit the scope of this exception have not been adopted.

Reimbursement for pathology services Table 1 shows commonly used Current Procedural Terminology (CPT) codes for GI pathology services and their 2015 Medicare reimbursement rates.

Medicare payments for the TC of the most commonly reported code for GI pathology work (CPT 88305) were reduced by 52% in 2013 and many commercial payers have since followed suit on this payment reduction. While operating a histopathology lab can still be a profitable proposition, GI practices need to perform a detailed analysis of the payment rates for their major payers and expect the rate of return for newly built pathology labs to be lower compared to previous years.

Notes about quality The insourcing of pathology services greatly improves the GI practice’s ability to take control of turnaround times and the quality of the service.

Many practices now guarantee a 1-2 day turnaround on pathology specimens and create a single report to the patient, including the endoscopy findings, pathology results and their interpretation. A single bill can be generated for the entire service.

When hiring pathologists, an effort can be made to find providers with subspecialty training in GI pathology.

Pathologists often participate in the GI practice’s journal clubs, peer review meetings and quality assurance projects, thereby facilitating the dialogue with their gastroenterology colleagues about complex clinical cases. While it is difficult to quantify the effect of this approach, we believe that having well-trained GI pathologists as an integral part of the GI team has resulted in substantial improvement in the quality of the service we provide to our patients.

Client billing Some GI practices that do not want to consider insourcing of pathology may instead choose to pursue another model known as client billing. With this model, the GI practice purchases pathology services at a discounted

Table 1. 2016 Medicare payment rates (national average) for commonly used GI pathology CPT codes

CPT Descriptor

Global Professional Technical Payment Component Component

88305 Surgical pathology, level IV

(gross and microscopic examimation)

$74.11

$39.74

$34.37

88312

Special stains (microorganisms)

$98.82

$28.29

$70.53

88313

Special stains (e.g. iron)

$69.10

$12.53

$56.57

$107.41

$37.24

$70.18

88342 Immunohistochemistry

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rate from an independent laboratory or pathology group. The GI practice then bills insurers and patients for this pathology work at the full rate, thereby realizing a profit in exchange for assuming the costs of specimen collection, billing and related administrative services.

The advantages of client billing include the practice’s ability to partake in the pathology reimbursement without having to assume the cost and the risk of insourcing this service. Practices that do not generate large volumes of specimens may find this option particularly attractive. However, Medicare rules prohibit client billing, and several states have passed disclosure laws and antimarkup rules that need to be reviewed to determine whether client billing is an option in a specific commercial market.

A list of states with direct billing and anti-markup laws can be found online.9 Take-home messages Here are three key take-home messages: • Insourcing the TC and/or PC of pathology services provides gastroenterologists with an opportunity for ancillary revenue. It is still feasible for medium- and large-sized practices even after recent reimbursement cuts.

• A detailed review by regulatory and legal consultants is necessary before internalizing TC/PC or pur-

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suing other models such as client billing arrangements.

• In an era of bundled payments, GI practices are well advised to internalize and thus control the operations and related quality and costs of all services that are integral to the performance of GI endoscopy, including the pathology evaluation of tissue specimens.

References 1. Ganz Robert A., The Evaluation and Treatment of Hemorrhoids: A guide for the Gastroenterologist.

Clinical Gastroenterology and Hepatology 2013; 11:593-603.

2. Cleator Ian G. Banding Hemorrhoids using the O’Regan Disposable bander. US Gastroenterology Review 2005;5:69-73 3. Johnson David A. Evolving Perspectives for Survival of Gastroenterology Practice: A Business Plan Assessment for improved Economic Success. EndoEconomics. August 2011: 5-7 4. Kelly S. M. A Prospective Comparison of Anoscopy and Fiberendoscopy in Detecting Anal lesions. J Clinical Gastroenterology 1986; 8(6): 658-660 5. www.aetna.com/healthcare-professionals/documentsforms/HOPP440Letter-GA-TBGA.pdf (accessed Dec. 13, 2015) 6. www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/downloads/MM6371.pdf (accessed December 13, 2015).

7. http://www.ama-assn.org/ama/pub/advocacy/ topics/in-office-ancillary-services-exception.page (accessed Dec. 12, 2015).

8. www.ama-assn.org/ama/pub/advocacy/topics/in-office-ancillary-services-exception.page (accessed Dec. 12, 2015) 9. www.cap.org/apps/cap.portal?nfpb=true&cntvwrPtlt_ actionOverride=%2Fportlets%2FcontentViewer%2Fs how&_windowLabel=cntvwrPtlt&cntvwrPtlt%7Baction Form.contentReference%7D=advocacy/advocacy_issues/summary_state_law.html&_pageLabel=cntvwr (accessed Dec. 12, 2015)

Harry Sarles Jr., MD, FACG, board certified in internal medicine and gastroenterology, currently practices at Digestive Health Associates of Texas (DHAT) in Dallas, TX and is the Director for the DHAT Research Institute. Dr. Sarles is the past president of the American College of Gastroenterology and the Texas Society for Gastroenterology and Endoscopy.

David A. Johnson MD, MACG, FASGE, FACP, is a professor of medicine and chief of gastroenterology at Eastern VA School of Medicine. Despite his primary focus on the clinical practice of gastroenterology, he has published extensively in the internal medicine/gastroenterology literature, contributing over 600 articles/chapters/invited reviews and abstracts in peer-reviewed journals and books, including editing Gut Microbiome: New Understanding and Translational Applications for Disease Management (published December 2015). He currently serves on the American Board of Internal Medicine (Gastroenterology) Board of Examiners and is a past president of the American College of Gastroenterology (ACG). His primary current research interests are esophageal reflux disease, the gut microbiome in health and disease, effects of sleep fragmentation on GI disease and colon cancer screening.

Klaus Mergener, MD, PhD, MBA, FASGE founder and director of the GI Roundtable conference, is board-certified in gastroenterology, medical management, and healthcare quality management. Dr. Mergener is a partner at Digestive Health Specialists and currently serves as the director for interventional endoscopy at MultiCare Health System in Tacoma, WA. He is also an affiliate professor of medicine at the University of Washington in Seattle, WA. Dr. Mergener is a recent member of the Governing Board of the American Society for Gastrointestinal Endoscopy (ASGE) and the current ViceChair of the ASGE Foundation Board of Trustees. He served as Associate Editor for Gastrointestinal Endoscopy through 2014.

will soon become a necessary part of doing business in healthcare. This is a concept whose time has come and the fact that it both reduces the potential of a professional liability claim and positively impacts economics is pretty powerful.

Five Star Service Excellence in GI

By James W. Saxton, Esquire

The lines have crossed in a historic fashion significantly increasing the importance of classic service excellence or enhancing the patient experience.

It has long been a subject of research and studies showing that the better the patient experience the less JAMES W. SAXTON, likelihood of a medical professional ESQUIRE liability claim. If anything, the relationship between the two has been undervalued! What is now coming into clearer focus is the correlation between high scores in the patient experience arena and positive economic consequences to a practice, particularly as value-based reimbursement becomes more dominant. Whether it is Medicare or commercial payors, there is a significant trend to move from payment for volume to value, and it appears to be taking place at an even quicker pace.1 It has also been shown that the stronger the patient experience, the less bad debt a practice incurs. This relationship is becoming more important as copays and deductibles continue to climb. These patient experience scores could drive invitations to narrow networks, Accountable Care Organizations or virtual clinically integrated networks which are growing around the country. There is no doubt these “scores” will be public and can drive referrals. Many health policy experts have concluded that patient experience scores

The related issue, which has been less discussed but is equally important, is that of GI patient engagement. Patient engagement is a key concept and although related to patient satisfaction, is very different. Engaged patients are actually a cornerstone of the new healthcare delivery environment.

When patients are better engaged they are more likely to understand their instructions. Engaged patients have been shown to have better outcomes in part because compliance is enhanced. True patient engagement involves making the patient, and at times, the family, as responsible as they truly are or should be. It has profound patient satisfaction implications and actually very significant positive liability implications. Clearly, increasing engagement is in keeping with our theme of being able to enhance your economics while concurrently reducing your liability exposure.

Once the goal of enhancing the patient experience is accepted, the question turns to how to assure survey scores will be ones you are both proud of and happy to share.

A couple of early steps. One needs to take the time to examine the culture of their practice and determine if you are truly focused on creating a 5 Star GI experience. Is the first impression what you want it to be? Are patients greeted with the right tone and body language? Have the staff and physicians received some basic communication training? Are the leaders of the practice “champions” of the concept? Are bonuses paid in part based on accomplishing good scores? Is it part of the orientation process and yearly evaluation? As part of this process, also look at some very specific points of patient and family contact. Consider: • Greetings both on the phone, web, as well as when one first enters the practice.

• The way patients are “called to their visit. Are they called out or invited?

• The interaction with the assistant and nurse • The all-important visit with the doctor. Is it on time?

Does he or she give undivided attention? Does the EMR get in the way of the communication between the doctor and patient. Is there time for questions? Body language of the doctor… rushed or calm?

• Is there documented shared decision making, critical in this new high deductible environment.

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• Has the patient acknowledged understanding of instructions and is it well documented?

• Have you used a GI specific informed consent, again documenting engagement?

• When there are patient complaints (always happens no matter how hard we work), is there a process to diffuse and do a “service recovery”?

• Is there a process to handle staff complaints? 5 Star needs to be internal as well as external. Staff has difficulty delivering 5 Star when they are not treated that way.

Next, this will not happen in a serious fashion unless one measures the patient experience. It is best to use a scientifically created GI patient experience survey tool.

Homemade surveys are discouraged because poorly created questions that lack statistical support can be misleading.

Use a GI specific survey tool, since when an overly generic patient survey is used, the results you get are less valuable.

Make sure your survey tool yields strong responses, meaning a high percentage of patients respond. The one I am familiar with obtains returns in the 35% range so that there is no doubt that there is statistical relevance.2 You want it to be simple for patients to use and verify the questions have been scientifically created with help from a psychometrician.

(Yes, there is real science on how these surveys are created!)

Make sure you are getting results real time, not months down the road, and that you have comparable statistics.

Then use the survey results as a management tool for all your providers and staff. This is powerful information which allows you to focus on where improvement is needed. There is nothing more frustrating (for your providers or staff) to be “fixed” in areas where there is no corresponding need.

Time is too valuable. Knowing who you need to help and in what areas, allows you to focus your efforts on where it counts. You will begin to see trends. Is it the phone system which needs attention? Does the front desk need training?

How did your doctors do in the engagement area? Are instructions understood? Seeing how doctors compare to not only each other but their peers is powerful. You have the ability to now determine what your educational programs need to address. It allows you to compare sites and move to best practices. What is office A doing compared to B? Why are their scores consistently better? These scores can also be used to protect you and your practice from other low-yield, web-based measuring organizations. This will be a scientifically valid score you can use.

Now it gets interesting. We have seen groups use this data to negotiate higher reimbursement, to market more effectively, to obtain new referral sources. This type of data is exactly 12 |

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what will be needed as the value-based world becomes a bigger reality. Health policy experts consistently stress that Medicare is phasing out fee-for-service and replacing it with value-based contracts. The commercial insurers will follow. Narrow and ultra-narrow networks are being formed.

Having strong patient experience and patient engagement scores will be key to keeping you in the game. On-going measurement is critical. Obtaining a baseline but then looking at their scores and using the data to focus on continued improvement is critical to your on-going success.

Payors have told us that finding practices (GI practices) that are willing to measure and use results to improve are the practices they want in their network! The results will also create an environment your patients will appreciate, talk about and score highly. It’s an environment your staff will value and retention of the employees will increase as well.

Conclusion There is little doubt that the environment is going to continue to change. Some may think this is just another trend which will reverse itself over time. However, these changes are fairly organic and all sides of the political spectrum are agreeing that the way healthcare is both paid for and delivered has to change. The safe bet is to be proactive.

Enhancing patient satisfaction and engagement in a GI practice has multiple advantages. Really, for the first time in history, the lines have crossed. You can incorporate certain pragmatic changes and both reduce your liability risk and enhance your economics. As with any change, the key is to take it on seriously. Make it consistent and persuasive — meaning all the time by everyone. This is why measurement is so important. Put this on your next agenda; it’s time to get serious about the “patient experience” in your practice.

References 1. See for example: Radnofsky, L. (2016, March 3). Obama Administration Hits Medicare Payment Target Early: Shift in the Way Payments Are Made Emphasizes Quality of Care over Quantity. Wall Street Journal. Retrieved from http://www.wsj.com/articles/obamaadministration-hits-medicare-payment-target-early-1457040340 2. See generally SE Healthcare Patient Experience Platform at http://www.sehealthcarequalityconsulting.com/physician-empowerment-suite/the-patient-experienceplatform/

James W. Saxton, Esq., CEO, Saxton & Stump, LLC, has sustained an active litigation practice for more than 30 years, representing hospitals and physicians before state and federal courts in professional liability and complex litigation matters. Leveraging his extensive experience as a litigator, he advises physicians, hospitals and longterm care facilities on understanding and reducing their professional liability risk. Jim is a nationally known speaker on healthcare issues and has presented to many prominent healthcare organizations including the Society of American Gastrointestinal and Endoscopic Surgeons, American College of Surgeons and the American Society for Metabolic and Bariatric Surgery. Jim is also a Board Member for SE Healthcare Quality Consulting, LLC. He can be reached at jws@saxtonstump.com.

Medical Entrepreneurship in GI

By Rajiv Sharma, MD

If there was ever a time for GI physicians to seize the reins of medical entrepreneurship, this is it.

trendsetters, to be innovators. What does this require?

RAJIV SHARMA, MD

The healthcare system is rapidly evolving, creating obstacles for physicians who want to remain independent and earn a good living in the process. While it may be easier to accept an employed position, for many physicians this will be a shortterm solution, and one that is often unfulfilling.

Fortunately, thanks, in part, to advances in social media and digital technology, this is not the only option. While changes in healthcare are creating challenges, they are also bringing tremendous opportunities — opportunities for physicians to be leaders, to be

It takes a “thought”; it takes a “first step”; it takes a “decision.” We must take control of our destinies, and capitalize on the many years of hard work we put in just to become physicians.

This means not only finding ways to remain independent, but maximizing our earning potential in the process. Every year of our life needs to be looked at as a fiscal year. We need to evaluate our life in “three-year plans.” There needs to be personal and professional growth in these fiscal periods.

While some may frown upon the idea of doctors working to make more money, that’s an antiquated idea. We are being treated (and taxed) no differently than businesses. Then why can’t physicians, who dedicate themselves to their craft and are the worker bees that drive the healthcare system, not only

earn the respect they deserve but the compensation that should come with that respect? Isn’t this still America, where you have freedom to maximize your earnings?

We can, and that’s where medical entrepreneurship comes in. By thinking outside of the box — or, as I like to say, being a “Jack-outside-thebox” (copyright Rajiv Sharma) — and investing in yourself, you can not only survive in this ever-changing, everchallenging healthcare environment, but flourish and find happiness with the practice of medicine. You owe this to yourself — but know that it won’t be handed to you.

There are many different ways to be medical entrepreneurs. Here are just a few areas to consider focusing to enhance your earning potential.

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Dietitian Programs Wellness is a “balanced” state of mind and body. As physicians, we preach the importance of nutrition, eating well, exercise and sleep as critical components of healthier living. Unfortunately, patients struggle to follow this guidance because they lack the tools necessary to do so on their own.

An essential component is typically the employment of a dietitian. A dietitian acts as an extension of the physician, serving to guide patients on how to effectively follow the recommendations provided by their physician. The dietitian is available to review the guidance, answer questions and check in with patients to learn whether the guidance is followed, and, if not, what needs to be done to get patients back on track.

Our practice has a dietitian, and my patients regularly thank me for the associated services. And as much as my patients appreciate the work of the dietitian, I do so as well. My dietitian provides a way for me to keep an eye on my patients in a manner that I would not be able to do on my own. This also enhances quality (and quantity) of follow-up visits as this approach empowers patients. This could be a source of additional revenue, especially cash revenue, depending upon the efficiency of the model.

Commerce To further capitalize on the services provided by a dietitian, a medical practice can include a commerce component.

It’s easy to tell patients to avoid unhealthy foods and cook better. For some patients with allergies, we advise them against eating specific foods.

Then we send them on their way to determine what purchases to make to follow our guidance. What often

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happens next? The patient will either wander around a supermarket, trying to determine what items comply with our recommendations and which do not, or they will go on online to do research. In either scenario, a patient can feel overwhelmed by information and choice.

We can make this better.

At a minimum, a practice can provide meal-planning services, sell recipes and cookbooks, and make restaurant recommendations that will give patients a roadmap for success. Or take it one step further and actually sell food and dietary supplements.

On a small level, that may include vitamins and dietary supplements from the physician practice itself instead of purchasing these items from Amazon, Wal-Mart or their friend who just joined a multi-level marketing hustle. Not only is this an added convenience you can offer, but patients will feel better knowing they are bringing home quality products that you believe in. I have a physician colleague who makes well over $500 in profits a day after having added a supplements and wearable devices sale component to his practice. That’s about $10,000 a month — passive. His front desks is trained to collect payments. Now that’s innovation!

On a bigger scale, my dream practice shall have a small kitchen or cafe area where we can sell smoothies and healthy meals, either made fresh or pre-cooked for patients to take home with them.

With these offerings, we can facilitate healthy behavior by providing these items immediately after providing patient education — the heightened emotional and readiness to take action phase. Your practice will become a one-stop point for health and wellness.

By doing this, you will 1) empower and help your patients succeed in their health goals, 2) oversee their diet intake, 3) enhance your revenue, and 4) enhance happiness (both for you and your patients).

Ambulatory Surgery Center ASC ownership by GI physicians is written about and presented on frequently, but I would be doing a disservice if I failed to mention their value in a column about medical entrepreneurship.

There are two sides. When you work as an employee, you’re working in someone else’s shop. You’re an employee who receives a certain paycheck. While you have important medical decisions to make, your work ultimately benefits the institution much more than yourself. As mentioned earlier, employment is an option for physicians, and one many choose to take. There are undeniable benefits to employment, but I believe that owning an ASC outweighs those benefits.

When you own an ASC, you own your own shop, and feel the excitement and satisfaction of running a business. You call the shots. Yes, it is true that you will have important, often difficult clinical and business decisions to make from time to time, and it’s not all peaches and cream. But when those business decisions are made wisely, you reap the rewards.

A well-run ASC, with adequate ancillaries such as pathology, anesthesia, etc., could generate good passive revenue. Physician run practices and hospitals seem to be very successful.

To me, it just makes more practical sense for someone who understands a “physician’s” lifecycle and struggles to make important decisions that affect the physicians. Didn’t Colonel Sanders know how to make spicy, crispy chicken himself first before he created the

KFC concept? There are numerous examples of physician-run organizations that succeed, from the thousands of physician-owned ASCs throughout the country to Cleveland Clinic (Dr. Delos Cosgrove, CEO and President). There’s every reason to believe you could be yet another example.

Marketing “If you build it, he will come.” This famous quote from the film “Field of Dreams” (frequently misquoted as “If you build it, they will come”) used to be true for physicians. It wasn’t long ago that if you opened a practice or ASC, patients would find their way to you without much effort on your part.

But that is quickly changing.

As patients have become more tech savvy, with online resources available to them rapidly growing, and take on more responsibility for the cost of their care, they are spending more time researching their medical options, both who will provide their care and the facility where they will receive the care.

This is particularly true with younger generations, who are highly digital.

It’s no longer enough to simply have a building and an address in the yellow pages. If people don’t have a way to learn about you — a lot about you — you essentially do not exist. That’s why marketing is becoming increasingly important for your practice, ASC and any other endeavor you pursue.

On a simple level, marketing today requires having a website. But even just a simple website may no longer be enough to attract patients.

Consumers are looking for reasons to choose one medical provider over another. The physicians who can convey this information most effectively are more likely to “win” the business of that consumer. It’s really no

different than running a grocery store.

Grocery stores need to earn and keep the business of their shoppers, as do physicians. Consumers need to know why they should purchase your medical product (service) and not someone else’s.

Conclusion

For physicians to earn business, they must tell the story of their business on their website, and make the story compelling. That may include details on patient satisfaction and outcomes, such as a high adenoma detection rate. It may require highlighting credentials and specialty training. It may even require an emphasis on cost-effectiveness. Money is a driver of consumer choice, but consumers generally lack education about facility costs (Hospital vs ASC).

If entrepreneurship sounds appealing, and hopefully I have helped add a little fuel to your fire, one of the first steps to consider taking is to identify physician entrepreneurs and innovators who have found success doing what you want to do. Then pursue ways to learn from them, either by reading or hearing them present on their work, or even consider reaching out to them for a discussion.

Marketing efforts can — and likely should — go beyond a website. They can include developing a presence on social media and working with a marketing company (preferably one with experience in the medical space) to target specific demographics with pertinent messaging.

When marketing is successful, and it’s coupled with great care, consumers will not only flock to you and return as repeat customers, but they will become your best referral sources. If patients really like and value their doctor, they will be first in line to support new initiatives. If their insurance tells them they need to see a different doctor, these patients will not only push back, but won’t mind paying out of pocket for their treatment if it means they receive care from you.

It’s time for medical entrepreneurship and there are numerous ways to start the journey. What I presented here is just a brief overview. This is not a journey you need to take alone.

There are many physicians, myself included, who are eager to speak about the passion we have for entrepreneurship and innovation. And we are just as eager to hear about ideas and visions from other likeminded physicians. When entrepreneurship is successful, physicians, patients and the entire healthcare system wins.

Please feel free to reach out to me via email at raamsconsultingllc@gmail. com and rsharma@egmhealthinc. com. I can also be reached via social media — find me on Twitter, Facebook, Instagram and LinkedIn.

Rajiv Sharma, MD, is a board-certified gastroenterologist and wellness physician in private practice. He is the founder of RAAMS Consulting, clinical advisor at EGM Health and author of the book “Pursuit of Gut Happiness: A Guide for Using Probiotics to Achieve Optimal Health,” which was published in 2014. For more information, visit http://rajivksharmamd.com.

Physicians must work much harder today to grow patient volume. But a strong marketing plan will get consumers in the door and help earn their loyalty for life.

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What Every Physician Should Know From

GI Roundtable 2016

By Carol Stopa, Editor in Chief SVP, Business Development, Physicians Endoscopy The 6th GI Roundtable (GIRT) took place in March in Fort Worth, Texas. The annual networking conference for physician leaders and practice administrators was organized and co-chaired by Klaus Mergener, MD, Tom Deas, MD, and Gene Overholt, MD. Physicians Endoscopy is an industry partner to GI physicians and a long-time supporter of GIRT. It is important to us that all physicians understand the resources available to them and the collaborative opportunity in participating at these types of conferences. We want to provide quality feedback to physicians who have not attended in the past, so following this year’s event, EndoEconomics interviewed four physician attendees about the valuable experiences they gained.

The physicians interviewed were as follows (listed in alphabetical order by last name):

NEIL HERBSMAN, MD

Dr. Herbsman is board certified in gastroenterology and internal medicine.

He practices out of Gastroenterology of The Bronx (NY). Dr. Herbsman earned his medical degree from the Mount Sinai School of Medicine in New York.

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ROHIT JINDAL, MD

MARCH SEABROOK, MD

CORY VERGILIO, MD

Dr. Jindal is board certified in gastroenterology and internal medicine.

He practices out of Gastroenterology Associates of York (PA). Dr. Jindal earned his medical degree from Maulana Azad Medical College in India.

Dr. Seabrook is board certified in gastroenterology and internal medicine. He practices out of Consultants in Gastroenterology (SC). Dr. Seabrook earned his medical degree from the University of South Carolina School of Medicine.

Dr. Vergilio is board certified in gastroenterology and internal medicine. He practices out of Digestive Healthcare Center (NJ). Dr. Vergilio earned his medical degree from the University of Medicine and Dentistry of New Jersey.

These physicians were each asked the same four questions. Here are their responses (provided in no particular order).

Q: Why did you attend the 2016 GI Roundtable?

Dr. Neil Herbsman (NH): During the past few years, it has become clear to me that the pace and nature of change in healthcare requires physicians to become more knowledgeable and proactive in shaping the destiny of their future. I feel this applies regardless of the nature of where we practice medicine, whether it be as a solo physician in a small single specialty group, megagroup or hospital-employed position. The breadth and depth of lectures at GIRT offered an excellent opportunity to acquire the information necessary to more effectively navigate my future as a gastroenterologist.

Dr. Rohit Jindal (RJ): GIRT is an excellent conference where representatives from many of the successful GI practices across the country come together and exchange information and ideas.

My practice has been attending GIRT for five years, and each year my partners and I have had the opportunity to learn from experts in the fields of policy, practice management and clinical aspects of GI practice. This year, again, I wanted to find out what changes my practice could incorporate to remain successful and continue to provide the most effective care to our patients.

GIRT provides a good opportunity to learn from peers and experts, and also provides a “peek” into the future of GI practice.

Dr. March Seabrook (MS): A colleague of mine with whom I worked closely in developing and supporting the South Carolina Gastroenterology Association has been asking me to attend for many years. The other reason I wanted to at-

tend was because I was an attendee at the South Carolina Gastroenterology Association meeting this past September. Dr. Mergener (GIRT co-chair) was invited to speak as a guest. I heard his pitch and support for GIRT, and it further validated my need to attend. I felt this was the year to finally make the trip, and I’m glad I did.

Dr. Cory Vergilio (CV): With all the changes coming to the practice of gastroenterology, from the emphasis on defining what makes a quality practitioner, to taking that definition and deriving data from it, to using that data to shape the future of how we do what we do, my hope was that GIRT would help provide current information as well as give me some national perspective on what we do locally and in our practice to meet these goals.

Medical delivery systems are changing rapidly from a fee-for-service structure, and GI practice has not traditionally been dominated by value-based reimbursement, alternate payment models and bundled care strategies.

That is what our future holds, and my goal in attending GIRT was to look at potential practice and implementation strategies to best care for our patients in this new environment.

Q: What were your highlights and top takeaways from the meeting?

CV: There is zero doubt to me that how we must practice is changing fast, and will change even faster in the next four years. The advent of payment reform to begin in 2019, with value- and performance-based models becoming the way in which we receive reimbursement, will necessitate reorganizing and reinventing how physicians see patients, and how services are delivered and paid for in order to best meet efficiency and quality goals in the new system.

Being fortunate to practice in a group that is at the forefront of many of these initiatives, having the chance to hear on a national level at GIRT that we were indeed rewriting our future by working hard to provide quality GI care at the lowest cost was reassuring at this challenging time. Our work to develop internal data to demonstrate and measure our progress is also key in succeeding in a landscape that will be dominated by alliances across hospital systems, physicians and payors to provide quality care that is available and affordable. The content of GIRT reinforced that for me.

NH: Highlights of the meeting included the ability to engage with other gastroenterologists from across the country, interaction with the senior medical officer in the Centers for Medicare & Medicaid Services and the wealth of constructive advice provided by the lecturers. Perhaps the most important takeaway from the meeting was that at this stage in the transformation of healthcare, gastroenterologists are still able to have control over their future if they proceed in a proactive manner to shape their own future. Amongst numerous attendees and lecturers was an optimism regarding this objective that was empowering and often lacking in physicians’ thoughts about the future of medicine.

RJ: We are in a practice landscape that is changing at an amazingly fast pace. The practices that aspire to remain successful need to stay abreast of the upcoming changes and adapt accordingly.

The concepts of value-based effective care and the demands for high-quality, low-cost care are here to stay. GI practices need to identify their role and place in the complex world of accountable care.

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Each month, newer technological advances are available in the fields of GI medicine, electronic records and management, and practices have to dedicate resources in order to select from and apply these advancements.

trends in large group formation.

These vehicles will likely be necessary to provide the best care in a vibrant practice environment that is equipped to thrive in the coming decade and beyond.

MS: As a senior member of a group of eight independent gastroenterologists, with a very busy practice and two endoscopy centers, I wanted to confirm some of the things we were doing and thinking about with peers at the conference — specifically, thoughts and philosophy around remaining independent as a specialty. My goals were to listen and learn about the successes and challenges of trying to be a nimble group that can adapt quickly.

It is important to me to play a role in helping shape how GI care is delivered in a cost-effective, outcomes-driven manner.

NH: I absolutely intend to participate in future GIRT meetings. Attending the conference provides one with the opportunity to remove themselves from the clinical environment and create dedicated time to plan constructively for the future of your practice. More than ever, there is a need to continuously evaluate the quality and efficiency of both the clinical and business aspects of a gastroenterology practice. Attendance at events like GIRT is an important component in this endeavor.

Q: Do you plan to attend next year’s GI Roundtable? If so, why, and what will you hope to gain from the meeting?

MS: My goal is to attend next year.

Furthermore, I would like an additional partner to attend, as well as one of our senior administrators. I specifically want to hear about challenges, successes and perspective from other groups around the country, and learn how they are tackling the issues of the day, whether they be regulation driven, clinically driven or practice driven.

CV: The format of GIRT is unique in that it provides an update on some of the most recent advances we offer in our practices within the context of the business, administrative and information systems that make our practices run. The presentations were current and useful, so I do indeed plan to attend next year. As changes in the business of medicine occur so fast, my goal would be to stay current in changing payment structures and

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RJ: Yes, I plan to attend GIRT next year as it is a well-organized and informative meeting. From what I learn over the course of a weekend, I hope to take home ideas to make my practice better.

Q: For members of the GI community who have not attended the GI Roundtable, would you recommend doing so? If so, why?

RJ: I highly recommend that GI practices that have not attended GIRT yet consider sending their key physician and management representatives to the conference next year. I think there is a wealth of practical knowledge that can be gained from this meeting.

MS: I would definitely recommend attending a future GIRT meeting. I had a very enjoyable experience at my first meeting, and came away with a wealth of great information that will help me make better informed decisions for my practice and endoscopy centers.

CV: It is impossible to perform efficiently in private practice without understanding the impact of treatment decisions we make. We control huge

sums of money in the diagnostics we perform and order as well as in the treatments we prescribe. As the emphasis switches from fee-for-service to value- and performance-based models, how we practice on a daily basis will determine our viability as the reimbursement system evolves and takes the cost of what we do into account.

GIRT gives a concise, informationpacked practical synopsis of what we need to consider, both on a clinical and an administrative basis, to continue to be successful in our practices for years to come NH: I would highly recommend attendance at GIRT for those who have not done so previously. It is very easy to get caught up in the day-to-day management of a practice and fail to take the time to plan a long-term strategy for success. GIRT provides the tools and knowledge to help create and maintain a thriving gastroenterology practice.

• Variable Rates fluctuate with some type of index such as the prime rate or LIBOR. In a market where rates are expected to increase, loans with variable rates can become quite expensive if not monitored properly.

Financing Terms and Tips in the Ever Changing Economy

• Fixed Rates do not fluctuate and remain the same throughout the life of the loan. The rate is slightly higher than a variable rate but protects against interest rate increases.

Types of Loans provide you options based on your financial needs. There are several common loans that may be used: • Term Loan where principal and interest are paid monthly over a set period of time.

• Line of Credit (LOC) where an amount of credit is preauthorized by the lender and you can borrow up to that credit limit at any time. Generally, interest rates are variable and only interest is required to be paid monthly.

By Karen Sablyak, CPA and Tara Hamburger, CPA

Whether or not you follow interest rates, many people are wondering when interest rates are going to increase. In light of global pressures, mid-March 2016 the Federal Reserve decided to keep key interest rates unchanged that could impact the slowing of the US KAREN SABLYAK economy. Many now think that the Fed will likely take a more gradual approach to raising interest rates, with maybe two rather than four increases during 2016.

But all of this is really speculation.

The last time there was a significant change in the prime interest rate was seven years ago in 2009 when the rate dropped from 4.0% to 3.25%. It has TARA HAMBURGER remained at that rate for six years with the most recent increase to 3.5% as of December 17, 2015.

You may ask, what does all of this matter if I’m a GI physician?

Many physicians have practices and ASCs that have existing loans, or your businesses may be anticipating significant equipment or capital expenditures in the near term. Therefore, you may want to think about what this means in terms of the cost of financing now versus later.

Let’s start with an understanding of some of the most common terms associated with a loan document which will help you decided the best financing option for your situation.

Interest Rate is the amount charged for borrowing the funds.

There are generally two types of rates to consider:

Tip: A LOC is a great vehicle offering much flexibility when there are small capital purchases and you don’t want to impact operating cash. However, if you are not disciplined to pay down the principal, especially in the current market with increasing interest rates, you may find that the equipment originally financed can end up costing much more if you continue to only pay interest each month. You may want to take some time to review your LOC borrowings, and consider making monthly principal payments or converting them to fixed interest rate term loans under the current market conditions.

Term is the length of time you will make payments or the amortization period for the loan. Sometimes these are not the same which could result in a balloon payment at the end of the loan.

Tip: The term should closely resemble the life of the items that you are financing. For example, if you are financing computers that will likely be outdated in three to five years and replaced, it would not make sense to finance this equipment over seven years.

Guarantor (Guaranty) provides assurance that the debt will be paid and a guarantor basically steps into the shoes of the borrower if there is a default on the loan by the borrower.

Tip: Guarantees can be limited or released under certain circumstances, such as the borrower meeting certain financial covenants, so be sure to negotiate these terms.

Prepayment Penalty is the fee paid in addition to the outstanding principal if the loan is paid off early. The penalty is often quoted as a percentage of the outstanding principal balance or may be a very complex formula.

Tip: Prepayment penalties are almost always negotiable as part of the loan package, so always review these terms and make sure that you understand the calculation. This is especially

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important when interest rates are decreasing and you might expect to refinance a loan in several years.

Fees are charged by most banks for lending money. Some common types of fees include: • Commitment Fees are typically based on the amount of borrowing and expressed as a percent or basis points (e.g.

1/2% of amount borrowed). They can also be a fixed fee such as $2,000, $500, etc.

• Documentation Fees cover the lender’s cost of Uniform Commercial Code (UCC) filings and other administrative costs.

• Legal Fees may be included if the lender does not produce their own documents. You may incur a substantial cost for the production of documents, especially if you want to negotiate specific language and depending on the complexity of the lending arrangement.

Tip: Absolutely ask what the fees are as part of the proposal process and negotiate these as part of the deal.

Covenants and Reporting Requirements could be simple financial reporting requirements (e.g. submitting quarterly or annual financial statements or tax returns), or there could be a financial covenant requirement such as a Debt Service Coverage Ratio (DSCR). Reporting requirements can also be required of guarantors, so make sure you know what these are as non-compliance typically puts the borrower into a default situation.

Tip: Understand the reporting and covenant requirements and negotiate the least amount required. For example, does the lender really need annual audited financial statements AND a tax return, or just the tax return or just an internal financial statement. An audited financial statement is an additional expense for you. Covenant reporting (e.g. DSCR or AR reporting) is another task that someone from your staff (or your accountant) will need to perform.

Final Points Keep in mind that any capital equipment purchase will have tax consequences. On December 18, 2015, Congress passed a tax extender package which extended bonus depreciation rules for property acquired and placed into service during 2015 through 2019. The percentage is 50% through 2017, then declines to 40% in 2018, and 30% in 2019.

Why is this important in this financing discussion? Interest is a deductible expense and will follow the payments for tax purposes. Principal payments can vary depending if you finance with a term loan or LOC. This is important because tax depreciation can be accelerated under the bonus depreciation methods. However, the cash flow to service the debt will follow the terms of the loan causing taxable income and cash flow timing differences. It is always best to consult 20 |

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your tax advisor when making decisions on capital purchases and financing options to ensure you are planning for the tax consequences and differences of the options.

If you have existing loans, here are some things to consider given the current state of the interest rate market, which is expected to see rising interest rates: • Review your existing loans for variable rates and consider whether it is prudent to convert to a fixed term loan. Or if you have a LOC, begin making voluntary principal payments.

• You may find your existing loans carry higher interest rates and you could refinance at a lower fixed rate. Now might be the time to do so before interest rates increase further, but be careful of any prepayment penalties, refinance costs, etc.

• Review current loans for any future balloon payments or an interest rate reset date, as you may find yourself in a couple of years financing a large amount when interest rates are higher. It is not uncommon for banks to amortize longterm mortgages over twenty years but with five-year resets, meaning the interest rate resets every five years based on the index rate at the time the five years expires.

As a final note, don’t be afraid to shop around for some comparisons. Ask questions of the lender to make sure you understand all of the terms, negotiate with the lender to ensure favorable terms, and always consult your tax advisor.

Karen Sablyak, CPA, is the CFO of Physicians Endoscopy (PE) and is considered to be a founder of the company, co-writing the business plan with Barry Tanner that has evolved and grown into what exists as PE today. With nearly 30 years of experience in the healthcare industry, Ms. Sablyak oversees the extensive services that PE provides to its partnered centers including billing, finance, human resources and payer contracting. She and her team also provide substantial support to the business development team in evaluating de novo and acquisition opportunities as well as legal and risk review. From a corporate perspective, Ms. Sablyak also provides the strategic financial vision needed for PE to continue to grow and prosper while faced with the many challenges of Healthcare Reform. A key focus for Ms. Sablyak is for PE to continue to deliver superior, value-add services to their partnered centers while finding ways to improve efficiencies. For more information, Karen can be reached at ksablyak@endocenters.com.

Tara Hamburger, CPA, is the Executive VP of Finance at Physicians Endoscopy (PE) and has over 15 years of experience in finance and accounting. At PE, Ms. Hamburger oversees the entire financial management process and ensures that accounting procedures and reporting conforms to Generally Accepted Accounting Principles.

She provides leadership and coordination of financial reporting, tax compliance and budget management functions for PE as well as its partnered centers. From a corporate perspective, Ms. Hamburger assists the CFO with monitoring the Company’s debt structure and covenant compliance and provides critical financial insight and strategic support to the senior management team. A key focus for Ms. Hamburger is for the finance team to provide timely and insightful financial analysis to PE and its partnered centers. For more information, Tara can be reached at thamburger@endocenters.com.

Hemorrhoid Banding: The Implications of Introducing the Procedure to a GI Practice

Figure 1: The CRH O’Regan System Ligator (CRH Medical Corporation)

O’Regan System has dramatically improved on this technique.

With an updated model now comprised of an integrated obturator in order to ease insertion, this ligator uses gentle manual suction to draw tissue in, making the procedure much more comfortable for the patient.

Performed in an office or ASC, the treatment only takes a minute and typically allows patients to return to work the same day.

Due to the efficiency of the procedure, many GIs will schedule their hemorrhoid patients in blocks, typically performing five to six procedures per hour. A typical patient will require three procedures – one for each hemorrhoidal column. Only one column is treated per visit in order to minimize the risk of complications. With this protocol, complications have shown to be less than 1% with a recurrence rate of 5% at two years.3

Incorporating the CRH O’Regan System into a Practice

By Jessica Diduch With the recent reimbursement cuts to endoscopic procedures, many GI practices today are looking for ways to introduce new sources of revenue while remaining in line with their core competencies. Hemorrhoid treatment, in its various forms, has become a line JESSICA DIDUCH item for many groups over the past several years, with more realizing the opportunity every day.

Due to the fact that hemorrhoids affect approximately 75% of the population at some point in their lives, gastroenterologists are now diagnosing hemorrhoids on a routine basis — many times through a colonoscopy.1 Though not life threatening, the inability to definitively treat a patient who often times has been experiencing the discomfort and embarrassment of hemorrhoids for months, if not years, can be frustrating.

Providing a continuum of care to these patients not only offers economic advantages to the practice, it also allows the physician to provide relief to patients who would have otherwise had to go elsewhere, or continue to suffer.

Rubber Band Ligation The most common in-office technique for the treatment of hemorrhoids is rubber band ligation (RBL).2 RBL is widely used to treat all grades of hemorrhoids by placing a small rubber band around the apex of the hemorrhoid, causing the banded tissue to necrose and slough. The resultant scarring fixes the remaining tissue in place, keeping the hemorrhoidal tissue from prolapsing, and in doing so, eliminating the patient’s symptoms. Unlike traditional band ligation which uses metaltoothed forceps and an anoscope, the disposable CRH

Though initially something gastroenterologists were hesitant towards introducing, often because education in anorectal care had not been part of their training during their fellowship years, hemorrhoid treatment has now become a significant extension of many GI practices.

CRH Medical has now trained over 2,200 gastroenterologists at 800 practices across the country, offering a complementary physician-to-physician training program and comprehensive clinical and operational support to ensure a seamless integration.

The decision to incorporate a new procedure into a practice can be a balancing act, with the need to look at clinical outcomes, the ease of transition, the training required, and the economics involved.

When asked what propelled them to introduce hemorrhoid banding, several physicians trained on the CRH procedure responded with their take: Dr. Reed Hogan III (GI Associates & Endoscopy Center – Jackson, MS): Anorectal disorders are grossly ignored by the GI community, and I knew I could create a niche in this market. For years, patients have been conditioned to not discuss hemorrhoids with their doctors because they’ve been given two bad treatment options: ineffective creams or very painful surgery. However, being able to offer an effective and painless alternative is just plain fun. Patients are excited and grateful. Recurring office visits with positive results creates unique and excellent physician/patient relationships.

Dr. Jatin Bidani (Bardmoor Gastroenterology – Seminole, FL): I introduced CRH as there was a vacuum in the community, surgeons feel it is too small for them, and patients do not want to go to a surgeon (they have heard one too many horror stories). I could provide this service to patients who would suffer without knowing that a painless solution is available.

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Dr. Nolan Perez (Gastroenterology Consultants of South Texas – Harlingen, TX): Hemorrhoids are very common and ligation is the most effective treatment that we have to offer to patients. Office-based ligation is very convenient and effective for patients, and it is a value-add service for my practice.

Dr. Jose Rodriguez (Texas Gastroenterology Institute – McAllen, TX): We introduced band ligation of hemorrhoids to our practice given the common nature of the disease and patient dissatisfaction with other available remedies such as topical creams.

In a survey conducted by CRH Medical in 2013, 46% of physicians surveyed indicated that ancillary revenue was one of the primary reasons they decided to incorporate the procedure into their practice.

Financial Impact The financial implications this procedure has on a practice are meaningful, regardless of size. Reimbursement for hemorrhoid banding is, on a per minute basis, higher than for endoscopic procedures, including colonoscopy (Figure 2). This in itself makes banding a procedure that not only allows the physician to improve patient care, but also augments practice revenue.

When looking at Medicare data, Dr. David Johnson noted that hemorrhoid ligation (with the CRH O’Regan System) generated reimbursement rates that were 2-4 times higher than many common endoscopic procedures.4 These numbers increased even more when taking overhead costs into account and do not factor in the reimbursement cuts to colonoscopy made in 2016. In comparison to endoscopic banding, the CRH O’Regan System offers the same reimbursements with decreased costs associated with the product and overhead.

A pro forma outlining the potential hourly revenue generated by treating hemorrhoids with the CRH O’Regan System can be seen in Table 3.

Table 1: Revenue for rubber band ligation, upper endoscopy and colonoscopy as compared per unit of time. Rates based on 2016 Medicare national averages.

it is a practice’s ability to put processes in place in order to identify and educate their patients on hemorrhoid disease and treatment that is the single biggest contributor to volume of procedures performed.

Table 2 looks at a sample of practices performing hemorrhoid banding at varying levels and settings. A solo practitioner in Colorado performs under twenty procedures per month which relates to approximately six patients; whereas the threephysician practice in Florida that performs 940 procedures per year is performing just under 80 procedures per month, corresponding to nine patients per physician per month. If the seven-physician practice in North Carolina emulated the group in Florida, they would more than double their revenue from banding.

Table 2: A snapshot of how several GI practices have benefited from the introduction of the CRH O’Regan System.

# of Procedures # of GIs State Per Year

Annual Est. Revenue*

Office/ ASC

1

CO

220

$70,646,40

Office

3

FL

600

$200,472.00 Office

3

FL

940

$341,849.80 ASC

7

NC

1,040

$312,093.60 Office

*Estimated revenue based on local 2016 Medicare reimbursement rates. Revenue for office based procedures includes professional fee and E&M (CPT 99212). Revenue for ASC includes professional fee and facility fee.

Table 3: Hourly revenue based on national average 2016 Medicare reimbursements.

Reimbursements

Office ASC

Professional

$273.90 $195.00

E&M Facility Total Per Procedure Visits Per Hour

CPT Procedure Revenue Procedure Location

Code Time Per Minute

Revenue Per Hour

Hemorrhoid 46221 Ligation

Office

12 minutes

$22.83

Costs

Hemorrhoid Ligation

46221

ASC

12 minutes

$31.03*

Cost Per Hour

Upper Endoscopy

43235

ASC

30 minutes

$18.37*

Net Revenue Per Hour

Colonoscopy 45378

ASC

30 minutes

$20.69*

Litigator and Disposables

*Includes procedural and ASC fees

One might expect the amount of revenue generated from hemorrhoid banding at a practice to be proportional to the number of physicians performing the procedure. However, 22 |

EndoEconomics SPR ING 2016

$43.68 — — $176.52 $317.58 5 $1,587.90

$372.37 5 $1,861.85

$73.00

$73.00

$365.00

$365.00

$1,222.90

$1,496.85

The procedure can be performed in either an office or an ASC as no special equipment is required. The decision on where to perform the procedure typically comes down to availability of space, costs to the patient, and reimbursements for the procedure.

Figure 3: Advantages and disadvantages of performing the procedure in an office and ASC settings.

Growing a Practice As hemorrhoid treatment is added to the list of procedures and services a practice offers, many will begin to see an increase in the number of new patients seen – especially when a degree of marketing comes into play (through the practice website, referring physicians or local advertising). Often times, these new patients will require other treatments such as colonoscopy, and will continue to remain a patient in the years ahead. Though beneficial for most physicians, those who are just starting in practice often see the greatest impact. In addition, due to the effectiveness of the procedure, patients will often times begin to refer their physician to friends and family who may also be suffering from hemorrhoids, helping to further expand the practice.

“There is no doubt that banding has expedited the growth of my practice. So many of my hemorrhoid patients are referred by their friends and family members who also had a great experience with good results from the CRH System.”

– Dr. Reed Hogan III References 1. Baker H. Hemorrhoids. In: Longe JL, ed. Gale Encyclopedia of Medicine. 3rd ed.

Detroit: Gale; 2006: 1766–1769.

2. Kann BR, Whitlow CB. Hemorrhoids: diagnosis and management. Tech Gastrointest Endosc 2004;6:6–11.

3. Cleator IGM, Cleator MM. Banding hemorrhoids using the O’Regan disposable bander. US Gastroenterology Review, 2005:69–73 4. Johnson, David A. Evolving Perspectives for Survival of Gastroenterology Practice: A Business Plan Assessment for Improved Economic Success. EndoEconomics, August 2011:5-7

Jessica Diduch is the director of business development for CRH Medical Corporation. CRH is dedicated to bringing innovative solutions to GI practices across the country and is committed to delivering the highest level of service.

The company provides a turn-key program with a complimentary physicianphysician training session at your center as well as comprehensive operational and marketing support. To schedule a training or to learn more, call 800.660.2153 x 1023 or visit physicians.crhsystem.com.

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Marketing

Buzz

Digital Strategy:

(Part II)

Utilizing Your Greatest Marketing Tool

By Lori Trzcinski, Marketing Communications Specialist

a new website that are crucial for the planning and building stages. In part two, I will examine the steps you should take to promote your new website once it is live, and why it is so important to your online search success.

On average, we conduct 12 billion searches per month on the web in the United States1 with 88.5%2 of the total U.S. population currently using the Internet. With the majority of the country utilizing such technology, business-toconsumer (B2C) companies are focusing their efforts on an executable digiLORI TRZCINSKI tal content marketing strategy to drive such relevant Internet traffic their way—ultimately converting a search into a customer and a tangible piece of ROI.

You’ve taken the time to re-vamp your messaging and branding, integrate new design elements and update imagery—a first step in making a good impression on consumers with your new website and with your business. In fact, 87% of small and medium businesses are making websites their top digital marketing priority.4 Now as you transition past the development phase of your website and into the “go live” stage, this is the perfect time to ramp up your online marketing campaigns to help drive traffic to your site. Knowing this, do you have a plan to get the right people to your site? You need a website marketing strategy.

When asked in a B2C Content Marketing 2015: Benchmarks, Budgets, and Trends—North America survey by the Content Marketing Institute and MarketingProfs, 65% of B2C marketers said that they were presently working on better converting visitors on their website, while 61% said they were working towards optimizing and organizing their website content.3 As we technologically progress, the shift in focus from print to digital marketing continues to grow in effort and size.

There are many benefits to marketing your website, especially with good, responsive web design. Your website acts as an online marketing company for your business—displaying and explaining services or products—and when implementing a solid website marketing strategy, it will attract your desired audience (potentially even away from competitors sites)—converting browsing and clicks into profit and sales.

Sometimes the new features of your site make the ease of use a reason for increased relevant traffic, and you see an uptick in leads and sales from your website.

In part one of this two part mini-series, featured in the Winter 2016 issue, I explored factors to consider when building 24 |

EndoEconomics SPR ING 2016

Marketing

Buzz What steps do you need to take to successfully market your website?

Figure 1

Sample Broad GI Industry Keywords:

Step #1: Decide on website management

• Gastroenterologist

The first major decision in developing a new website is who will lead the project? It is important to have at least one person who can make changes and updates when necessary so that your site can stay up-to-date. A website should be looked at as a living, breathing marketing machine that needs to be frequently updated and maintained. Ongoing maintenance can come in the form of a dedicated employee (or employees) and/or a monthly support/marketing package through a website or marketing company. Now that you have your new site, updates must be made both on the back-end (to help it continually function at its full potential), as well as the front-end (to frequently offer new content to visitors)—allowing the site to stay relevant in the eyes of search engines and your customers.

• Colonoscopy

Step #2: Focus on the right keywords During your website rebuild phase, there will be a point in the development process where you and the website design company go through an SEO (search engine optimization) exercise to identify the right keywords to target. These keywords (as shown in Figure 1) are used (and should appear) in everything from your web page titles and meta descriptions down to the text found on your site.

These statistically significant keywords should be incorporated into everything indexed by search engines that your company publishes including blog posts, whitepapers, images and press releases. Keywords help your site build organic search traffic, attract relevant visitors and allow for prospects to find you with ease. When paired with the right content and calls-to-action, the right keywords are a great opportunity to capture qualified leads.

Step #3: Produce new content Content marketing generates three times as many leads as traditional outbound marketing, but costs 62% less.1 It is crucial that once your new site is up and running that you have a content creation plan. Content can refer to a multitude of items, but for your website, the main content to be created post site launch includes blogs, press releases, case studies, images, and even videos (see Figure 2).

• Endoscopy • Endoscopic Ultrasound • Gastroenterology Services • Surgical (Surgery) Center • Endoscopy Center • Colorectal (Colon) Cancer Ideas to Make the Broad Keywords More Specific: • Include descriptive words related to main keyword (ex: state-of-the-art endoscopy center) • Include location (city/county/state) of center or practice (ex: Manhattan, NYC endoscopy center) • Include features specific to the facility—any certifications, awards, products or equipment that you use (ex: Endochoice’s first internationally recognized Fuse® center of excellence) • Include physician name(s) (ex: Blair Lewis MD endoscopy center)

The most difficult part of marketing your new site is creating the content itself. The content must be unique, relevant, and appeal to your target audience in order to be effective.

Remember to incorporate your SEO keywords (where applicable) when creating new content. In addition to the standard of creating content in-house, there are other ways in which content can be created. These include hiring an external marketing company; working with free-lance writers and designers; utilizing contacts, partnerships, and resources in your industry. The very journal you are currently reading is a prime example of such created content.

Step #4: Distribute the content The nice part about content, is that once it’s created, you can distribute and re-purpose it so that you don’t need to constantly create new content. You may want to change specifically how it is re-purposed depending on the platform (for example, on social media: Facebook vs. Twitter vs. LinkedIn). A piece of content you published, like your blog, can be easily modified to fit your needs. It can be a snippet preview on social media or a call-to-action in an ad or an email campaign; it

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Marketing

Buzz Figure 2

can be used to secure a guest blog post on an industry trade publication’s blog where you can attract new readers and audience members (by linking back to your own website). You should distribute and use your content to the advantage that best suits your business needs (see Figure 3). Be creative. The more eye-catching and original the content, the more likely people are to read, interact, and respond to it.

As with any new piece of content, keep all relevant parties informed. Are there new whitepapers or introductory videos? Did anything change on your website since its new launch? Make sure those in your organization that would benefit from education on these new offerings are made aware of their existence and availability for use. Make sure any new features are highlighted. Any and all of these tools can be valuable assets to the team to use when engaging with clients or interacting with leads.

Step #5: Track visitor traffic and ROI (return-on-investment) With the re-build of your website, your new site design and corresponding new content will improve your site’s SEO. Over time, you will be able to track and see the new visitor traffic patterns and the visitor demographics based on your re-vamped website efforts (see Figure 4). You will want to know who is (now) visiting your new site, how that compares to what you’ve seen in the past, and how it has affected the response you’ve seen to your content and, ultimately, to your leads. Which initiatives have been successful? Which ones could use some more development?

Figure 3

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EndoEconomics SPR ING 2016

Marketing

Buzz Figure 3

According to Search Engine Journal, SEO leads have a 14.6% close rate, while outbound leads (such as direct mail or print advertising) have 1.7% close rate.1 The cost of producing digital content is not nearly as expensive as producing print (outbound) content. This means that the more time spent on your digital marketing, the better your return.

Begin the process Fully executing each of the five steps above will take a significant amount of time and planning, but when put into place will be effective and show results. Each step may not happen immediately, but over time when you build upon those steps, you will see how your website can become one of the greatest marketing tools at your disposal.

Source: 1. “Marketing Statistics, Trends & Data - The Ultimate List of Marketing Stats.” Marketing Statistics, Trends & Data - The Ultimate List of Marketing Stats. HubSpot, n.d. Web. 25 Apr. 2016. <http://www.hubspot.com/marketing-statistics>.

2. “Internet Users by Country (2016).” - Internet Live Stats. Internet Live Stats, n.d.

Web. 25 Apr. 2016. <http://www.internetlivestats.com/internet-users-by-country/>.

3. Pulizzi, Joe, and Ann Handley. “New Content Marketing Research: B2C Challenged with Measurement.” Content Marketing Institute. Enveritas Group, 15 Oct. 2014. Web. 25 Apr. 2016. <http://contentmarketinginstitute.com/2014/10/2015b2c-consumer-content-marketing/>.

4. 99 Designs. “87% of Businesses Are Making This a Priority. Are You?” 12 Apr. 2016.

E-mail.

Lori Trzcinski is the marketing communications specialist at Physicians Endoscopy and the managing editor of EndoEconomics. With over seven years of marketing experience, Ms. Trzcinski leads the corporate and center marketing initiatives of PE and its affiliated centers. Ms. Trzcinski earned a B.A. in Business & Economics and Media & Communications from Ursinus College. For more information, she can be reached at ltrzcinski@endocenters.com.

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Front and

Center Congress Visits:

Congratulations:

How Do You Promote Blue?

Congressman Michael Fitzpatrick (PA-R) toured the Endoscopy Center of Bucks County in Newtown, PA on March 7th. Rep. Fitzpatrick met with physicians and staff to discuss topics related to access to care, equipment costs and various bills impact to the ASC vs the hospital. Fitzpatrick is one of the first co-sponsors of the Removing Barriers to Colorectal Cancer Screening Act of 2015. He serves as the U.S. Representative for Pennsylvania’s 8th congressional district.

Congratulations Dr. Robert Bartolomeo — recipient of the 2016 American Gastroenterology Association (AGA) Distinguished Clinical Award. The award is given each year to one Robert Bartolomeo, MD member in private practice and one in clinical academic practice to “recognize members of the practicing community who, by example, combine the art of medicine with the skills demanded by the scientific body of knowledge in service to their patients.” Dr. Bartolomeo is President of Gastroenterology Associates, PC and an owner at Long Island Center for Digestive Health.

In February 2000, President Clinton officially dedicated March as National Colon Cancer Awareness Month. Since then, the spread of awareness has grown throughout the country with thousands of patients, survivors, caregivers and advocates joining together to promote the cause. Highlighted below are initiatives some centers accomplished in March:

(L) Kristen Braun, MD and (M) David Popper, MD with (R) Congressman Michael Fitzpatrick

Congresswoman Kathleen Rice (NY-D) toured the Long Island Center for Digestive Health in Long Island, NY on March 14th.

Rep. Rice met with patients and physicians discussing the importance of early detection and colon health screenings. She co-sponsored the Removing Barriers to Colorectal Cancer Screening Act legislation that doctors say will remove financial barriers to life-saving colorectal cancer screenings and treatment for Medicare beneficiaries.

Both Physicians Endoscopy and WinthropUniversity Hospital representatives were in attendance.

ASGE Endoscopy Unit Recognition Program: Numerous GI centers were honored as part of the ASGE Endoscopy Unit Recognition Program (EURP).

Participants are part of a growing national network that is recognized for their dedication to high-quality care. They show a strong focus on patients, continuous quality improvement, involvement of the entire organization in the pursuit of quality, and use of data and team knowledge to improve decision making. Congratulations to the following Physicians Endoscopy centers: • Berks Center for (Wyomissing, PA)

Digestive

Health

• Burlington County Endoscopy Center (Lumberton, NJ) • Carnegie Hill Endoscopy Center (New York, NY) • East Side Endoscopy and Pain Management Center (New York, NY) • Endoscopy Center (Hagerstown, MD) (L) Leonard Stein, MD with (R) Congresswoman Rice

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EndoEconomics SPR ING 2016

at

Robinwood

• Long Island Center for Digestive Health (Garden City, NY)

Advanced Endoscopy Center (NY) premiered its newsletter “AEC Scope” which was emailed and distributed to patients, primary care providers, etc. The newsletter celebrates accomplishments and milestone of the center and its providers, as well as GI related industry news and events.

Berks Center for Digestive Health (PA) and Reading Hospital hosted a digestive health night where doctors gave presentations on colon cancer. The hospital turned their fountain blue for the entire month. The center and office were decorated blue, and office staff wore jeans and blue tops with a button “why blue” to open the dialogue.

Digestive Disease Endoscopy Center (IL) ran a radio ad and public service announcement promoting Colorectal Cancer Awareness Month. The check-in kiosk was decorated with a bigger than life like colon, and myth buster facts about colon cancer screening were displayed throughout the center. Patients received thank you cards with a star pin and blue wrist bands. The Center also celebrated Dress in Blue Day on March 4th.

East Side Endoscopy and Pain Management Center (NY) distributed a variety of promotional materials branded “Colorectal Cancer is Preventable – get a screening Colonoscopy” as well as Center brochures.

Eastside Endoscopy Center (WA) in Bellevue and Issaquah signed up to participate in Get Your Rear in Gear Seattle, being held Saturday, September 24th. Get Your Rear in Gear is a 5K Run/Walk & Kids’ Fun Run taking place at Marymoor Park in Redmond.

Front and

Center The Endoscopy Center at Bainbridge (OH) and practice, University Gastroenterology Associates, hosted a community Health Matters presentation “Understanding Your Digestive Health” at UH Ahuja Medical Center. Drs. Koehler, Abbass, Rozman, and Shapiro discussed topics including colon cancer screening, dysphagia, GERD and IBS. The Center also celebrated Dress in Blue Day on March 4th.

Endoscopy Center of Western New York (NY) distributed Colon Cancer Awareness flyers to the local community during the month. The Center and practice, Gastroenterology Associates, LP, sponsored the 2016 Buffalo Undy Run/Walk on April 30th, a family-friendly event created by the Colon Cancer Alliance, where participants dress up and get talking about colon cancer. The Center also celebrated Dress in Blue Day on March 4th.

Garden State Endoscopy Center (NJ) displayed posters around the Center and distributed blue rubber bracelets for colon cancer awareness to their patients.

ECB Dress in Blue Day

Endoscopy Center at Robinwood (MD) hosted its Annual Colorectal Cancer Awareness Basket Raffle donated by local businesses and individuals. Proceeds from the raffle as well as the center’s annual Bob Evans Community Fundraiser go to the John Marsh Cancer Center. Office staff wore blue t-shirts imprinted with screening messages every Friday in March. The Center also advertised colon cancer awareness on billboards in the Robinwood community.

The Endoscopy Center of Bucks County (PA) visited primary care providers with promotional goodie bags and posters regarding colon cancer awareness. The Center was decorated with posters and blue balloons in March. ECBC celebrated Dress in Blue Day on March 4th by wearing blue and giving patients a single blue carnation.

Endoscopy Center of Niagara (NY) participated in the Undy 5000 on April 30th in Buffalo. The center held Dress in Blue Day giving patients a copy of their cookbook “Tried and True and Blue.” During the first week of March, patients received a bouquet of flowers. The Center participated in “Niagara Falls Go Blue” in which Niagara Falls was illuminated blue on March 4th for Colon Cancer Awareness.

Hudson Valley Center for Digestive Health (NY) along with New York Presbyterian-Hudson Valley Hospital (NYP/HVH) sponsored a Colorectal Awareness Fair on March 10th in the hospital’s lobby. HVCDH hosted a booth with educational materials, giveaways and a raffle. Dr. David Lin presented “Current Clinical Concepts in Colorectal Cancer Management” alongside the Oncologists and GI surgeons at NYP/HVH. The Center held a weekly raffle for a $25 gift card, and every patient scheduled for a colonoscopy received a water bottle and other giveaways.

Island Digestive Health Center (NY) in conjunction with their hospital partner Good Samaritan Health, participated in a community program as well as the Good Samaritan employee health fair. IDHC and the Colon Cancer Foundation participated in a health fair at a local mall featuring the Rollin Colon.

During the month, the center was decorated in blue with a “Colon Cancer Awareness Get Screened” banner curbside visible to passing traffic.

Anthony Galan, MD doing radio PSA

Laredo Digestive Health Center (TX) participated in Colon Cancer Awareness day at the local mall where staff handed out information on colon cancer awareness and raffled off a free colonoscopy.

All month patients received blue colon cancer awareness bracelets. Laredo Digestive Health physicians recorded bi-lingual public service announcements for radio and TV which aired throughout the month. Dr. Elsa Canales spoke at a local high school providing information about colon cancer.

Long Island Center for Digestive Health (NY) participated in the Winthrop University Hospital Colon Cancer Awareness Day—an interactive day of informational sharing open to the community. Dr. Andrew Rosenberg presented on “Colonoscopy Screening Guidelines and Recommendations.” The Center participated at the Nassau Community College Health Fair. LICDH was also a spot light presenter at Adelphi University’s “Beyond 4 Years” Health Fair.

Michigan Endoscopy Center and MEC Providence Park (MI) held their annual “Strike Out Colon Cancer” bowling event, a fund raiser through the Colon Cancer Alliance in which the employees of both endoscopy centers jointly participated.

Physicians Endoscopy (PA) kicked off Colon Cancer Awareness with guest speaker Maria Grasso, Executive Director of Get Your Rear in Gear Philadelphia, at PE’s annual corporate meet- Maria Grasso speaking at PE Corporate Meeting ing earlier in the year.

Maria spoke of the awareness the event brings and the success of the Get Your Rear In Gear event across the country. Each year Physicians Endoscopy (PE), a premier sponsor of the event, organizes a company team bringing together staff, friends and family and nearby affiliated centers. PE also celebrated Dress in Blue Day on March 4th.

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Current

GI Opportunities Submit your CV online at www2.endocenters.com/opportunities

Cortlandt Manor, NY An opportunity in Northern Westchester with a two-physician practice.

• Full-time or part-time: perfect for young families • State-of-the-art endoscopic equipment • Physician efficiency and optimal patient quality of care • Light call schedule: 1:6 • One hour to New York City • Beautiful scenic area For more information, contact: Annie Sariego, CASC, VP, Operations (215) 589-9008 • asariego@endocenters.com

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 speciality, 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.

For more information, contact: Annie Sariego, CASC, VP, Operations (215) 589-9008 • asariego@endocenters.com

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.

For more information, contact: Lisa Burcroff at LMBurcroff@hinet.org

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EndoEconomics SPR ING 2016

Laredo, TX

Gastroenterology Consultants of Laredo – Laredo Digestive Health Center

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 • 2 Nurse Practitioners with over 11 years of GI experience

For more information, contact: Lara Jordan, VP, Operations (215) 589-9038 • ljordan@endocenters.com

Central New Jersey

Garden State Digestive Disease Specialists, LLC 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 Surgi-Center 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.

Interested gastroenterologists may submit CV/or inquiries to: Ms Liza Macalincag, Practice Administrator Lmmac@comcast.net

Current

GI Opportunities Submit your CV online at www2.endocenters.com/opportunities

Lima, OH

Lumberton, NJ

Gastro-Intestinal Associates, Inc. The physicians of Gastro-Intestinal Associates are seeking a BE/BC gastroenterologist to join our six physician, 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 physician-owned 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

Gastroenterology Consultants of South Jersey 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 that is located among several growing communities in Southern NJ. •

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Located within 30 minutes of Philadelphia and within 1 hour of New York City Affiliated with Burlington County Endoscopy Center, a three room ASC which is physician owned and operated 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

Please contact Monica Awsare, MD at 215-718-6085 or monicaawsare@gmail.com

For more information, contact: Robert Neidich, MD, President of Gastro-Intestinal Associates Phone: (419) 227-8209 ext. 100 Fax: (419) 222-6007

On-Site Endoscopy

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.

For more information, contact: Amy Fasti • afasti@securemdca.com Toll Free: 1-877-613-3494

Cleveland, OH UHMP Gastroenterology Associates

Williamsville, NY

Gastroenterology Associates, LLP

An established practice with a solid referral base, Gastroenterology Associates, LLP, located in western New York, seeks a board-certified/board-eligible gastroenterologist to join our growing eleven physician practice. ERCP experience is a plus.

With two clinical sites and two physician-owned state-of-the-art endoscopy centers, this opportunity includes: • Partnership track in a premier quality driven group • Competitive compensation and benefits package • Nursing staff in our Centers with extensive GI experience • Fully integrated EMR environment. Meaningful Use attested • Professional management staff • 9 mid-level providers including registered dietitian We are located within easy driving distance of The Finger Lakes Region, The Adirondack Mountains, The Great Lakes and Toronto.

For more information, contact: Peg Centola, Human Resources Manager hr@gastrowny.com • Phone: 716-626-5250 • Fax: 716-565-0665

The physicians of UHMP Gastroenterology Associates, a private gastroenterology group affiliated with University Hospitals of Cleveland and CWRU School of Medicine, are seeking a gastroenterologist to expand the practice. This candidate will have ownership opportunity in their two thriving endoscopic ambulatory surgery centers. These freestanding, state-of-the-art ambulatory procedure centers are located in Chagrin Falls and South Euclid, Ohio (suburban Cleveland).

This Opportunity Offers: • Physician owned and controlled centers.

• State-of-the-art endoscopic equipment.

• Medicare licensed and AAAHC approved.

• Physician efficiency and optimal patient quality of care.

• Nursing staff has extensive experience in GI endoscopy.

• All physicians and nurses are advanced cardiac care life support certified.

• An outstanding benefit package is offered.

• Professionally operated and managed.

For more information, Michael Koehler, MD • UHMP Gastroenterology Associates contact: (216) 691-3602 • michaelkkoehlermd@gmail.com SPR I NG 2 0 1 6 EndoEconomics

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