EndoEconomics Winter 2016

A Journal Dedicated to Economic Issues Impacting GI ASCs and Practices

WINTER 2016

Survival Guide for Ancillary Income Page 6

Understanding Business Valuation Page 11

Revenue Cycle Management Page 16

The GI Journal of:

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

WINTER 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.

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Content 4 Message from the President 5 Status Quo: Not Likely in Your Lifetime

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

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11 Understanding Business Valuation

Copyright © 2016 by Physicians Endoscopy.

13 What GI Physicians Should Know from the New York Metro ASC Symposium

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16 Revenue Cycle Management Turnaround: A Case Study 20 Digital Strategy: Factors to Consider When Building a New Website 23 Raising Colon Cancer Awareness with Get Your Rear in Gear 24 Front and Center 26 Current GI Opportunities

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Message from

the President The new year has arrived, and along with it comes a mix of hope, fear, anxiety and the opportunity to initiate change. Front and center this year will be the upcoming BARRY TANNER presidential elecPresident and CEO, tion in November Physicians Endoscopy and all of the rhetoric that will precede the election itself, including the continued debate surrounding the Affordable Care Act (ACA). However, at the end of the day, 2016 will likely close with little, if any, change to the current law, and that will most likely continue through 2017.

That certainly does not mean that change within healthcare will take a holiday for the next two years. On the contrary, the pace of change in healthcare and the microcosm of the ASC industry are expected to continue at an unprecedented pace.

To learn more about the most significant challenges and opportunities facing gastroenterologists, and learn what some GI physicians are doing to proactively shape their future, I strongly recommend attending the annual GI Roundtable (GIRT) conference, taking place March 10-12 in Fort Worth, Texas. Physicians Endoscopy is proud to sponsor this terrific meeting, organized and co-chaired by Klaus Mergener, MD, Tom Deas, MD, and Gene Overholt, MD. More information can be found at www.giroundtable.com and on p. 15 of this issue.

One of the topics that will certainly be discussed at GIRT is the new CMS physician professional fee schedule that went into effect on January 1. This resulted in substantially lower professional reimbursement for the performance of colonoscopies. How this change will affect all GI practices is yet to be determined; however, it seems inevitable that physicians will have to reexamine the efficiency of their 4 |

EndoEconomics WINTE R 2016

practice at all levels with an eye toward reducing costs and/or even consider limiting future access to the practice by Medicare recipients. It is such a shame that flawed data, leading to flawed analysis and ultimately to flawed conclusions, should be the result gastroenterologists must live with.

Another important issue for the coming year is the future of the ACA, which may be determined, in part, by the election of the next president. CMS reported that little progress is being made toward getting more young adults to sign up for healthcare policies on the federal or state exchanges.

CMS also reported in early January that with less than a month to go in open enrollment, 26% of the roughly 11.3 million who have signed up for coverage through federal and state-run exchanges were ages 18 to 34. These numbers are nearly identical to the comparable period for last year and far below the goals targeted by actuaries when the exchanges were launched in 2013.

The original estimate was that approximately 40% of all enrollees would be adults between 18 and 34. This translated to a number that would help to hold premiums at bay by balancing total healthcare spending across a proportionately younger and healthier population. There have long been concerns that a shortage of younger people signing up for health coverage would lead to a preponderance of both older and sicker people. This would result in increased premiums, thereby discouraging additional younger, healthier people from signing up for coverage. The end result is we have experienced a continued increase in health insurance premiums.

There was a poll conducted by the New York Times and the Kaiser Family Foundation that included a survey of nearly 2,600 adults nationwide from ages 18 to 64. The New York Times reported in January that approximately 20% of people younger than 65 with health insurance reported having problems paying their medical bills during the past year. By comparison, it reported

that 53% of people without health insurance said the same. While it is not surprising that a majority of people without insurance would experience difficulty paying medical bills, the proportion of those with health insurance coverage but still experiencing the same problem seemed to be indicative of the shift that we have witnessed for several years now—passing more and more insurance coverage costs on to the recipients of such coverage who are the consumers. The survey highlights the substantial shift toward patients being burdened with higher out-of-pocket costs.

We are at a point where more people have obtained health insurance coverage and the ever-increasing cost of care delivery has slowed, and yet the trend toward higher cost sharing with the consumer has put an increasing number of people at risk of being underinsured. While I applaud the ACA, it has not solved the problem of access to affordable care.

As I reflect on the foregoing, it reminds me that what we are doing in partnership with GI physicians and hospitals—by supporting and promoting the continued independence of GI physicians and the development and/or efficient operation of GI-focused ASCs—will be a big part of the solution to both the cost, access and delivery of future GI care. As the insured/consumer plays a larger role in the decision of when and where to seek GI care, the value proposition offered

by GI-focused ASCs is virtually unmatched.

For those physicians who may ponder what the future holds for ASCs, I suggest that the longer-term strategy should be to increase efficiency, reduce costs where practical, increase the quality and the transparency of both care and costs, and partner with people who can help you maximize those deliverables and share in the cost. I believe that will be a winning formula for the next decade.

I want to wish everyone all if the best for 2016. I look forward to seeing many of you at GIRT!

While these are true throughout all of healthcare, they are particularly relevant for gastroenterology practices which have faced continuous decline in high-value endoscopic reimbursement over the past decade, with profound cuts (-15%) in colonoscopy reimbursement in 2016.

Status Quo: Not Likely in Your Lifetime

The good news is the 2016 annual GI Roundtable (GIRT) conference, taking place at the Worthington Renaissance Hotel in Fort Worth, Texas, from March 10-12, will address all these issues. The conference will feature expert faculty that includes the following keynote speakers: • Patrick Conway, MD, MSc, Centers for Medicare & Medicaid Services, chief medical officer and director of the office of clinical standards and quality; and

By Thomas M. Deas, Jr. MD, MMM and Klaus Mergener, MD, PhD, MBA Many of us love the new year because of the opportunity to adapt, improve and sometimes pursue a fresh start. For others, our deepest desire is for a period of status quo and stability so we can take a deep breath and catch up. Dream on! If you are in the healthcare profession, the status quo will prove unsuccessful for your organization. As a result of many initiatives deriving from the Institute of Medicine (IOM), Affordable Care Act (ACA) and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), healthcare is in more upheaval than ever before. Status quo is not an option.

While there is room for debate on many issues of healthcare transformation, there are significant trends that will clearly improve the value of care for our patients. A system redesign is required which provides greater value to consumers through higher quality and lower cost, and greater transparency for both. These goals compel new compensation models that reward value. Our focus should now be on care that is safe, effective, patient-centered, timely, efficient and equitable. These IOM objectives and the Triple Aim (better care, better health, lower cost) require:

• Tom Morris, PhD, founder and chairman of the Morris Institute, author, strategic advisor for Fortune 100 companies and electrifying presenter.

Consider joining your colleagues at GIRT 2016 for two days of networking and an exchange of knowledge in a relaxed and stimulating atmosphere. Let’s jointly figure out how to get beyond the “status quo” to keep our GI groups positioned for success while continuing to provide the best possible care for our patients.

Thomas M. Deas Jr, MD, MMM, is the director of physician development for North Texas Specialty Physicians in Fort Worth, Texas. He is a past-president of the American Society for Gastrointestinal Endoscopy (ASGE). Dr. Deas will serve as co-director for GIRT 2016.

Klaus Mergener, MD, PhD, MBA, is a partner with Digestive Health Specialists and the director of interventional endoscopy at MultiCare Health System in Tacoma, WA, serves as an affiliate professor of medicine at the Univ. of Washington and is vice chair of the ASGE Foundation Board of Trustees. Dr. Mergener is the co-founder of the GI Roundtable and will serve as the co-director for GIRT 2016.

• innovative payment incentives and service lines; • focused strategic planning; • organizational structures to support care coordination; • advanced information technology and communication tools; • employer engagement; and • greater practice efficiencies.

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(Part I) 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 Steve Morris, MD, JD, MBA, FACG; Reed Hogan II, MD, FACG; and James Leavitt, MD, FACG

DAVID JOHNSON, MD, MACG, FASGE, FACP

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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STEVE MORRIS, MD, JD, MBA, FACG

REED HOGAN II, MD, FACG

JAMES LEAVITT, MD, FACG

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.

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.

Part one of this two-part series discusses anesthesia services, radiologic imaging and in-house pharmacies. This discussion is not meant to be applicable to every practice but will hopefully encourage gastroenterologists to

By Steve Morris MD, JD, MBA, FACG

Anesthesia Services When we first began using anesthesia assisted sedation with propofol almost a decade ago in our ambulatory surgery centers (ASCs), the resistance to change came from a variety of sources, some

anticipated and some very unexpected.

The easily anticipated pushback was from the insurance industry which did not want to pay for any new services as it was ratcheting down fees for basic endoscopy and colonoscopy. The unexpected resistance was from our own national societies (the Tri-society paper), colleagues and academic centers to which change and progress was anathema.

We have now evolved to where most ASCs and hospitals utilize MAC, with either anesthesiologists or CRNAs as the standard of care, and insurers, for the most part, reimburse for the service (with pockets of resistance still on the West Coast and other isolated areas).

In fact, anesthesia services provided in the ASC have become an important source of ancillary revenue in many GI practices around the country. The main danger to this revenue stream is not lack of reimbursement but danger of falling askew of Stark and anti-kickback laws.

The 2012 OIG unfavorable advisory opinion (No. 12-06) that questions the legality of some of these arrangements has been the aegis for the government to aggressively pursue actions against healthcare providers, which was ongoing as this was written.

The question for gastroenterologists is, under this environment, can a GI practice still benefit from anesthesia financially while minimizing or eliminating regulatory risk? The easiest and safest model is to have the ASC enter into a contract with an anesthesia provider to provide the services and bill and collect from the patients. No money flows to the ASC or the GI doctors.

There are a variety of other models to consider depending on your needs and end goals. In addition to selling the entirety of your existing anesthesia business, one option is to enter into a joint-venture arrangement with an anesthesia management company.

This ultimately allows you to maintain

a level of financial interest. You would benefit from an ongoing revenue stream while having the day-to-day operations managed for you. This can also be an option for those who have already built up equity in their anesthesia business and would like to monetize a portion, as well as those who are introducing anesthesia for the first time.

Regardless of the direction taken, there is still what I term considerable “soft” dollars savings in anesthesia-assisted sedation. Compared with traditional conscious sedation, the productivity and throughput of the average GI lab is considerably enhanced, with more cases done per room and significantly reduced recovery time. In addition, the use of highly trained anesthesia personnel in every endoscopy room and during the pre- and post-operative care of the patient can result in considerable employee costs savings to the GI practice and ASC.

Radiologic Imaging

By Reed Hogan II, MD, FACG With the current rate of decline in reimbursement to gastroenterologists, there is constant pressure to develop ancillary revenue in nontraditional ways. Stealing market share from other service providers (an option in any competitive industry) can be attempted in a variety of ways. But in the case of gastroenterology, success is much more achievable when pursuing needed GI services by aggregating in centralized sites of service, and providing needed adjunct services with competitive pricing and enhanced customer satisfaction.

In the ideal, perfect patient lifecycle, concentration of ancillary services in a convenient location improves patient care and satisfaction.

The addition of radiologic services such as ultrasound, computed tomography (CT), and elastography as ancillaries to traditional GI services is a marketing draw for patients and allows the GI

center to cultivate more advanced clinical services to differentiate itself from some of its other community-based, nonacademic competitors. In-house services promote patient satisfaction as well as physician satisfaction as a result of faster turnaround time on results.

Like every decision made by the organization’s administration, there are implications for financial management.

Intended and unintended consequences should be anticipated at the time implementation decisions are made.

Unforeseen results seem to occur no matter how carefully the decision is made. The finance division of the practice should be expected to present the most appropriate conservative pro forma incorporating all known assumptions that represent best-case, worstcase and most likely scenarios.

CT/ultrasound The most sensitive feature of the pro forma is the volume assumptions.

Volume drives three of the four essential elements of the income statement (gross revenue, net revenues and variable expenses). The only element that volume does not primarily control is fixed expenses. The “bonus” question for radiologic services is always how to verify, validate or simply believe that proposed volumes are achievable for the services that have never been performed at the GI center in the past? In anticipation of adding CT and ultrasound as ancillary services, a prospective review of physician use of these services is paramount.

This must encompass not just units of service ordered, but site of service, payor demands and patient preferences.

Volume estimates for CT and ultrasound are relatively simple since they are normal services of a GI practice and therefore tracking current use should not be a significant task.

In our practice, we can purchase a quality used CT scanner for $300,000 to $350,000. Ultrasound equipment in the range of $50,000 to $80,000. Leasing is W I NTE R 2 0 1 6 EndoEconomics

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a very viable option to reduce capital outlay. While cost is a critical factor to consider, volume is the most important consideration. Although the intent is to capture all the services in house, in reality, that rarely happens.

Elastography For elastography to be justified as a profitable line of service, the ability to develop an accurate pro forma is difficult since the field is evolving. It is much more difficult to estimate volumes when services are in evolution; past and current trends may not accurately reflect future needs of this service.

Institutions with much greater capital resources than the typical GI practice struggle with the investment in these devices. There is considerable concern as to the best practices available, but certainly in the interest of patient care, elastography must be considered as a potential ancillary. A revenue source is desirable, but hepatologists are seeing

a shift in the standards of care in that the number of liver biopsies can be dramatically reduced.

The least expensive entry into elastography is with ultrasonic technology.

The machines cost about $100,000 to $140,000. The available machines are Fibroscan, Siemans and Supersonic (developed by different companies).

The use of ultrasonic technology is being challenged in that this approach is compromised in patients with fatty liver changes, prompting some experts to recommend MRI as the modality of choice. There are some estimates that up to 40% of potential studies would be uninterpretable due to obesity.

Many academic institutions utilize Fibroscan-type technology with a default to MRI elastography if indicated.

It would appear that newer 3 Tesla MRI scanners will be required. With a cost up to $3 million, it is a significant investment for any institution. In this author’s contacts, Fibroscan is utilized in larger practices with larger liver patient volumes, most commonly in hepatology centers in academic settings. The CPT code was released in 2015 with average reimbursement ranging from $20 to $90 with an average of about $50 in busy centers.

MRI tends to only be utilized in major medical systems, most frequently in academic settings. An MRI approach would be financially difficult in the typical private practice GI clinic. Until best practices are established with adequate time to be sure that financial investments are recoverable, using limited capital for this ancillary may not be a wise decision.

Working with radiology and build-out consultants, a series of assumptions must be defined before investing in CT, ultrasound or Fibroscan imaging.

The basics include the capital costs: equipment and construction/ renovation. If expertise is deficient

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within the organization, financial consultants will be compulsory to generate the pro forma, which should include volumes, charges per test, revenue, payor mix, contractual allowances and employee costs. The more detail included in the pro forma, the less likely there will be major surprises.

Radiology services financial predictions are fairly straightforward. The costs for equipment should be acquired through competitive bidding. An early, major decision is in the quality of the equipment and if the clinic is willing to accept “good” used equipment with limited warranty (which we are doing in our 26 physician practice.) Negotiations with the radiologists reading the CT and ultrasound studies can vary from allowing reading and collection of all professional fees, to negotiating a cost per reading, with the GI group retaining a portion of the professional fees along with the technical fees.

The latter is optimal, if the contract is appropriately developed, with some of the professional reading fees staying within the practice.

An even better option, if volume is adequate, would be to hire radiologists within the group structure and bill from within. Starting salaries for a full-time radiologist start at the $250,000 to $300,000 range. In these times of decreasing reimbursement of physician’s fees for our services, these radiology services certainly deserve our due diligence to see if they might provide alternate services and enhanced care for our patients.

Pharmacy: Adopting In-house Pharmacies

By James Leavitt, MD, FACG Pressures to increase practice revenue and patient satisfaction have led many groups to expand and diversify their services. The practice of dispensing

prescriptions in-office is becoming more common. Done safely, an inoffice dispensing system can be a win-win situation for patients and the practice. In-office dispensing saves the patient time and increases convenience because it eliminates the need to make another stop to pick up medications. Since many prescriptions remain unfilled, the physician can feel more confident that the patient will take the medication when dispensed during the office visit. An in-office dispensing system also reduces pharmacy callbacks and provides additional revenue for the practice.

Dispensing your most commonly prescribed medications directly to patients has a number of additional benefits. The practice can generate a new source of cash flow and profit to help offset declining reimbursements and the rising costs of managing a practice. According to the National Center for Health Statistics, the typical doctor sees 25 patients a day and writes 1.4 prescriptions per visit for an average of 35 prescriptions written daily. If the practice were to make $10 on each of the 35 prescriptions, it could increase daily gross revenue by $350 per physician without occupying any more of a doctor’s precious time.

Increased productivity and time savings can also be realized. By reducing pharmacy phone calls and fax requests, dispensing medications can actually save your staff time, helping your practice to focus more on patient care and the patient experience with your practice. The physician is the best advocate for patients and has their complete medical history. Directly dispensing prescriptions ensures the patient receives the exact medication you prescribed.

Increasingly, physicians are being evaluated on patient outcomes. It is

estimated that between 28% and 31% of new prescriptions are never filled, potentially leading to serious health conditions. Directly dispensing your prescriptions can increase patient compliance.

In-office dispensing can also improve the patient’s perception of your practice. You will be seen as a more complete “one-stop shop” that provides improved services compared to other practices. Patients will no longer have to spend time traveling to another site to obtain medications.

In 2003, changes in Medicare Part D allowed physicians to not only collect copays for prescription drugs, but to bill insurance companies for reimbursement. There are several models for prescription dispensing for physicians to consider. Larger practices and medical groups often opt for an inhouse pharmacy, which is regulated on a state-by-state basis. Such business models enable practices to manage their own inventory and thus maintain higher margins, but they also require significant volume to be profitable since overhead can be high. Costs include the square footage required to operate the pharmacy and the employment of a licensed pharmacist and/or pharmacy technician, which can cost six figures depending on your market.

The key is to hire a retail pharmacist, because hospital pharmacists market to a completely different patient base. Practices that operate their own pharmacy also assume the administrative burden of doing realtime claims adjudication (verifying a patient’s coverage before dispensing a drug), prescription record keeping required by the state and contracting with pharmacy benefit managers at each of the insurance companies with which they participate.

As a result, many small- to mid-sized practices stick with the more costeffective physician-office dispensing, which generally does not require a licensed pharmacist. Most also use third-party vendors to process the paperwork and stock their offices with prepackaged quantities of the drugs they prescribe most. The average family practice can conservatively realize an additional $25,000 a year of supplemental income, although specialists such as gastroenterologists should expect lower returns. Most of these vendors provide a software program that integrates with your existing electronic health record, thus allowing e-prescribing from your electronic medical record (EMR).

They also allow you to verify patient eligibility, calculate copays on site, electronically bill and adjudicate the claims. Practices can often get started for under $1,500 including the cost of contracting, setup and initial training.

If you are considering in-office dispensing, there are a number of factors that you will need to take into account in order to decrease your risk. First, you must consider the office space required for a pharmacy or dispensing area as well as storage needs for the pharmaceuticals. It is highly advisable to understand your prescription habits and volumes so that inventory costs can be controlled. You will also need to determine which medications can be profitable for you. There may well be some instances where the adjudicated payment to you is less than your medication acquisition costs. Needless to say, you will want to avoid dispensing those medications at your center.

You will also need to closely track these prices since there are definite fluctuations over time. This will require you to adjust your in-office formulary from time to time.

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Be sure the system or vendor you select has certain essential capabilities.

If you have an EMR system, be sure the in-office dispensing system interfaces with it. Choose a system that interfaces with your patient database and has the capability to check for allergies, interactions and contraindications on the Web. The system should also provide patient education that is similar to the information sheets from a pharmacy and is in a format and at a reading level that the majority of your patients can understand.

It is critical that you know your state laws regarding dispensing. In-office dispensing is legal in most states.

However, Arkansas, Massachusetts, Montana, New Hampshire, New Jersey, Texas and Utah have certain prohibitions or severe restrictions.

Proceed with caution in these states.

Note that most states restrict inoffice dispensing to the practice’s patients only. Check your state’s

board of medicine to see if there are licensing rules to be a dispensing physician. Know and follow the board of pharmacy regulations for your state, as many regulate who must actually hand the medication to the patient.

Many states require that the physician “hand” the medication to the patient and that it is not given by staff or “left at the front desk” to be picked up.

Be aware of the potential risk issues.

Hiring a knowledgeable attorney to guide you is highly advisable.

Do not dispense beyond your specialty. Be extremely reluctant to stock controlled substances, as this can raise multiple concerns—from placing the office at a higher risk for breakins to increasing the possibility for employee theft. Recognize that in-office dispensing takes the pharmacist out of the loop, an important consideration as it is often the pharmacist who alerts the physician to issues, such as multiple prescriptions of controlled substances from other providers.

Finally, make sure that medication education is provided to the patient at the time of dispensing.

Adding medication dispensing capabilities to your current service offerings is another way to increase profit to your practice and provide improved services to your patients. Many people appreciate the option to fill prescriptions in the privacy of their doctor’s office. The benefits of increased profit to the practice and the “4 C’s” of convenience, cost, compliance and confidentiality to the patient are readily achievable with thoughtful planning.

For part two of this two-part series, which will discuss hemorrhoid banding, clinical research and pathology, see the Spring issue of EndoEconomics.

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David A. Johnson MD, MACG, FASGE, FACP, is 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 peerreviewed 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.

Steven J. Morris, MD, JD, FACP, is the cofounder and managing partner of Atlanta Gastroenterology Associates, LLC; the largest GI practice in the United States with 86 physicians and 30 PA’s/NP’s. They have been leaders in developing integrated care for their patients with ambulatory surgical centers, imaging, pathology, anesthesia and infusion centers as well as robust hepatology, liver, pediatric and research divisions. Dr. Morris is a strong advocate for the private practice of gastroenterology while maintaining critical hospital, collegial and community relationships that benefit all patients.

Reed B. Hogan II, MD, is a gastroenterologist at the Jackson GI Associates and Endoscopy Center and the Madison GI Associates and Endoscopy Center. Dr. Hogan was elected by his peers for inclusion in Best Doctors in America®: 1996-2013. He has an extensive list of research experience and has authored numerous scientific publications. In addition to working at the GI Associates, he is Clinical Assistant Professor of Medicine at the University of Mississippi School of Medicine and is Chairman of the American Society of Gastrointestinal Endoscopy (ASGE) special interest group for Ambulatory Endoscopy Centers and also serves on the Practice Management Committee for ASGE. James Leavitt, MD, FACG, has been in practice since 1980 and is the President of Gastro Health, the seventh largest private practice Gastroenterology groups in Florida with almost 60 physicians. Dr. Leavitt is board certified in Gastroenterology and Internal Medicine, and has been named one of the top 28 Gastroenterologists in America by Becker’s ASC Review and has been named

by U.S. News as one of the nation’s Top Doctors. Dr. Leavitt currently serves on the ASGE Practice Management Committee.

Understanding

Business Valuation

By Matt Sobieralski, Senior Business Analyst, Physicians Endoscopy

Corporate valuation is a topic rarely on the physician’s mind over the course of their typical day. From clinical decisions to hospital rounds and a packed appointment schedule, most physicians don’t have the time to study the intricacies of a business valuation.

The topic only becomes relevant when a physician (or a group of doctors) decides to test the waters and sell an interest in their ambulatory surgery center (ASC), practice, anesthesia business or other entity. With over a decade of experience in mergers and acquisitions, corporate valuation and investment management, I thought a discussion on the topic would be beneficial for any physician exploring a strategic transaction involving their center. In my professional experience, I think there are three key items to focus on when considering a sale of an equity interest in an ASC: valuation, timing and diversification.

Valuation Methodologies

valuation is based.

Investment bankers and valuation experts rely on numerous methodologies to arrive at a reasonable valuation for a business. Some of the more prevalent approaches include discounted cash flow analysis (DCF), historical multiples of cash flow, revenue or earnings, as well as asset-based valuation and internal rates of return analysis (IRR), among others. For the most part, ambulatory surgery centers (ASCs) rely on historical multiples of cash flow as a basis for valuation. This multiples-based method is likely driven by both the straightforward approach to understanding its result and the inability to incent top line growth in a healthcare based setting (due to Anti-Kickback laws). For any projection-based valuation (DCF, IRR), a buyer would prefer the option to incentivize revenue growth to meet (or exceed) the projections on which the

There are two critical components to discuss for the cashflow based, multiples approach MATT SOBIERALSKI to valuation: 1) EBITDA, and 2) valuation multiple.

EBITDA stands for Earnings Before Interest, Taxes, Depreciation and Amortization. It is used as a proxy for actual cash flow and accurately captures the earnings potential of the business’ operations, in this case an ASC. A quick description on the basis for using EBITDA. Interest is added back because it is capital structure dependent. Some owners may choose to finance their ASC with debt and others may choose to use strictly equity financing; either way, the operating performance of the center is not

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impacted. Taxes (specifically, income taxes) are added back since they are owner dependent. Some ownership entities may be pass through entities where little or no income taxes are withheld; other entities may be taxed at personal income tax rates. Again, the tax status of the owning entity should not impact the operations of the business. It’s important to note that any state specific surgery center tax would be included since it is not owner dependent. And finally, depreciation and amortization are added back since they are non-cash expenses, and our goal is to get as close to operationally based cash flow as possible.

The second critical component for the cash-flow based multiples approach is the valuation multiple.

Rooted in the multiples of publiclytraded competitors, ASC multiples are adjusted for liquidity, size and risk concentration discounts. From there, the valuation multiple applied to a specific ASC will be adjusted for idiosyncratic growth and risk factors.

An ASC that recently brought on new doctors or is expanding its facility footprint to handle increased volume would likely command a premium multiple. An ASC that is owned by physicians near retirement or a poorly managed center would likely obtain a discounted multiple.

One of these components is within your control (EBITDA) and the other is completely out of your control (valuation multiple). Since multiples are market derived, it’s difficult to control what multiple your ASC would command outside of marginal adjustments. On the flipside, EBITDA is a reflection of an ASC’s ability to produce revenue, control expenses and efficiently deliver care. Physicians should focus their attention on maximizing EBITDA, so when the time comes to sell their ASC,

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they can enjoy the full benefit of their equity interest.

Timing is Everything Timing is another crucial factor to consider when exploring a sale of your ASC. Timing relates to both internal (strategic parameters impacting the individual ASC) and external trends (capital markets and the healthcare delivery landscape).

From a micro perspective, the age of practicing physicians, growth initiatives, maintenance capital expenditure requirements, and a host of other factors could play a role in the valuation of your ASC. From a macro perspective, capital market performance and upcoming or recently passed healthcare legislation could impact ASC valuations. The goal is to manage your ASC for steady growth and efficiency and show prospective buyers the potential for continued opportunities.

Wait too long and the producers most responsible for financial performance may be approaching retirement age, putting downward pressure on valuation.

Plan for marketing initiatives and cost efficiency projects well in advance to show a track record of results. Additionally, the current macro-environment happens to be a particularly enticing time to sell an ASC given healthcare market dynamics and high equity market valuations.

Driven by the Affordable Care Act and an overall push toward efficient, lower cost healthcare delivery settings, ASC multiples have enjoyed rapid expansion over the past few years.

A Diversified Portfolio A final consideration in selling a portion of your ASC is the portfolio concept of diversification. The value you are able to derive from your ASC is critical to a successful divestiture, but there

are additional benefits to selling a portion of your equity stake and diversifying into other assets. New technologies, reduced reimbursement rates, regulatory changes and everything in between have the potential to reduce the value of one of your primary assets. To protect against these and other adverse events, it is important to consider diversifying your personal investment portfolio across numerous, non-correlated asset classes. Proceeds from the sale of a portion of your equity stake in an ASC could be re-invested into other, non-related assets (real estate, equities, fixed income, annuities, etc.). This assures an efficient investment portfolio that will protect against these ASC-specific risks.

As always, you should consult your personal financial and tax advisors when considering any investment decision, including a sale of your ASC. The old investing adage says the easy part is knowing when to buy, but the hard part is knowing when to sell. If you manage your ASC to consistently grow and provide efficient, high quality care, the decision to sell will be that much smoother and easier to undertake.

Focus on the controllable, internal factors and the macro backdrop will be less impactful. Understanding how you can maximize the value of your ASC for the benefits of both physician-owners and a new corporate partner will provide the foundation for a successful, ongoing partnership.

Matt Sobieralski is the senior business analyst at Physicians Endoscopy (PE). His primary responsibilities include analyzing and supporting acquisition and de novo transactions, and researching the healthcare investment landscape. Prior to PE, he spent over six years managing a portfolio of healthcare and REIT equities, and over four years advising distressed businesses in M&A, refinancing and restructuring engagements.

For more information, Matt can be reached at msobieralski@endocenters.com.

What GI Physicians Should Know from the

New York Metro ASC Symposium

By Carol Stopa, Sr. VP Business Development, Physicians Endoscopy

New York City in the fall—what a great place to be. It’s where all the action is thanks to the non-stop hustle and bustle of millions of people. If you live in the Big Apple, you have your choice of several options for how to navigate the city, such as public transportation, Uber, Lyft or just walking. But if you need to commute by car from the suburbs, timing is everything, and can make the typical two-hour ride from eastern Pennsylvania into a five-hour trip. Just like the future of healthcare, to successfully navigate New York City requires strategy, planning and knowing your market conditions!

However, no matter how long the trip, the New York Metro ASC Symposium (nymetroasc.com) has become an annual event I look forward to.

The second annual ASC Symposium, held Oct. 15, 2015, was an intensive and highly focused one-day event

organized and run by Garfunkel Wild, a healthcare law firm with offices in three states: New York, New CAROL STOPA Jersey and Connecticut. At this year’s ASC Symposium, more than 250 healthcare professionals and 35 industry sponsors and exhibitors were in attendance. The symposium is designed to provide thoughtful content relating to the most vital issues fundamental to the ASC industry. Faculty members ranged from federal and state governmental representatives, national and state policy leaders, to experts from the private sector in various disciplines.

While this conference is mostly dedicated to the New York metro area that includes New York, New Jersey and

Connecticut, much of the discussion is highly relatable to ASCs throughout the country.

The agenda included several discussions on key issues, such as architecture and engineering, quality reporting requirements and regulatory matters, reimbursement implications of payor mergers and provider alignment, dealing with a security breach, creating operational efficiencies that enhance value, tri-party deals, bringing together healthcare entities to maximize value, compliance and white collar enforcement actions, surviving and prospering in the online world, and key tax and financial considerations for individual ASC owners.

While each session was extremely informative and educational, I want to focus on a few topics relevant to the industry and related to the metro states’ regulatory processes.

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ASCA Update In the opening session, William (Bill) Prentice, CEO of Ambulatory Surgery Center Association (ASCA), provided an update on the ASC industry. ASCA is the national organization representing approximately 5,400 Medicare-certified ambulatory surgery centers in the United States1. It provides advocacy, education, benchmarking and staff training for its many members.

The Ambulatory Surgical Center Quality and Access Act of 2015 (H.R. 1453) and the growing disparity in reimbursement between ASCs and hospital outpatient departments (HOPDs) were main topics of focus during Prentice’s update. Some of the highlights of his presentation included the following: • The Ambulatory Surgical Center Quality & Access Act of 2015 would move the ASC reimbursement update from the Consumer Price Index for All Urban Consumers (CPI-U) to the hospital market basket update, which better measures the cost of practicing medicine.

• This legislation would require Centers for Medicare and Medicaid Services (CMS) to post similar quality metrics of ASCs and HODPs online in a “side-byside comparison.” The publicly available data would include quality measures and copay amounts for both sites of service in the same geographic area.

• ASCs currently do not have a representative on the Advisory Panel on Hospital Outpatient Payment, which controls various aspects of physician payment rates. This legislation would add an ASC industry leader to that panel.

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• The bill would also add transparency to the healthcare industry by requiring CMS to disclose which criteria they use to deny certain procedures from being performed in an ASC by requiring them to publically share the results of quality reporting measures that apply to both ASCs and HOPDs. • Hospitals have the added advantage over ASCs in that hospitals can receive Medicare reimbursement for 300 more outpatient procedures than ASCs. ASCA is working to help resolve this issue by working to change Medicare policy to allow ASCs to perform all procedures currently done in the hospital outpatient department.

New York Each of the three metro states’ ASC associations were represented at the conference by their own leadership: Thomas Faith, president of the New York Association of ASCs; Larry Trenk, who served as president of the New Jersey Association of ASCs until recently; and Lisa Winkler, who spearheaded the development of the Connecticut Association of ASCs (CAASC). They provided an overview of each state’s ASC situation and regulatory process.

New York has approximately 130 ASCs. One of the challenges in obtaining licensure to establish an ASC in New York is the required certificate of need (CON). If the CON is approved, the Public Health and Health Planning Council will only issue a five-year limited license. The ASC will reach permanent licensure status once it can demonstrate it has met the charitable care requirements with a look back of the five-year period. At that point, the

ASC is required to submit a second application for extended licensure.

New Jersey New Jersey has over 300 surgery centers. It is one of the few states that has an ASC tax in place which helps provide the state approximately $4 billion in revenue. In 2009, the Cody Law placed a moratorium on development of new ASCs in New Jersey. No new ASC licenses are issued in the state except in the case of transfer of ownership, relocation of a facility within 20 miles of the current location or if the facility is jointly owned by a hospital.

Connecticut With 61 ASC members, CAASC is most likely one of the few state associations that enjoy 100% membership from all of its state’s surgery centers. The state requires a CON for establishment, adding an operating room or moving the facility and service lines. Like New Jersey, Connecticut has now imposed a 6% gross receipts tax as of October 1, 2015; however, the tax is not imposed on the first million dollars of gross receipts of the ASC in the applicable fiscal year.

CON Roundtable Frank Cicero, president and owner of Cicero Consulting Associates, moderated the Department of Health (DOH) CON Roundtable. Cicero’s office does a great deal of work in New York in preparation and submission of CON applications and monitors submitted applications through the governmental review process.

The roundtable included three members from the N.Y. State Department of Health: Charles Abel, acting director for health care facility planning, licensure and finance; Ruth Leslie, director of hospitals and

PE’s Experience in the Metro States – New York and New Jersey: New York Physicians Endoscopy (PE) is currently affiliated with eight single-specialty GI ASCs in New York. While it is certainly an arduous process to obtain CON approval, it can definitely be accomplished with the right team in place.

ASC healthcare lawyers and CON experts are a must. PE has worked with Garfunkel Wild on several of their New York and New Jersey transactions, and the law firm provided expert leadership and guidance throughout the process. Additionally, PE has utilized the Cicero team for all eight centers it has developed in New York as well as those centers that have expanded services. Each application has received successful approval. In 2016, PE plans to open two new GI ASCs in New York; each center includes a hospital partner. In addition, PE was recently successful in obtaining approval for the expansion of services for two centers located in Manhattan and on Long Island.

New Jersey PE is currently in the process of building a new ASC in Northern New Jersey in partnership with two physician groups and a hospital partner. The physician groups, comprised of 11 GI specialists, each have a one-room surgical practice. The physicians made the strategic decision to merge their practices and develop a state-of-the-art, four-room endoscopic licensed ASC. The ability to own a larger facility will provide them the opportunity to grow and consolidate operations. The ASC is scheduled to open toward the end of March 2016.

PE also completed the acquisition of Garden State Endoscopy Center in Kenilworth, N.J. Since the physicians wanted to sell 51% equity, state approval was required for the change of ownership. Utilizing one of the best New Jersey healthcare firms that had strong relationships within the DOH helped ensure a quick and successful approval process in order to close the transaction in a timely fashion.

diagnostic and treatment centers; and Udo Allain Ammon, AIA, director of the Bureau of Architecture and Engineering Review Division of Planning and Licensure.

Requests that typically fall under CON laws are establishment of new facilities, change of ownership, and significant construction of an existing facility. Physical plant and architectural review also fall under CON in New York. One of the most important requirements of a CON for new establishment requires the applicant to demonstrate public need.

While New York, New Jersey and Connecticut each requires a rigorous CON or licensure process that can significantly impact both the opportunity and timeline of developing a center, acquiring a center or requesting a change of ownership, centers that receive successful approvals benefit overall. These regulatory requirements essentially help to: 1) limit the number of ASCs, providing a less saturated market; 2) reduce competition centers; and

between

surgery

3) positively impact the overall center’s value through the holding of a CON. Plan to attend the next ASC Symposium annual meeting on September 14, 2016, to learn more about what is happening for ASCs in the New York metro area. I hope to see you there!

Carol Stopa is senior vice president of business development and marketing at Physicians Endoscopy.

Carol is responsible for developing new market initiatives as well as identifying and generating qualified business opportunities within the physician community in regards to new partnerships, acquisitions and hospital/health system joint ventures. She is also the editor-in-chief for EndoEconomics. Prior to joining the PE team, Ms. Stopa worked in clinical and administrative healthcare including mental health centers, correctional facilities, and psychiatric healthcare management companies. She may be reached at cstopa@endocenters.com.

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Background

Revenue Cycle Management Turnaround:

During late 2014 and into 2015, we were engaged by a community hospital with hundreds of employed physicians and extenders (nurse practitioners and physician assistants) encompassing multiple specialties to review its employed provider network’s (EPN) RCM. The culture was open and “provider friendly,” and physicians relished the benefits and protections that accrued from employment. We would soon learn why physicians were so enamored with the system and senior management, to both parties’ detriment.

Figure 1

A Case Study

By Jeff Gorke, Senior Vice President, Coker Group

Revenue is the lifeblood of any business.

Without revenue, regardless of the market segment or service line, an enterprise cannot thrive, let alone survive. Whether privately held or publicly financed (e.g., stocks/equity, bonds), the inflow of revenue and efficient operation precede the viability of any business.

JEFF GORKE

Given the margins in healthcare, this is no less true in the operation of ambulatory physicians (or private practices) employed by health systems. Stunningly, some institutions continue to under-invest or place on the “back burner” the significance of revenue cycle management (RCM) and its accompanying component pieces. Healthcare margins are tighter than many service-oriented businesses outside of healthcare and, arguably, hampered by greater and more prolific regulation than for typical companies.

With that in mind, accurate billing and revenue management, from A to Z, is more crucial for a physician enterprise than for your local convenience store. Processes as delineated below are requisite.

In this case study, we explore the situation of a hospital system and one of our clients at the Coker Group that struggled with its RCM until the point that its financial foibles caught the C-suite by the tail and threatened the fiber of the organization, forcing the system to seek outside investment.

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As the system’s employed model grew (see Figure 1), its problems grew in kind. Tangentially, the manager of the structure was weak, with the senior managers having few skills and little management experience. The position of vice president of the EPN had been vacant for some time, foisting the practice operational duties and the RCM onto the chief financial officer (CFO). Exacerbating the deficiencies were the frontline managers of the practices—the managers who handled the day-to-day varying tasks of the smaller groups.

These managers were ill-equipped to handle the complex tasks of practice management, and there were few standard policies or procedures in place. Not all of the practice managers were sub-standard in their skills and experience, but they required training and leadership, which was lacking from the top down. A controller was brought in to assist with the RCM. The director of the central billing office (CBO) was then asked to expand her job horizons outside of employment with the system. As Figure 2 illustrates, this leadership vacuum, on top of an already weakened system, fomented further chaos.

Figure 2

For several years, the system had buried the fact that its contractual adjustments were woefully understated, offering the peaceful fallacy that revenues were better than they were. Figure 3 provides a simplistic, but directionally appropriate, summary.

Figure 4

Figure 3

In this EPN, practices were on-boarded, and commitments were made to providers that they could keep their PMs/ EMRs, staff and processes, and the system would manage the RCM process as it existed. Logically, this was a no-brainer for physicians who were selling their practices or engaging in professional services agreements (PSAs) to the system so as not to disrupt current operations or create undue tension among staff.

If the figures above were anywhere near the real dollars involved, the system could have continued its ways. Instead, the system found itself nearly $30 million in the hole, with cash on hand dwindling quickly.

One supposes that the CFO, for some time, inexplicably thought that the situation would eventually remedy itself. In other words, perhaps fudging the numbers for one month would be okay. And then, when that proved easy, maybe it was simple to alter the numbers again for another month.

And at some point, the die was cast and the snowball began to roll, overtaking the then-CFO. Whatever the case, that gamble was troubling and fraught with mathematical error. With the lack of structure, process and policy in place for the RCM, there was little chance that the charade would last over the long term, putting the system’s finances and the CFO’s job in jeopardy.

After two years of understated contractual adjustments and overstated revenue expectations, cash flow winnowed away, board members started asking questions and bondholders began to worry about longevity.

Challenge Faced: Multiple IT Systems The revenue cycle for the system’s employed groups was an amalgamation of differing computer systems (practice management (PM) and electronic medical records (EMR) systems). The main CBO had two different computer systems deployed: “System 1” and “System 2.” One of the recently acquired practices had its version of System 2; we’ll call it “System 2.1.” Another practice under the EPN umbrella had yet another system deployed, “System 3.” Figure 4 illustrates the PM and EMR computer systems model.

In many instances, when health systems purchase practices, the goal is to minimize disruption, quashing the prospect of dissension and/or politics that often attend the onboarding of new practices. In the near term, this peace offering keeps providers happy, keeps their staff relatively content and, in some ways, goes toward closing the deal. It’s a very palatable approach to a tumultuous endeavor. The result, however, is a mix of systems and processes that require different inputs, work and functionality, and the vanishing of any prospect of efficiency. To add, now that the providers no longer needed to manage their RCM as a way to ensure their compensation, they were removed from the equation and had no dog in the fight (i.e., no concern of the proper billing/collecting for the practice).

Given critical and significant structural deficiencies, the system’s RCM was already set up for painful, if not fatal, times.

We found a system with average days in accounts receivable (A/R) hovering near 65, flat charges and collections, bloated “aged” buckets (e.g., >120 days), few standard policies and procedures, minimal upfront cash collections, a fractured credentialing process and little educational feedback to staff.

Challenge Faced: Credentialing The RCM is too often viewed in pieces versus as a system with multiple inputs and variables.

Figure 5

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For instance, systems often fail to coordinate new provider contracting with credentialing. As Figure 5 shows, in the current case, the system hired new physicians and added them to the EPN, while involving credentialing was essentially an afterthought. (i.e., less than systematic).

Thus, the system had physicians who were on staff and had privileges in the hospital but were not credentialed with payors. In some instances, this lasted with some payors for more than one year.

Challenge Faced: Provider-Based Billing Also, the system had converted many of its ambulatory physicians to provider-based billing (PBB). When properly deployed, PBB is a challenging proposition, at best. Illadvised deployment, in this case, left many with little oversight and management, with few in the senior level of the RCM fully apprised or understanding the impact of PBB and its billing and collections. In many instances, the process was manual. When things went badly, the inevitable finger-pointing soon followed. In this case, the casting of blame occurred between the ambulatory CBOs and the hospital billers.

code errors, etc. As might be expected, similar errors continued to arise. All charges were entered at the CBO level that took on the accountability. At the practice level, claims were submitted from some of the medical practices and then follow-up performed at the CBO location—an entirely different place. Feedback and errors were handled haphazardly with little education or corrective action taken.

No policies or procedures were in place to manage the educational flow of information, training or criteria for staff remediation apropos of their annual evaluations.

To compound “bad,” some A/R improvement was realized by staff writing off, at their leisure, collectible amounts versus working the accounts. We ended that process.

As noted, physicians who joined the system were indeed delighted because they received protection from the “pain” of running a private practice. They joined what they assumed was a financially sound system and were essentially offered carte blanche regarding running their practices, which included the “logic” of creating the multiple CBOs that billed on behalf of the physicians and the multiple EMRs that were deployed.

Challenge Faced: Tax Identification Numbers

Action Steps

The issue of tax identification numbers (TINs) was another problem that surfaced. TINs were not transitioned timely for newly acquired practices. In some instances, monies flowed into the “old” TIN of the medical practice that created cash flow anomalies, inefficiency and extra work for the CBO.

Just before we arrived on site to begin work, the CFO was asked to seek employment elsewhere. During the project, which lasted several months, the CEO also resigned.

The controller, who had previously served as a CFO, was promoted to CFO and became our project touchstone. He also began managing the RCM via the directors and the operations of the practices (as noted in Figure 2).

The system would acquire new practices and establish a new system TIN, which created multiple different TINs for the different practices. Given the lag in credentialing, a decision was made by the former CFO to bill the claims under each practice’s old TIN that was already active in the health plans’ systems.

Challenge Faced: Multiple CBOs Further complicating matters was the performing of coding and charge entry at the clinic sites. Charges were billed from the CBO. Payments would process and be posted by the payment posters. Denials and outliers would be sent back to the “main” CBO where the account representatives would review and work the accounts. These claims would then be resubmitted by the billers.

Historically, attention had not been given to patients who did not pay after three to four months; few accounts were ever turned over to collections and managers. From the CBO on down to the office managers, there was almost no feedback offered regarding coding errors, diagnostic

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We arrived on site in early 2015 and performed a broad macro review and assessment overview of the CBOs. We had been told that the CBOs were in varying stages of disarray.

This description may have been the understatement of understatements. In general, we found the CBOs to be a hodgepodge of policies, training, procedures, informational loops and lackluster follow up. Components of the CBOs were housed in four different locations: two were recently acquired medical practices and the other two were business offices.

To help turn the system around, the following items were implemented: • designed, developed and implemented policies and procedures for the CBO(s); • began plans to consolidate the CBO and its employees in one location; • established reporting structures and consistent lines of communication;

• placed an interim seasoned healthcare executive to serve as the interim director of the CBO (after the previous director resigned); • consolidated, where possible, disparate processes that occurred throughout the organization; • oversaw realignment and streamlining of staff; instituted better-defined positions; • improved feedback to the practices so that errors created at the practice level were now “fixed” at the practice level, placing some of the onus for repairs on those who had submitted erroneous work; • improved front office (e.g., at check in) collections of co-pays and deductibles; • suggested long-term strategy of migrating to a single platform information technology solution; and • automated processes, where applicable, efficiencies (e.g., payment posting).

for

Twelve months in, the system is struggling, but improving.

It has an external suitor who will bring needed stability and capital to the partnership. An interim CEO is helping to right the ship, and the CFO continues to manage both the EPN and the RCM. (He is, though, taking our counsel to hire a vice president of the EPN and a director of the RCM to ensure both are managed appropriately.)

For the aggregated CBO, at the outset of the project, days in AR hovered near 65. After deployment of policies and procedures, and with a consistent effort monitoring and measuring outcomes, days were reduced to roughly 48 days in AR. Over the same measured period, charges and collections increased. Physicians took a more active role and reduced lag days (days from time of service to closing of charts) and as noted previously, point of service collections grew. The increase in charges translated, with effort and management on the “back end,” increasing total collections.

Lastly, deployment of processes enabled the CBO to better manage “aging” accounts thereby reducing the dollars that resided in the “>120 days” bucket.

Jeffrey T. Gorke, MBA, brings approximately 26 years of healthcare experience to the position of senior vice president with Coker Group.

His primary focus has been strategic and operational work assisting clients in macro and micro structural change to enhance processes and programs, drive efficiencies, and improve profitability. At Coker, he uses that experience to assist clients with operational assessments (both hospital and physician practices), physician compensation reviews, employed physician network turnarounds (with quantifiable results), financial and revenue cycle assessments, and strategic planning. For more information, contact Jeff at jgorke@cokergroup.com

Results Aside from process and procedure improvements and structural changes, our implementation plan involved objective measures to prove out the value of suggested improvements.

Cash collection were handled with differing levels of sophistication. We reviewed the current status of collections and then, with management’s imprimatur, increased budgeted amounts by 20 percent. Over the measured period, the practices not only attained the 20 percent budgeted increase but exceeded the budget by 22 percent.

Figure 6

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Marketing

Buzz website can not only increase new business and save you money on traditional advertising, but also attract a new type of consumer and demographic, and allow for your business to communicate directly with potential consumers.

Digital Strategy: Factors to Consider When Building a New Website

In the case of patients, more and more are going online to research, manage, and improve their health. In fact, 91 percent of patients in the United States look online for health and medical information, with 66 percent of patients using a mobile app to manage their health.1 Whether you’re ready to take that first step and build a brand new website for your practice or center, or looking to update your existing site, the process can be very overwhelming and time consuming—especially if you don’t have a definitive plan of action or know where to start. I’m often asked,

“We want to build a website for our center; where do we begin?”

By Lori Trzcinski, Marketing Communications Specialist, Physicians Endoscopy

Despite the soaring popularity of social media and online review sites, the company website still remains the greatest provider of services to your consumer base. A website is an extension of your company and should easily connect you to consumers. It can help to boost their knowledge and LORI TRZCINSKI be an extension of your current offerings, such as providing a way for a patient to pay his or her bill, learn more about the services you offer at your center, or obtain nutritional and health information for ways to improve one’s diet.

Digital consumption has significantly increased over the past decade. Maintaining a simple website with pictures, an address, and contact information no longer suffices as a good digital representation of your organization. The website you build must have a purpose and add value to your business. It must be easy to find and navigate—as user friendly as possible—whether it’s accessed from a desktop computer or the latest smartphone browser. An effective 20 |

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In part one of this two-part mini-series, I’ll explore factors that will help you to accomplish building your new website and to be confident going into the process.

Factor #1: What is the purpose of your site?

Is it to introduce your company, practice, or center to the community? Is it to promote the latest equipment or products you use? Is it so that a patient can pay their bills online?

Identify its specific objective(s). The goal of your website will help determine all other decisions you make in developing your new site.

Factor #2: Who is your target market?

Clarifying your target market early on in the development process will also affect all other decisions you make for your new site. In some cases, you may have more than one target market that your website must speak to; for example, patients and referring physicians. The design and content of your site must be of value to those browsing it. It must speak to them.

If you do not already know your ideal target market(s), find out by examining your current customers and what their identifying characteristics are that apply to your business (e.g., age, gender, ethnicity), as well as what information they would find most useful and relevant from you.

Factor #3: How much are you willing to spend?

The full cost of a website should be considered when planning

Marketing

Buzz for one. This amount includes the initial expense of creating the site, followed by any unforeseen costs of developing the site, hosting fees, and, most importantly, any monthly maintenance charges that you may incur once the site is live.

Ideally, once the site is up and running long term, your site should make you money through referrals, new patients, etc., and provide a good return on investment.

Factor #4: What will your domain name be?

Simply put, the domain name of your website is the web address you type into your Internet browser (e.g., google.com, endocenters.com). It should be short and easy to remember.

It should be easy to tell people and easy for them to spell when you direct them to your site. It should be a name you like the sound of and one that represents your business as it will appear on business cards and marketing materials. You cannot change this easily afterwards, so spend a substantial amount of time selecting the right domain name.

Factor #5: Who will design it?

Costs for a designer of a new website typically range from a couple thousand dollars to tens of thousands of dollars. Each company is different in its level of involvement in the actual site design, so that will greatly affect the cost. Do you want a website made from an existing template or design, or do you want a website made based on your custom needs? The more custom your site, the higher the cost. Keep in mind that typically the less money you spend on a website designer, the more of a role you will be expected to play in the project, and the more “do it yourself” the website process will become.

Spend time researching website design companies. Speak with them to get a better idea of what your true website needs are. That will help you to determine what company may be the best fit for you. Designers should be able to help you to create an easy-to-use website that reflects your company and its brand through colors, images, fonts, a responsive design, keywords, etc., and helps attract your target market.

Factor #6: What’s your timeframe?

Having a deadline for when you would like your website to go live is crucial. Do you have a specific event or ideal time in mind by which you would like it to be completed and launched? The complexity of the site’s design and revisions necessary before the site will be seen by the public affects the timeline of when your site actually does go live. No matter how hard you plan, there will always be unexpected factors

that will change the course of your site’s timeline. You will need to be prepared to handle them.

Factor #7: Who will take the lead?

As with any project, there must be a designated lead person who hands down the final approval for each step of the website design and development process. You may have a team of people who discuss what they would like to see on the site and come to a consensus about changes, but for a website to be developed in a timely, efficient manner, you must still have the main decision maker and liaison between your company and the developer.

Factor #8: What content will you provide?

The website of your dreams cannot be created without the initial content in which to fill it. This content may include text, videos, sounds, images, forms and animations. If you’re designing a new website and never had one previously, this content can be a bit more challenging to come up with and may require you to conduct research ahead of time.

It may even require you to schedule time with a writer, photographer, and/or videographer to help generate relevant content specific to your business to use. If you’re refreshing your website by updating an existing one, now is a good time to review what you already have on your current site and determine what you need to keep and what may need updating. A website designer can only go so far before the use of content comes into play in the development phase of your site. Oftentimes, website companies will offer a service to help you develop content for your site. This may be an option to consider if you do not have someone to dedicate towards generating this content.

Factor #9: Who will be your hosting company?

The hosting company will store and power your site once it is viewable to the public online. There are a multitude of hosting servcies available out there to choose from. A quality hosting company will be able to provide its customers with fast, reliable website page views and downloads (i.e., your new website will load quickly and without any issues). A good hosting company will also be able to provide you with a reliable place to house your site so it rarely goes down and will back up your site in case something happens to it.

Factor #10: What security measures are in place?

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Marketing

Buzz site is 100 percent hack- or spamproof. When building a site, there are other measures that developers (and you) can take to protect your site from cybercriminals. Typically all parties are involved in helping keep your new website secure—from the developer and hosting company, to the company providing monthly support (if you choose to have it) and even yourself. All provide a very important role in making sure that your website and the information on it are safe and secure. Basic steps you can take to improve the security of your site include: periodically changing the login and password used to access the back-end, editable sections of your website; maintaining the latest

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version of your website platform (e.g., WordPress, Drupal, Joomla); and even having your developer install coding or plug-ins to your site to deter spam submissions (e.g., invalid “contact us� form submissions).

What Now? Each of the aforementioned factors play a large role in navigating through the process of creating a new website for your business. Although every potential factor that can arise may not be mentioned, these 10 are what I consider to be the most influential when doing so. They serve as a guide to help make the journey a little less intimidating and overwhelming.

In part two of this mini-series, I will examine the steps you should take to promote your new website once it is live online. It will be available in the Spring 2016 issue of EndoEconomics.

Source: 1: Everseat. (2015, October 20). Patients Outpace Doctors in the Use of Digital Technology. Retrieved from https://www.everseat.com/blog/patients-outpacedoctors-in-the-use-of-digital-technology/

Lori Trzcinski is the marketing communications specialist at Physicians Endoscopy and the managing editor of EndoEconomics. 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.

Grasso’s passion for giving back to the community has its roots with her father, who was a popular soccer, baseball and softball coach in the area where she grew up.

Raising Colon Cancer Awareness with Get Your Gear in Rear

“My father was well-loved in our community and often made a difference in someone’s life,” Grasso says. “If I can reach and encourage one person to get an early screening, it could very well make a difference in survival. Statistics tell us colon cancer is expected to take the lives of more than 49,000 people in 2016.”

Grasso credits her sponsors for the growth and success of her efforts. “Our sponsors provide the much needed support for an event like this,” Grasso says. “As partners, we have shared goals to raise awareness. The sponsors and many survivors, caregivers, families and friends of people affected by colon cancer continue to bring teams to participate in the event.”

For more information on GYRIG Philadelphia, www.coloncancercoalition.org/philadelphia.

By Maria Grasso, Executive Director, “Get Your Rear in Gear Philadelphia” There are no words when a loved one is lost to cancer. Maria Grasso lost her father and grandfather to colon cancer. Since no words could ever describe the pain she felt—especially when she knew that the disease was 90% curable if caught early enough—she decided to take action.

Colon cancer, the third most commonly MARIA GRASSO diagnosed cancer and the second leading cause of cancer-related deaths in the United States each year, is highly preventable through routine screenings that lead to early detection.

Grasso, a resident of Mount Laurel, N.J., decided she would be a warrior on behalf of not only her father and grandfather, but all people affected by colon cancer. In March 2008, Grasso contacted the Colon Cancer Coalition and expressed her interest in launching “Get Your Rear in Gear (GYRIG) Philadelphia” to raise money to fight the disease and raise awareness on the importance of early detection through colon cancer screenings.

Colon Cancer Coalition started in 2004 as one women’s reaction to the loss of her sister to colon cancer at the age of 46. The first GYRIG event was held in March 2005 in Minneapolis. Through GYRIG events, the Colon Cancer Coalition raises funds to increase screening and awareness for colon cancer. Money stays in the local communities where it is raised. Nearly 50 GYRIG events are held annually in states across the country and the list is growing.

Since 2009, GYRIG Philadelphia has raised significant money for education, research, screenings, treatment and patient care in the Delaware Valley region. GYRIG Philadelphia is an annual four-mile run, two-mile remembrance walk and kids’ fun run. The event has grown from 1,200 participants to more than 4,000. This year’s eighth annual event will be held Sunday, April 3, in Fairmount Park at Memorial Hall in Philadelphia. Survivors, caregivers and those lost to colorectal cancer are honored at GYRIG Philadelphia.

visit

Maria Grasso is the executive director of “Get Your Rear in Gear Philadelphia,” an event support by the Colon Cancer Coalition. Born in Philadelphia, PA, Grasso and her family currently reside in Mount Laurel, NJ. She started “Get Your Rear in Gear Philadelphia” in 2009 after losing her father and grandfather to colon cancer. Under Grasso’s direction, this annual event has raised well over $1 million dollars. These funds stay in the region to support research for colorectal cancer and educate the community about the importance of screenings and patient care.

Programs Funded by “GYRIG Philadelphia” • Kimmel Cancer Center at Jefferson – Center to Eliminate Cancer Disparities. Director, Dr. Edith Mitchell’s work will be used to develop a greater understanding of the factors that lead to development of colon cancer to facilitate prevention strategies and develop better treatment interventions. Additionally, Dr. Mitchell and her team plan to analyze data that will help elucidate factors that promote proliferation, response to therapy, resistance to standard chemotherapeutic agents and development of new agents for treatment.

• The Jefferson Division of Colorectal Surgery. The division intends to further its work with granted funds to evaluate biopsies of patients who have completely responded to preoperative treatment (no tumor left) versus those who do not have an effect from chemo/ radiation. Using genetic technology (NanoString), researchers and physicians hope to identify a pattern of genes that will allow care specifically for the individual rectal cancer patient.

• The American Association of Cancer Research (AACR) Scholarin-Training Awards. These help assure that young researchers have the opportunity to present their work before the international research community and participate fully in the most important and largest cancer research meeting in the world.

• West Philadelphia Gastrointestinal Health Outreach and Access Program. Abramson Cancer Center’s community outreach work of Penn Medicine’s medical oncologists Carmen Guerra, MD, MSCE, FACP, and Michael Kochman, MD. This demographically targeted program offers navigation, transportation assistance and counseling for early colon cancer screening in an underserved area of Philadelphia.

• Understanding Quality of Life Issues Following Recovery from Colon Cancer Treatment. Under the team of Jeffrey Farma, MD, FACS, team at Fox Chase Cancer Center in Philadelphia.

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Center 480 lbs. of food was donated. Physicians Endoscopy also supported the Holiday Mail for Heroes Drive sponsored by the Red Cross which benefits US Veterans in VA hospitals and VA nursing homes. Through the drive, PE was able to send over 100 holiday cards to veterans across the country.

Lawmakers

Giving Back to the Community Laredo Digestive Health Center (LDHC) celebrated Veterans Day last November by donating food and beverages to two local veterans’ centers in their town of Laredo, TX. LDHC staff met with the veteran center staff, volunteers, and even patients to commemorate the day. They were the only company in town that provided any sort of “gift” for the veteran center patients.

Physicians Endoscopy (PE) participated in numerous give-back programs for the winter holiday season. PE sponsored a local family of a service member who was killed in the line of duty through the Liberty USO’s Survivor Outreach Program. PE employees raised over $1,600 to be used towards food, clothing and holiday gifts on their wish list for the children. PE also participated in a local food drive collecting non-perishable items to donate to the Doylestown Food Pantry. Over

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Center Anniversaries Congratulations to the following Physicians Endoscopy partnered centers who have hit their 5-year, 10-year, and even 15-year anniversary mark since the center opened: • AZ West Endoscopy Center (opened in 2011) • Berks Center for Digestive Health (opened in 2001 and expansion in 2013) • Central Arizona Endoscopy (opened in 2006) • Kalamazoo Endoscopy Center (opened in 2006) • Long Island Center for Digestive Health (opened in 2006) • Lone Star Endoscopy (opened in 2006)

Berks Center for Digestive Health (BCDH) On November 20, 2015, Congressman Ryan Costello (PA-06) and his district director, Kori Walter, visited BCDH after the center was chosen as a direct result of the ASCA Capital Fly-in last September 2015. Rep. Costello met with Robert Puglisi, Vice President of Operations at Physicians Endoscopy; Louis La Luna, MD; John Altomare, MD; Nirav Shah, MD; Christopher Ibrahim, MD, and the center administrator, Christine Yoder, RN. The group thanked the congressman for cosponsoring the Removing Barriers to Colorectal Cancer Screening Act of 2015 (H.R. 1220/S. 624) and discussed the Ambulatory Surgical Center Quality and Access Act of 2015 (H.R. 1453/S. 2071).

Certifications and Awards East Side Endoscopy (ESE) has a 100% certified Endoscopy Technician staff. Each technician was certified as of November 2015. The center also had other members of the staff pass the SGNA CGRN exam and the CFER exam.

Hudson Valley Center for Digestive Health (HVCDH) received the National APEX Quality Award for Patient Satisfaction. Given to only 104 healthcare facilities nationwide

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Center in 2015, this national distinction recognizes outstanding healthcare organizations and care teams who have demonstrated the highest level of excellence in patient satisfaction and overall care over the preceding 12 months. Winners are determined solely based on patient feedback and evidence-based success.

Physician Leaders to Know

Robert B. Cameron, MD

Congratulations to Robert B. Cameron, MD, of The Endoscopy Center of Bainbridge and University Suburban Endoscopy Center (Ohio), as

well as Lawrence Kosinski, MD, MBA, AGAF, FACG of Elgin Gastroenterology Endoscopy Center (Illinois) as they were named Becker’s ASC Review’s “164 ASC industry physician Lawrence Kosinski, MD leaders to know” for 2016. Those chosen were physicians establishing, leading and partnering with ambulatory surgery centers.

Endoscopy Directors’ Course Brett Bernstein, MD, FASGE, Medical Director of Mount Sinai Health System and

Brett Bernstein, MD, FASGE

East Side Endoscopy Center in New York City is co-directing the “GI Endoscopy Unit Leadership— Endoscopy Director’s Course: Cultivating a Successful Team” with David H. Robbins, MD, MSc, FASGE, Medical Director of Manhattan Endoscopy.

The course is scheduled to be held April 8-9, 2016, at the ASGE Institute for Training and Technology in Downers Grove, IL. It will focus on leaders’ roles and responsibilities to align teamwork around clinical and operational issues.

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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: 1:3 • 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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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: Monte Allen, DO - Medical Director (956) 795-4776 • mallen@gastrolaredo.com

Garden City, NY

Gastroenterology Associates – Long Island Center for Digestive Disease The physicians of Gastroenterology Associates, a large single specialty private gastroenterology group, are seeking a BC/BE physician to start immediately or July 2016.

This candidate will have partnership/ownership opportunity in the affiliated endoscopic ambulatory surgery center. This three-room facility, located in Garden City, NY offers: • Physician-owned and controlled center • State-of-the-art endoscopic equipment • Physician efficiency and optimal patient quality of care • Professionally operated and managed Gastroenterology Associates, one of the oldest and most respected GI practices on Long Island, has always prided themselves on being leaders in delivering the highest quality of specialized patient care.

For more information, contact: Kathy Harren, Office Manager (516) 248-3737 • gastrophysicians8@gmail.com

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 (GCSJ) is a privately owned, eight physician practice located in Lumberton, NJ. GCSJ is a well-established practice located among several growing communities in southern New Jersey.

• Located within thirty minutes of Philadelphia and within one hour of New York City.

• We are affiliated with Burlington County Endoscopy Center, a three room Ambulatory Surgical Center • The ASC is physician owned and operated.

• Our practice is seeking to add a full or part time gastroenterologist.

• Our large practice offers an attractive call schedule of 1:7 and an opportunity to perform ERCP and EUS (not required).

• Partnership will be offered in the practice and endoscopy center.

For more information, contact: Monica Awsare, MD • monicaawsare@gmail.com

For more information, contact: Robert Neidich, MD, President of Gastro-Intestinal Associates Phone: (419) 999-1088 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 dietician 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 W I NTE R 2 0 1 6 EndoEconomics

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