Who’s Who in the Ambulatory Surgery Industry — The Facilities

As part of Who’s Who in the Ambulatory Surgery Industry, today’s surgicenter also honors the excellent facilities that make up the backbone of the industry. These five centers, stretching from North Dakota to South Carolina, cover the gamut of outpatient specialties from laparoscopy to orthopedic surgery, consistently bringing the latest technological advances and convenience to their respective operating rooms and patients.

Surgical and Endoscopic Center of Stephenville

The Surgical and Endoscopic Center of Stephenville (SECS) opened in October 2006. The center is the first facility of its kind in Erath County, Texas, offering a wide variety of day-surgery procedures including colonoscopy and other digestive evaluations, cataract and laser eye surgery, laparoscopy, podiatry, orthopedic, pain management, as well as ENT procedures.

Unlike outpatient surgery at hospitals, the Surgical and Endoscopic Center runs on a strict schedule where every effort is made to adhere to the time the patient is scheduled. Patients are not postponed due to an unexpected higher priority case being scheduled in their place.

The modern design and image of comfort is what patients have come to appreciate. The 12,000-square-foot outpatient surgery center boasts state-of-the-art medical equipment and cutting-edge technology which includes two surgical suites, a GI procedure room, as well as a YAG laser room.

The center currently has 14 credentialed physicians on staff, but will soon be adding more as the number of services increases. The building was designed with future expansion in mind, complete with a tear-out wall. As new physicians and procedures are added, more operating and recovery rooms could become a reality. But before that can take place, new services that are currently unavailable to patients in the area will need to be added.

The facility’s medical director, Janie McMillion, MD, said when planning the facility, a lot of detail was put into the center’s appearance. Creating a place for patients to enjoy was important to her. “I believe it’s important for patients to get the feeling that they will be well taken care of during their stay,” she said. “Creating a beautiful place helps us give them that comfort.” McMillion also said that visits to the surgery center are designed to be brief. Surgery patients stay an average of four hours.

Another advantage for patients at the center is their out of pocket expense. Surgeries performed at outpatient surgical centers cost patients one-half to one-third less than in the hospital outpatient setting. All of the worry for the patient’s cost factor is erased due to the global fee billing. Once a patient is scheduled, they know the exact cost of the procedure with no surprises when they receive their statement.

Two years ago, the dream of an outpatient surgery center became a reality, and SECS continues to think of new ways to better serve their patients. Patient satisfaction surveys have been very positive. Sheila Poston, RN, director of nursing, states, “We are continually striving to provide the best care in the most efficient manner. We have a very caring and compassionate staff that always places the patient first.”

Bismarck Surgical Associates

Bismarck Surgical Associates LLC, of Bismarck, N.D., is a multispecialty (orthopedic, ophthalmic, ENT, pain management and oral surgeries), free-standing, physician-owned ASC with three ORs. The center will be celebrating its 10th anniversary in February.

“(We) take pride in the services we offer our community as evidenced by our high approval ratings,” declares Todd Neiss, business manager of Bismarck Surgical Associates. We run an efficient operation averaging 9.62 regular hours per case. This, along with an effective cost control program results in a net income to net production ratio of 42 percent. Our staff is second to none and we work hard to retain our staff, as evidenced by our low turnover rate. In 1999, we had 16 FTEs and of those, we still have 10 original staff members and we have grown to 32 FTEs.”

Parkridge Surgery Center

Parkridge Surgery Center is a 12,000-square-foot, freestanding, multi-specialty ambulatory surgery center in Columbia, S.C., that opened in November 2003 as a joint venture with Palmetto Health, the state’s largest nonprofit healthcare system, and individual physicians.

Parkridge Surgery has consistently ranked in the top 10 percent in the nation in both patient and employee satisfaction and most recently, Palmetto Health was named among the 100 Best Places to Work in Healthcare by Modern Healthcare. “Our staff, without a doubt, is what sets us apart from everyone else. We are completely committed to providing high quality, patient-centered care and are continually looking for ways to improve,” says administrator Emilie Keene.

Clinical director Lisa Waters-Davis agrees. “We have such a strong quality improvement program with active employee participation. We don’t focus on problems, we focus on solutions.”

Timberlake Surgery Center

Situated in the beautiful West County area of St. Louis, Timberlake Surgery Center began operations in the summer of 2003 and relocated to the present location in 2006.

Timberlake is a multi-specialty center that includes orthopedics, pain, podiatry and plastic surgery. Occupying 14,988-square-feet of space, the center has a total of four ORs and one procedure room. Presently, there are eight active physician partners that represent 68 percent of the total annual case volume and 93 percent of the surgical case volume.

In 2004, the facility joined with Symbion Healthcare as a corporate partner, who exhibits a collaborative relationship with energetic and visionary leadership; together delivering exceptional value.

A measure of success is shown by the satisfaction of patients, physicians and employees. Through its entire group of employees, anesthesia and dedicated physicians living up to its core vales, Timberlake is a supportive workplace for staff that focuses on quality, services and cost.

“Being part of an effective group of healthcare providers makes taking care of patients an honor instead of a job,” states Kim Thornton, clinical director at Timberlake.

“Our caring and compassionate staff, anesthesia and surgeons make the difference,” states Beverly Baker, administrator at Timberlake.

Patient satisfaction is a top priority for the center and is monitored monthly. One service that has proven to be beneficial to patients is partnering with a local pharmacy to allow patients to leave with their prescriptions filled, saving the extra stop at the drug store. Patients continually rave about this added service.

In August, Timberlake recently joined the efforts of ASC Association’s National Open House Day to welcome local and state representatives. More than 50 people attended the Aug. 13 event, including a gubernatorial candidate and several local state legislators. In addition to touring the facility and meeting with the physicians, attendees received informational packets on the benefits of ASCs, as well as an overview of pending federal legislation. This event allowed us to become more than just a name to them. “If we don’t step up to provide leaders with this information, no one will.” said Baker.

Yellowstone Surgery Center

Specializing in procedures ranging from pediatric to geriatric, Yellowstone Surgery Center in Billings, Mont., has been offering state-of-the-art ambulatory surgical and pain management care since 2002. Owned and operated jointly between 50 independent physicians and the Sisters of Charity of Leavenworth Health Systems, over 7,500 patients are seen annually in the facility’s six ORs and its pain management center.

Yellowstone has a patient satisfaction rate of 99 percent, which reflects its commitment to caring, to quality and most of all, to an excellent patient experience.

In a time when medical professionals are highly recruited, Yellowstone has little staff turnover. In fact, 90 percent of the original staff has remained at YSC since it opened. That longevity means that patients have a positive experience and a familiar face every time they visit.

Who’s Who in the Ambulatory Surgery Industry — The People

For six consecutive years, today’s surgicenter has brought together the best and the brightest people and facilities in the ambulatory surgery center industry as part of our annual Who’s Who in the Ambulatory Surgery Industry. And this year is no exception. These 18 individuals and five top-notch facilities were selected from nominations by you, the readers, as outstanding examples to not only the ASC and healthcare industries, but to their communities as well. So we at today’s surgicenter join in applauding the efforts of each these award winners in making the ASC industry beacons of prosperity in difficult times.

Toni Angle

Toni M. Angle, MBA, is the vice president of facility development for Titan Health Corp. Inc., a national surgery center development, acquisition and management company.

Angle began her surgery center experience in 1989, when she served as the administrator for a start up ambulatory surgery center. “Surgery centers were relatively new at this time and it was a challenge to get the regulators and payors to understand the model, but we prevailed.” As a result of the need for networking and political action, Angle was instrumental in the development of the California Ambulatory Surgery Center Association, and is a current member.

Angle then moved into the ASC management consulting and development area of the business. From this experience, Angle co-founded an ASC and surgical hospital management and development company. This company merged with a national ASC management and development company where Angle served as the senior vice president of facility development and operations. At this stage, Angle had developed 30 ambulatory surgery centers and two surgical hospitals. Angle assisted in the development of the American Surgical Hospital Association, now the Physician Hospitals of America.

“I have a passion for the ambulatory surgery center business; I enjoy the dynamic and entrepreneurial nature of the industry,” says Angle. “Further, I have experienced the business from the point of view of an administrator, developer and patient; the excellence of the environment and care is superb.”

Mark Brown

Mark Brown, MD, is passionate about helping people with low back pain control their symptoms and maintaining productive lives. Effectively addressing and treating low back pain can have a profound impact on a person’s quality of life. That is why he opened Innovative Back Care Center, LP, a single specialty ambulatory surgery center designed to treat low back pain utilizing interventional techniques.

As a board-certified anesthesiologist and pain medicine physician, Brown wanted a setting that exceeded patient safety standards. As medical director, Brown personally oversees all quality activities. He is a strong supporter and champion for ASCs because he believes “they provide a valuable service to the community.” Despite Medicare cuts, Brown continued to pursuit his dream of creating a safe and comfortable environment to treat pain.

Jim Corum

Jim Corum serves as vice president of operations for HealthMark Partners, where he has operational accountability for several surgery centers. His passion for the ASC industry includes helping his physician partners through successful business and ownership restructuring.

Over two years, Corum has quickly become one of the rising stars in the business, not only proving himself to be a savvy operator, but also in restructuring centers for continued success beyond the first life cycle of a center. Corum is consistently well respected by his physician partners who learn quickly his ability to identify and address critical issues to the centers success. Physicians often comment that it is nice to work with someone who they know early has their best interests at heart.

Prior to HealthMark, Corum led the in-market development efforts for Surgis Inc., a Nashville-based management company, which merged with United Surgical Partners (USPI) in April 2006. Throughout his tenure in outpatient surgery, Corum has worked with numerous physician groups on syndications including both de novo and turn-around projects.

Corum has participated in many outpatient surgery center conferences, serving as a panelist at the today’s SurgiCenter conference and as a speaker at the ASC Communications conference.

Suszon Daniel

Suszon Daniel, RN, is currently a part of Olympus America Inc. as an EndoSite nurse consultant.

Her work includes delivering a high-quality strategic planning and project facilitation service to remodel or develop new office-based endoscopy (OBE) or ambulatory surgery centers (ASC); managing 10 ongoing OBEs or ASCs within the first year of employment and selling product offerings to customers. She is also involved in redevelopment of policies and procedures for OBE and ASC and developed the “Do It Yourself” program for customers in New York requiring accreditation.

“Suszon is a very knowledgeable, pragmatic and organized nurse consultant. She always delivers her projects on time,” says Joanne Muturi, an EndoSite advisor in the ASC industry. “Her customers love her and her colleagues value her input. She is a team player and is always willing to go the extra mile for her customers and colleagues. Even her former employer wanted her back for a very long time. She deserves to be recognized.”

“I enjoy working with physicians in building their OBEs or ASCs,” says Daniel. “It is truly a constant work in progress from the ground up.”

Boyd Faust

Boyd Faust, CPA, has been working in the surgery center industry since 1986. He was chief operating officer for National Surgical Care and served in various roles at Medical Care International, then the largest operator of outpatient surgery centers in the United States.

He has held leadership positions in the broader healthcare services business as chief operating officer for Alliance Care, senior vice president of a multi-hospital healthcare system in the Carolinas and senior manager of Ernst & Young’s Southern Region Healthcare Finance Group. He currently serves at the chief financial officer for Titan Health Corp. Inc., a national ASC developer and operator. Faust has also authored articles in national trade publications and spoken at national meetings and conferences.

“Boyd has the ability to see the industry from a wide ranging perspective but also understand, at a detailed level, how the industry works,” says D.J. Hill, chief development officer of Titan. “He is one of the hardest working members of the ASC community and can always be counted on to roll up his sleeves and contribute.”

Gregory George

Gregory George MD, PhD, founding principal of SurgCenter Development, partners with local surgeons to create physician-owned and operated ASCs.

George graduated from the Massachusetts Institute of Technology, received his medical degree from Duke University, and earned a PhD from Duke in the field of ocular physiology. As an ophthalmologist with a very busy practice and high surgical volume, George recognized the necessity for surgeons to have more control over their daily schedule, surgical time, operating room protocols and surgical staffing.

Under his leadership, SurgCenter Development has developed over 60 successful, profitable, physician-owned ASCs. Nearly 100 percent physician, patient, and staff satisfaction levels combined with state-of-the-art highly profitable facilities, establish George and SurgCenter Development as clear leaders in the industry.

Julie Greene

Julie Greene, MBA, is the executive director of the Grand Valley Surgical Center and Grand Valley Health Management in Grand Rapids, Mich. In her diverse roles, Greene oversees operations of one of the largest ambulatory surgery centers in western Michigan, and also consults with other centers and physician groups who are either exploring the development of a surgery center or require assistance in operations, regulatory compliance and business planning.

Greene is committed to creating a greater awareness of the benefits and contributions that surgery centers make to their community. “The ambulatory surgery center industry saves money for everyone, especially our patients,” Greene says. “I am grateful to be part of a solution that is focused on positive outcomes, demonstrating value and driving down healthcare costs.”

In addition to her daily responsibilities, Greene is an outspoken legislative advocate of surgical centers at both the federal and state level. As past president of the Michigan Ambulatory Surgery Association, she is very active in increasing cooperation between surgery centers for the good of the industry. Greene would like to impact the area of purchasing in Michigan by creating an alliance that allows ASCs to purchase at pricing currently available for large facilities only.

Going to work at Grand Valley Surgical Center is personally very rewarding. “I have the absolute privilege of working with outstanding staff, investors and a board who truly believe in providing the best surgical experience possible for our patients, physicians and family members. We are making a real difference in people’s lives. The fact we can provide the same high quality service for a lower cost gives me an incredible amount of satisfaction. Everyone wins.”

Kenneth Hancock

Kenneth Hancock has over 20 years of healthcare-related experience. He currently serves as a founding partner and president and chief development officer for Meridian Surgical Partners, an ASC management company in Brentwood, Tenn.

“Working closely with Kenny for the past several years, I can say that he is one of most genuine and passionate people I know,” says Catherine Kowalski, RN, executive vice president and chief operating officer from Meridian Surgical Partners. “From a professional perspective, he sets the bar high for building and nurturing relationships. His enthusiasm and dedication in developing fruitful partnerships is the secret to his success and the success of the companies for which he has played a key role.”

Prior to this role, Hancock co-founded and served on the senior management teams of two other healthcare companies. In 2003, Surgical Alliance developed New Albany Surgical Hospital, an orthopedic facility with of 35 physician partners, 41 inpatient beds and eight operating rooms. In 1995, he co-founded OrthoLink, an orthopedic surgery center development company that was later acquired by USPI. Hancock began his healthcare career by spending more than 11 years in various capacities with the DePuy Corp.

Hancock enjoys sharing his knowledge by presenting at various industry events as well as contributing to ASC and other healthcare publications. “Being in partnership development most of my career, it’s easy to look back and see a common theme – trust,” says Hancock. “Without that, no partnership will thrive. In the ASC industry, management companies have to connect with physicians in a way that ensures them you understand their unique challenges, and have the resources and expertise to help them achieve their goals. ASC-corporate partnerships can and should be a win-win scenario.”

Jerry Hill

Jerry “Les” Hill is currently a senior operations director for Robert C. Williams & Associates Inc., a full-service development and management company for ambulatory surgery centers. With expertise in taking a project from initial discussion through syndication and development, construction, equipment planning, and surveying and licensure to day-to-day management.

William Massingill, chief executive officer of Polkinghorn Group Architects Inc., says, “Having managed surgery center practices in Texas and having participated in the development of surgery center facilities throughout the state, Les utilizes his low-key personality to befriend the clients (physicians or others) with whom he works, then utilizes his outpatient surgery expertise in navigating his client through the project development phase of a given project. In my opinion, he’s an integral part of a project that often doesn’t get appreciated.”

In managing the owner-side project management task for two recently completed surgery center projects in Stephenville and Abilene, Texas, Hill effectively guided the physicians, nursing staff, equipment planners and design team participants through each planning, design, bidding and construction stage of each project.

Hill has served as a past president of the Texas Medical Group Management Association, and as vice president of the Texas Association of Surgical Centers.

Charles Hughes

Charles “Chuck” Hughes, general manager and lead educator for SPSmedical Supply Corp., has worked over 25 years in the healthcare industry in areas of R&D, regulatory affairs, manufacturing, microbiology, sterilization training and consulting. He is involved with many healthcare organizations, including the ASC Association, the Association for the Advancement of Medical Instrumentation (AAMI), the International Association of Healthcare Central Service Material Management, the Association of periOperative Registered Nurses and more.

As the lead educator of SPSmedical, Hughes, travels internationally to provide sterilization and infection control training/presentations on industry best practices to surgery centers, hospitals, medical device manufacturers, and surgical service organizations. In addition, Hughes sits on numerous AAMI standards committees where he contributes to writing recommended practices for sterilization.

“His passion for infection prevention is unmatched,” says Matt Beauchaine, sales and marketing coordinator at SPSmedical. “He has devoted much of his personal time and his career to the continuing education and advancement of operating room, infection control, sterile processing and surgical service personnel.”

Marion Jenkins

Marion K. Jenkins, PhD, is founder and CEO of QSE Technologies, based in Englewood, Colo. QSE is a national vendor for IT systems design and implementation for ASCs and medical office buildings. From their first surgery ASC project over four years ago, today they have completed over 50 ASC/MOB design and implementation projects in 26 states.

QSE is an “I.T. General Contractor,” and likes to get involved early on in the ASC design process. “We like to work where we can make changes to the IT system with a pencil and eraser (or AutoCAD drawing), instead of a drywall saw and a jack hammer,” says Jenkins. “That makes a huge difference.”

Jenkins and QSE have become avid supporters of the ASC industry, participating in – and usually a major sponsor of – numerous state and national ASC conferences, and he is a prolific speaker and contributor to many healthcare journals and publications.

Jenkins is also heavily involved in Project CURE, the largest national organization that collects usable medical supplies and equipment and distributes them throughout the underdeveloped world to needy hospitals and clinics. QSE was responsible for introducing Project CURE and, the Colorado ASC Association, and CASCA routinely assists Project CURE with sorting of medical equipment and supplies and doing medical site assessments.

“We are pleased to be involved with the ASC industry,” he says. “ASCs provide a higher quality product at a more competitive price in the marketplace. Our role is to make our ASC clients’ IT systems comparable to the best hospitals and other facilities.”

Charles Neal

Charles T. Neal, CPA, chief operating officer of Healthmark Partners, served as president of Alliance Surgery Inc. prior to its merger with HealthMark Partners. Neal was formerly with Symbion Healthcare Inc., where he served as president of the Multi-Specialty Group that managed 47 ASCs in 17 states.

Prior to joining Symbion, Neal was the co-founder and chief operating officer of Ambulatory Resource Centers Inc., which merged with Uniphy Healthcare Inc. in 1999 to become Symbion Healthcare Inc. Neal was a senior vice president in the Surgery Center Division of HealthSouth Corp. and a senior vice president for Surgical Care Affiliates Inc. (SCA).  He also served as the chief executive officer of various hospitals in Georgia and Florida for Hospital Corp. of America (HCA).

“Charlie grew Alliance Surgery Inc. as president and guided the company through merger with HealthMark Partners with strong positive direction and continues to provide expert strategic direction and daily operational oversight to our company,” says David Gross, administrator with HealthMark Partners.

Sean O’Neal

Sean O’Neal is a founding principal of SurgCenter Development, and has over 25 years of experience in health care management. As a hospital CEO for over 20 years, O’Neal was a true pioneer in bridging the gap between physicians and hospital administration by developing numerous physician joint ventures.

O’Neal completed postgraduate studies in health services administration at California State University, Northridge, and has served as a member of the board of directors of the California Association of Hospitals and Health Systems.

One of O’Neal’s physician joint ventures was an ASC he developed with ophthalmologist Gregory George, MD, PhD. The two went on to form SurgCenter Development and to date have developed over 60 successful, profitable, physician-owned ASCs. Under O’Neal’s leadership, SurgCenter Development enjoys nearly 100 percent physician and patient satisfaction and is positioned as a true leader in the ASC industry.

Lucie Owens

Lucie Owens, BSN, MPH, is an invaluable asset to the ASC industry. Since 2002, Owens has headed up Nueterra Healthcare’s development division and is responsible for overseeing the development and start-up for its ambulatory surgery centers, surgical hospitals and community hospitals. “Owens efforts towards her work come from a sense of vocation rather than just an occupation,” says John Schario, president of Nueterra Healthcare. “Her leadership style is inclusive and builds on her teams individual’s strengths which has led to the success of her division.”

Owens has over 20 years of ambulatory surgery experience which includes hands-on experience in ASC acquisition, administration, knowledge and expertise in facility design and operational start-up for both hospital-based and freestanding ASC projects. Prior to joining Nueterra, Owens was the co-founder and principal for two ASC development and management companies; Aspen Healthcare in Boulder, Colo., and Sereno Medical Company, in Los Gatos, Calif., serving as the chief operating officer. She has served as the executive director for five ambulatory surgery facilities and was responsible for overseeing their start-up, accreditation and licensing as well as their day-to-day operations.

Owens is currently serving on the Foundation Board for Association of PeriOperative Registered Nurses and has been a past board member for the California Ambulatory Association.

“Having an insider’s perspective as a nurse and a leader has been a great benefit when working with various physician boards,” says Owens. “A level of trust and security is developed when you are recognized as someone with hands-on knowledge.” Owens has presented at various industry wide conference including the American Society of Outpatient Surgeons, ASC Association, Medical Group Management Association and California Association of Ambulatory Surgery.

Mike Rickman

Mike Rickman is the chief operating officer of Practice Partners in Healthcare Inc. and one of the founders of the corporation. Rickman has 12 years of healthcare managerial experience and has assumed a wide range of responsibilities and experience over his tenure.

Prior to joining Practice Partners in Healthcare, Rickman was senior vice president for the surgery division of HealthSouth Corp. Larry Taylor, president and CEO of Practice Partners states, “Mike has an incredible knowledge of the surgical industry and has utilized his financial background to intertwine the operational aspects of the industry to create a fresh new observation and managerial aspect to ASCs.” Mike has developed proprietary financial models and pro forma data unique to the industry and has deployed them in all of Practice Partners start-up facilities.

Mike has made significant contributions to the management of ASCs,” says Taylor. “He takes the financial aspects necessary for the success of the center and translates them into real world situations for both clinical and non-clinical center personnel. Mike had managed both large and small companies and understands what translates into success.

Donna SanGiovanni

Donna SanGiovanni, CPC, CHI, oversees the coding for both office and surgical procedures at Yale University in New Haven, Conn. SanGiovanni has worked in the ASC industry for more than nine years, working at Hamden Surgery Center in Hamden, Conn. before accepting a management position at Yale University. She is also the founder and president of the Hamden, Conn., chapter of the American Academy of Professional Coders (AAPC), the nation’s largest education and credentialing association for medical coders.

“Donna is an exemplary member of AAPC and representative of the ASC industry,” notes Sheri Poe Bernard, vice president of clinical coding content for the American Academy of Professional Coders. “She is dedicated to continuing education and training others on the constantly changes codes and billing procedures in this specialty. She is very passionate about her work, and is an expert in her field.”

Louis Sheffler

Louis Sheffler started his career managing a 16-operating room suite in a 600-bed hospital in northern New Jersey during the 1970s. Currently, he oversees all clinical and qualitative operations for American SurgiSite Centers Inc., a chain of ophthalmic ambulatory surgery centers located predominantly in the Northeast U.S.

Besides maintaining above average industry standards for important metrics such as surgeon satisfaction, OR utilization, lower than industry standard infection rates, and higher than average throughput surgery rates. He has overseen standardization of central purchasing, central medical records and centralized, real-time, barcode inventory control.

This year, he coordinated a “Just in Time” bar coding system for ASC inventory that is interconnected to an ASC’s accounting system and automatically creates reorder reports. Sheffler also devised a Web-based EMR system for ASCs that utilizes touch-screen technology with customized individual menus for surgeons and anesthesiologists.

“Based on Sheffler’s medical-legal talents and based on the quality of his communicational skills pertaining to potential malpractice claims, we feel that the company has been protected from all claims arising out of hundreds of thousands of surgical procedures during our 20-year history. Simply stated, the ASC industry would not be where we are today without him,” says Glenn deBrueys, CEO of American SurgiSite Centers Inc.

Ronald Sollitto

Ronald J. Sollitto, MD, DPM, is the administrator and CEO of Saddle Brook Surgicenter Inc. in Saddle Brook, N.J. Established in 1993, it is a fully licensed, multi-specialty facility. It has built an outstanding reputation by adhering to what he refers to as his facility’s creed: “Quality, Experience, Compassion.”

A graduate of the University of Notre Dame, Sollitto has doctorate degrees in podiatric medicine and medicine. He is currently matriculating at Columbia University for a Master of Public Health in health care administration. As a member of both the national and New Jersey state ambulatory surgery associations, Sollitto has been a vocal advocate of the valuable role played by ambulatory surgery centers in healthcare delivery.

Physician Professional Development Requires Lifelong Learning

Lifelong learning is a concept that is being embraced by many industries, including healthcare, to emphasize ongoing personal and professional development that fosters knowledge growth and facilitates mastery in one’s field.

Known for decades as continuing medical education (CME), there is movement toward using the new term of continuing professional development (CPD) for physicians and surgeons. CPD is the structured vehicle by which professionals maintain, improve and broaden their knowledge, skill sets and core competencies, and develop the characteristics required by their profession. The Chartered Institute of Professional Development defines CPD as “the conscious updating of professional knowledge and the improvement of professional competence throughout a person’s working life. It is a commitment to being professional, keeping up to date and continuously seeking to improve. It is the key to optimizing a person’s career opportunities, both today and for the future.”

As medicine and healthcare undergo constant evolution and transformation, CME programs must keep pace with these changes to ensure that physicians have the best professional development resources available throughout their careers to translate new research into better patient care.

To that end, the Mayo Clinic convened a consensus conference in September that assembled more than 50 CME experts from the United States and Canada and also paved the way for a new CME enterprise. At the conference they established a blueprint for change designed to make CME a bridge to cost-effective, excellent healthcare and to ensure that CME serves as a lifelong centerpiece of physicians’ professional development.

A new CME enterprise will serve as a cohesive educational enterprise that links together the many disparate providers who now offer CME courses. Leaders say CME is currently too often an episodic, peripheral educational activity.

The conference was convened in response to a 2007 government report that concluded CME must become more rigorously scientific; more evidence-based and theory-driven; and more accountable to the public who entrust their health to physicians. Terrence Cascino, MD, executive dean of the College of Medicine at Mayo Clinic notes, “Our goal is to make CME focused and responsive to what is best for the patient.”

Over the next three years, conferees will collaborate to change CME using the following strategic imperatives to guide them. CME and its providers must:

• Function as a bridge to quality healthcare. CME’s mission is to help physicians and teams learn and improve, so the quality of healthcare services provided to patients also improves.
• Focus on collaborative best practices and patient-centered outcomes.
• Consider new instructional modes, such as issuing annual reviews of the best scientific literature in a field written both in a simplified style, as well as in the traditional scholarly scientific article format.
• Apply more widely and rigorously the science of quality improvement and its evidence to healthcare and physician practices.
• Ensure the highest ethics and integrity of healthcare information by eliminating conflicts of interest in CME offerings.

Richard Berger, MD, PhD, dean of the Mayo School of Continuing Medical Education and a professor of orthopedic surgery and anatomy, says the challenges to CME are urgent. “Doctors today must keep up with mountains of rapidly changing medical information needed to maintain a safe and up-to-date practice. Our task is to propose solutions based on sound learning theory, evidence and outcomes so we can integrate professional development through CME into physicians’ lifelong learning activities. With this conference the transformation of CME is underway.” The Mayo School of Continuing Education, formally organized in 1996, instructs more than 23,000 medical professionals annually through 200 courses.

Berger adds that transforming continuing professional development from episodic learning to more of a lifelong learning modality is a significant part of the purpose of the consensus conference. “We have established a mechanism for a coordinated national research agenda to formulate these strategies. What we do know is that several key elements must go into the lifelong learning process for healthcare workers to optimize their competence. This includes aligning the relevance of the education activity with scope of practice, transparent assessment of practice outcomes, and self assessment of knowledge and skills to detect gaps in competence, and then individualize learning processes to fill those gaps, strive toward point-of-care learning, recognize the effectiveness of team training, enhancing our awareness of and concurrence with validated practice guidelines founded upon evidence-based outcomes studies, with all of this embedded in a process of learning about quality and employing those lessons into everyday practice.”

Continuing medical educational leaders agreed to frame the CME improvement initiative as a “value proposition” that can motivate all stakeholders to seek it out and support it, from CME faculty members, to physician-students, to third-party payors, to hospital administrators, to members of the government. These leaders agreed that when CME is regarded as the first-line tool for improving healthcare and controlling medical costs through reduction of error and inefficiencies, everybody wins.

Murray Kopelow, MD, chief executive officer of the Accreditation Council for Continuing Medical Education (ACCME), comments, “We need CME that matters to patients and makes a direct, positive impact on patients by functioning as a reliable bridge to quality health care. We need this to be true everywhere CME is offered. And we need physicians to internalize lifelong learning as part of their professional identities. When this happens, patients can all be confident that his or her physician has the resources needed to keep up with evolving medical knowledge.”

As an increasing number of physicians explore new opportunities in health management organizations, integrated health systems, urgent care centers, physician group practices, ambulatory surgery centers and other healthcare facilities, they must possess the abilities that are critical in executive roles.2 Lois Lister, senior vice president and managing principal of the executive search division of Cejka Search, describes the aptitudes common among physicians: critical thinking skills, thoroughness, the ability to solve complex problems, strong motivation to be successful, and in many cases, the ability to work well with other physicians. Lister notes, however, “Medical training and clinical practice do not encourage development of all characteristics and habits that executives must have to succeed and advance into top-level positions.”

Berger says that it is imperative to define how CPD can support today’s physician’s practice skill sets. “We will be striving to learn more about how physicians and associated healthcare workers learn most effectively through a nationally coordinated research effort,” Berger explains. “Today’s physician has less time than ever to learn about more things than ever. The learning process needs to be as efficient and relevant as possible. We need to incorporate the core competencies, including communication and professionalism into as many learning opportunities as possible to strive toward the highest degree of integrity in practice as possible. There will need to be nimbleness to educational activities to keep them up to date, but at the same time recognizing the need for validation and evidence-based data.”

The challenge is that the vast majority of the more than 650,000 practicing physicians in the United States today have received little or no formal training in business administration. They have practiced medicine in a fee-for-service environment that has not required them to be aware of how the marketplace works and how a healthcare institution or practice must be run from a financial perspective. While they are clinical veterans, they are business novices in dire need of a new skill set that will help them navigate the choppy waters of post-managed care healthcare. Enter the physician MBA program. Although some physicians may have earned their master’s of business administration (MBA) degree through a traditional program, there are now MBA programs tailored specifically for physicians to prepare them for increasingly complex processes, systems and trends in the healthcare industry, including new reimbursement structures, increased public reporting, advanced quality improvement initiatives, and the nuts and bolts of day-to-day operations where clinical and business imperatives intersect in a healthcare facility. It’s a strategic mindset that isn’t part of the medical indoctrination but is essential to success in the fast-paced business world.

Francine R. Gaillour, MD, a business, career and executive coach for physicians and clinical leaders, and director of Creative Strategies in Physician Leadership, says that physicians should pursue an MBA in order to obtain a solid education in business, to learn the business world lingo, and to interact with other physicians who can help them broaden business knowledge, perspective and opportunities.4 There are dozens of established, accredited physician MBA programs around the country, according to the Association of American Medical Colleges, including offerings from the University of Tennessee, the University of California, Irvine has a Healthcare Executive MBA, and the University of Massachusetts, which offers an MBA through the American College of Physician Executives.

The focus of physician MBA programs should be on developing leadership skills and business acumen, according to Michael Stahl and Peter Dean, authors of The Physician’s Essential MBA, and members of the faculty of the University of Tennessee’s Physician Executive MBA program. Important subject matter that should be addressed in these kinds of programs, according to Stahl and Dean, include: strategic leadership principles, health policy and economics, skills for embracing change in a rapidly changing healthcare landscape, and more.

References:

1. http://www.cipd.co.uk/default.cipd
2. Pyrek KM. Making the Grade: Physician MBA Program Creates Medical Entrepreneurs and Physician Executives. Immediate Care Business. September 2007. Accessed at: http://www.immediatecarebusiness.com/articles/0791feat3.html
3. Lister L. 21st century physician executive: An in-depth look at healthcare recruitment in the 21st century. www.cejkasearch.com
4. Gaillour FR. Do You Need an MBA?  What do you learn in business school anyway? PhysicianLeadership.com. Accessed at: http://www.physicianleadership.com/articles/physician_MBA.htm
5. Association of American Medical Colleges. Group on Faculty Practice (GFP) MBA Programs for Executives and Physicians. Accessed at: http://www.aamc.org/members/gfp/mba.htm

Surgical Headlights: An Overview

Surgical headlights are a valuable part of every surgeon’s OR equipment day in and day out. Not only do they provide light in much-needed areas during a procedure, but they also optimize ergonomic function and comfort as well. Today’s surgicenter spoke with David Tufenkjian, senior product manager of WelchAllyn Inc., and asked him to impart some basic information and tips on choosing the right surgical headlight for your surgeon.

How much do surgical headlights weigh?

The lightest weight, high-end fiber optic surgical headlight we know of is 3.4 ounces, which includes the weight of unsupported (approx 24 inches) of the fiber optic light guide – in other words, the total weight the surgeon will feel on his or her head. Not sure how heavy they get, but they can approach a pound and a half easily depending on the materials and size of components.

What types of lights are used?

For the high-end products, xenon is the most popular. For the lower-acuity headlight found in many surgery centers and offices, Solarc MH-HID is the most popular. Finally there is halogen, least popular due to poor color temperature and short life. Both xenon and MH-HID lamps are arc lamps, which have many advantages over filament-based halogen.

What measures are taken to make them feel comfortable for the wearer?

The only objective measurements that can be taken are weight, however much more goes into comfort. Distribution of the weight is critical; flexibility and breathability of the headband is also critical to comfort.

It appears that most headlights have some portability in an OR. Are there any particular limits to them?

High performance fiber optic-based headlights are not portable. They require a high intensity light source running off AC voltage. This light source produces a tremendous amount of light. That light is transmitted to the headlight via a fiber optic cable. Anything “portable” cannot begin to produce as much light as a traditional fiber optic-based system and still provide the mandatory coaxial positioning of the luminaire. Coaxial positioning (placing the luminaire between the eyes so that the axis of illumination is “coaxial” with the line of sight) is mandatory for “shadow-free” illumination.

What types of methods are used to keep them properly maintained for each use?

The most important things a headlight user can do are as follows:

Keep the fiber optic cable optical surface clean. Do not drop fibers on the floor after use. Dirt on the fiber end absorbs the high intensity light in the light source and will burn the polished surface of the fiber reducing the transmission capability of the fiber bundle.

Handle fibers with care. Most headlight fibers are not shielded. Non-shielded fibers expose the delicate glass strands to all the handling forces, so small crushing and crimping forces can add up to many broken fibers over time. This will reduce the transmission efficiency of the fiber. Some fibers use a light-weight monocoil shield, either stainless steel of aluminum, to insulate the delicate glass fibers from the forces excreted through daily handling. These fibers generally last much longer than their unshielded counterparts.

Use the recommended replacement lamp supplied by the manufacturer of the light source. “Knock-off” lamps are available through third-party suppliers and some clinical engineers feel they are saving their institution money by buying third-party replacement lamps and rebuilding lamp modules. Manufacturers spend considerable time and money validating the safety and performance of their headlight systems during development. Specific lamps are chosen for a reason and specifications for those lamps are strictly controlled between the light source manufacturer and their lamp supplier. Third-party lamp resellers have no control over the batch of lamps they receive. Using third-party lamps can significantly alter the performance of a light source and potentially damage power supplies or fiber optic cables. Some lamp modules contain critical ultraviolet and infrared filters that if not properly reinstalled can lead to safety concerns. Most people take lamps and light for granted. In your home, you can interchange 40 watt lamps with 60 watt lamps and buy whatever brand is on sale at your local home improvement center. Arc lamps are in a different league. The same “wattage” arc lamps from different manufacturers can have different thermal properties, voltage/current characteristics and spectral distribution.

Replace lamps sooner rather than later. Older lamps are harder to start and can stress the igniter circuits. Trying to get 50 more hours out of a lamp is not worth ruining a power supply.

Replace pad sets on the headlight headband. Dirty, torn or wet headbands are a common source of frustration for the surgeon and add a level of dissatisfaction that is easily corrected.

When it comes to headlights, what do surgeons rate as the most important of these factors: Weight, light, comfort, convenience, portability, maintenance or power life? Why?

This is a hard question. Ask five surgeons, you may get five different answers. What’s important to one surgeon might not be so important to another. For instance, a surgeon who uses a 2.5x loupe will appreciate a larger spot size as opposed to a surgeon who uses a 4.0x loupe which has a much smaller field of view. Most surgeons who use a headlight more than a few hours a day look for the most comfortable headlight available. There are a lot of factors that go into the perception of “comfort.” Weight, weight distribution, ventilation, sweat management, luminaire size are but a few. Most people might think brightness would be the first answer every time, but some surgical specialties just don’t need all the horsepower of a 300 watt xenon system. In some facilities, rock solid durability is the overriding consideration.

Are there any new innovations or technology coming for surgical headlights in the near future?

Many surgeons, PAs and OR nurses are asking for a “wireless” or “untethered” headlight. They don’t want to be connected to a light source; it’s strictly a convenience issue. In some cases where a surgeon must move around during a procedure or change sides of a table during the same procedure, an untethered system would be beneficial. With a traditional fiber optic-based headlight, either the light source must be moved with the surgeon or a second light source must be available. In response to this request for an untethered headlight, many small start-up companies are trying to develop and market portable battery-operated headlights using LED technology. LEDs are fraught with technical limitations in headlight applications. Contrary to popular belief, LEDs of the wattage and efficiency needed for this application are not cool. In fact, thermal management is a huge technical challenge. A single LED cannot produce anywhere near the amount light that an arc lamp can produce. LEDs have a large point source relative to an arc lamp with makes it a very inefficient source for feeding light into fibers or focusing into a well defined narrow beam of light. In order to approach the light output of a fiber optic-based headlight system, LED headlights must resort to a non-coaxial positioning of multiple LEDs with poorly defined beams converging at one point is space. It is only at that point of convergence, a fixed distance from the headlight, where the brightness specification is applicable.

Compare and Contrast

Ask any business executive and they’ll tell you that one thing they want information on (next to their bottom lines) is how their company stacks up against the competition. Benchmarking is a means to achieve this; a measuring stick that businesses, including outpatient surgery centers, can use to determine where they stand.

So we asked Jennifer Green, RHIT, CMSC, vice president of network development at Surgical Outcomes Information Exchange, based in Richmond, Va., to discuss with us some of the ins and outs of benchmarking.

How does a facility conduct a benchmarking study?

Benchmarking can be done through a variety of means. Using a performance measurement system and by doing literature searches for the aspect of care they want to benchmark; by participating in studies offered by professional organizations or by canvassing colleagues in the field or other facilities in your area or corporate complex.

How can a facility benefit from going to a commercial benchmarking company, instead of using already published resources?

A commercial company has a reputation to uphold; after all, this is their business. If they don’t do a good job, they won’t be in business very long. A commercial company may be able to do most, if not all, of the data analysis, saving the facility precious time that they need to take care of their patients. A commercial company should provide uniform definitions and be able to assure “apples-to-apples” comparisons. With published resources, you may not know how they arrived at their “benchmark” or you may not be able to perform your study in exactly the same way. Remember, a benchmark is a standard by which you are going to compare your own measurement. It’s like using different rulers to measure the same thing – if you make your measurement in centimeters and I make mine in inches, we’re not comparing ‘apples-to-apples.’ You can’t always be sure of this when you have not actually “participated” in the establishment of the benchmark.

Finally, a commercial company should be able to offer benchmarks that are based on ‘national’ data. When you compare yourself to national data, you can find out how things are being done in other parts of the country. Is there a better way that has not been introduced to your area?

Typically what is the timeline for the study?

There is no exact timeline and it will depend on how large your database needs to be for what you’re studying. In other words, you’ll need enough cases to reflect meaningful statistics. A study can last indefinitely, or only a few days depending on what you’re studying.

For something like an infection rate, you could evaluate the rate each month, but you’d also want to keep a running total in order to know your overall average over the course of this year so that you can tell if the rate spikes during certain months. This kind of measurement is usually ongoing and never stops.

The bottom line is, you need to plan your study before jumping in. Know what you’re trying to measure – what do you want to learn from the measurement; what is the goal of the study? Then determine what volume you need and how long it will take you to reach that goal.  For a very large facility, a sample of 10 percent of their cases for one month might be sufficient, while for a very small facility, they may need to look at 100 percent of their cases for three years before they have enough data to make a definitive conclusion about the results.

What are the indicators used?

Again, it depends on what you’re measuring. The indicator should clearly state what you hope to learn. For example, if you’re looking at infection rates, do you want to separate ‘deep’ infections from superficial wound infections?  If you do a lot of procedures involving implants, your indicator might be the rate of deep wound infections reported within six months of the procedure. In a nutshell, the indicator can be just about anything, from ‘the percent of red cars that pass through xyz intersection every hour’ to ‘the percent of patients who complain of post-op pain following GI endoscopy.’

What is the action plan you recommend after acquiring an external benchmarking study?

That would be entirely dependent upon how your study results compared to the benchmarking study results. Your study might end up showing a result that is better than the benchmark, in which case, no action would be needed. On the other hand, if you know that you’re comparing likes to likes and your results are worse than the benchmark, then you would probably want to take action to improve your results. For example, if your recovery time in knee arthroscopy was 120 minutes, but the benchmark was 60 minutes, then you’d probably want to find out why your recovery time is twice as long as the benchmark and take necessary action to reduce and improve your recovery time. This is why it’s so important to be sure you’re comparing likes to likes. You’ve got to make sure you can hold yourself up to a given benchmark before you can determine whether or not you need to make a change.

How long does it take to show ROI after contracting a benchmarking study? In a tight economy, what is the strongest argument to move forward on one?

When you benchmark and compare yourself to certain standards or goals, you gain information that you didn’t have yesterday. The information may reassure you that you are as good as you thought you were, or it may point out that you’re as good as you thought. The point is, you know something today that you didn’t know yesterday, and it’s hard to put a dollar figure on knowledge. The cost factor in all of this is sometimes hard to measure, but everyone agrees that improvements in performance almost always equate to increased revenue, OR increased savings. Either way, conscientious benchmarking efforts always pay off and those who think otherwise are probably going about it the wrong way.

As far as ROI, it can be immediate, or it can be slow in coming, depending on the study itself. And, it depends a great deal on how you benchmark – if you are not comparing apples-to-apples, your return is going to be very small, if any. But if you know you’re measuring the same thing everyone else is measuring, and you’re measuring it in the same way, then the ROI can be quite significant, whether you find out you are better than you expected, or need to make some improvements.

Industry Leaders Reflect on ‘08, Predict ‘09 Trends

Even as the U.S. economy tries to right itself again after the mortgage meltdown, the credit crisis and a jittery stock market in the last quarter of 2008, the ambulatory surgery industry is attempting to maintain its equilibrium in the midst of this mayhem. Let’s take a look at this year’s big milestones.

The industry has witnessed several important changes to the way it receives reimbursement from the Centers for Medicare and Medicaid Services (CMS) in the last several years, and on July 3, CMS issued its proposed rule for 2009; it proposed additions of nine surgical procedures to the ASC approved list and reflects a mix of previously excluded procedures and newly added CPT codes.

“We had barely mastered the 2008 Medicare conversion to the modified Outpatient Prospective Payment System (OPPS), when CMS published the proposed changes for next year,” observes Caryl A. Serbin, RN, BSN, LHRM, president and founder of Surgery Consultants of America.¹ Serbin enumerates the challenges associated with the new payment system: “Managed care is becoming stronger and less likely to negotiate fair rates. Supplies are increasing in price due to the changing economy. Staffing is becoming more difficult as employees will not travel as far because of the high price of fuel. As these trends continue, ASC management teams must be fully aware of the changes in reimbursement, explore the specific challenges they will confront, and determine how to deal with them and still maintain a profitable center.”

“From a national policy perspective, the most profound event was the commencement of the long anticipated new payment system, which substantially impacts how much Medicare pays an ASC,” concurs Joshua Kaye, JD, a partner at McDermott Will & Emery LLP. “The new system became effective in January and bases ASC facility payments on a percentage of the amount Medicare pays a hospital for the same procedure. CMS also significantly changed how it determines what procedures will be reimbursable when furnished in the ASC setting by replacing a limited list of procedures to an approach that instead allows payment to an ASC for any surgical procedure, except those that CMS determines are either not safe when furnished in an ASC or that require an overnight stay.”

Kaye continues, “While reimbursement for certain procedures may decrease, the new payment methodology includes many important and welcome improvements. The fall-out from the New Jersey trial decision in Garcia v. HealthNet is also noteworthy as it drew into question physician ownership in ASCs on the basis of being operated as an extension of a physician’s practice, as well as co-payment/deductible collection practices by out-of-network facilities.”

“2008 has been an extraordinarily eventful year for the ASC industry,” states Lorin Patterson, JD, partner with ReedSmith. “The implementation of the APC reimbursement scheme involved the complete ‘overhaul’ by CMS of the way it reimburses ASCs for procedures performed within their facilities and its views on the types of procedures, which may be appropriately performed within the ASC setting. Although this scheme will be phased in over four years, we are already witnessing the effects of the rules through increased emphasis on certain specialties, such as orthopedics, which received relatively better treatment than other specialties.”

The stumbling U.S. economy is likely the most pressing issue of the year, according to industry experts we talked to. “The biggest event for ASCs for 2008 has to be the ongoing tumult created by the credit crisis and weakening economy,” says Scott Becker, MBA, JD, a partner at McGuireWoods. “This overall financial challenge has led to a decrease in procedures where patients can choose to delay surgery. It has less to more drastic reductions, depending on how ‘elective’ the surgery is. Further, the credit challenges and overall financial problems are leading employers to reduce payrolls and redouble their efforts to reduce healthcare costs. This is leading to payors who handle employee plans making more aggressive efforts in years to reduce reimbursement rates.”

Rick DeHart, CEO of Pinnacle III, points to the recent financial market corrections as the top event for 2008: “The financial market changes will definitely impact many ambulatory surgery centers, especially in those situations where business growth is tied to the need to secure capital. Capital needs could occur when making leasehold improvements to your facility or purchasing large equipment items. If your facility is established and possesses a good credit history with a lending institution, then you are probably alright. However, if you are a start-up with questionable cash flow, it will likely be very difficult to obtain the additional capital necessary to sustain your facility. De novo facilities will also be impacted, as the financing criteria will change with enhanced scrutiny.”

The proposed change to CMS language restricting overnight stays could impact facilities as significantly as the markets, DeHart adds. “If this language change on overnight stay passes, it will have a significant effect on the industry and healthcare in general. Many states have a 23-hour restriction, allowing a significant number of ASCs the option of performing higher acuity cases. The language change will have a huge financial impact on some facilities, removing the higher acuity volume and pushing it back to the hospital setting. This move will not only hurt ASCs but increase the financial burden on the patient.”

“The industry is still awaiting CMS’s action on the Medicare Conditions of Participation for ASCs,” Patterson confirms. “If the conditions are adopted as proposed, they could significantly curtail the manner in which many ASCs are operating. For example, the proposed conditions contain a requirement that all patients in a Medicare-certified ASC not be retained past midnight. A considerable number of ASCs may have to change their policy on 23-hour stays, even though the states in which they operate may expressly permit this practice.

Bob Zasa, MSHHA, FACMPE, of Woodrum Ambulatory Systems Development, explains that the credit crunch within the financial markets affected the ASC industry negatively in several ways, including the fact that physicians are holding onto their money and that some physicians are hesitant about buying into de novo centers. Zasa adds, “Non-recourse financing for ASCs dried up except for those centers already opened for 3 to 5 years and at least profitable. The financial markets also made a difference in the increasing number of ASCs that requested “reorganization” or turnaround services from mature surgery center management companies who have had a successful track record.”

Zasa adds that he has seen centers reducing their investment in new equipment, preferring to make do with their aging equipment for another year — another sign that the credit crunch is delaying facility capital improvements.

On the clinical side, the industry was rocked earlier this summer when 40,000 patients at the Endoscopy Center of Southern Nevada were potentially exposed to the hepatitis C virus during procedures requiring injected anesthesia. The Southern Nevada Health District notified patients following an investigation of several acute cases of the illness; the notification included patients who had procedures at the clinic between March 2004 and Jan. 11, 2008.

“2008 witnessed overwhelming attention on the preeminent issues of quality and patient safety,” Patterson says. “The debacle in Nevada in which thousands of patients were exposed to hepatitis because of unsafe practices in certain ASCs there has emboldened the opponents of physician-owned ASCs and caused state regulators in states other than Nevada to more closely scrutinize those facilities operating within their jurisdictions.”

Michael Kulczycki, executive director for the Ambulatory Accreditation Program at The Joint Commission, says that this event put the spotlight on infection prevention in ASCs, a topic taken for granted in an industry that has a very low infection rate compared to other healthcare facilities.

“This unfortunate situation created a groundswell of a response in the regulatory community, with rapid reactions both at the federal level with CMS, as well as at individual state levels well beyond Nevada,” Kulczycki says. “It highlights the issue of infection prevention as requiring a systematic response in ASCs, and that accreditation generally offers one system-level approach to an ASC having staff, intellectual and physical resources to combat and prevent infectious outbreaks. While accreditation is no panacea (as evidenced by some of the outbreaks having occurred at accredited facilities), it represents a solid building block for ensuring patient safety. We are also hearing examples from across the country that state surveyors, conducting Medicare resurveys, are also focusing on these issues as well.”

The industry also has weathered an erosion in the physician ranks, according to Elliott Jeter, CFA, CPA, ABV, a principal of VMG Health. “The ASC industry reached a tipping point in 2008, where the number of available physicians per ASC reached a historically low level. This dynamic was caused by not only the large increase in the number of ASCs, but also by the reduced supply of available physicians in certain markets,” Jeter explains. “Competition for available physicians has increased from hospital acquisitions of physician practices, hospital recruitment of new physicians to markets, and new physician-owned specialty and acute-care hospitals. 2009 will be a year of retrenchment. Good management decisions will be crucial. ASCs with excellent management and physician partners will thrive while weak players will consolidate or fail. This is a natural evolutionary phase for a maturing industry and will be healthy for the industry as a whole in the long run.”

Recent years have proved to be watershed years for the not only the survival of the physician-owned facility, but its role in a national move toward consumer-driven healthcare. Molly Sandvig, JD, executive director of Physician Hospitals of America (PHA), notes, “A number of important and interesting events impacting the future of healthcare have occurred this year. For instance, in 2008 more than in the past, healthcare has been very publicly acknowledged as one of the primary drains on the American family’s economic stability. Also, the concept of universal healthcare or universal coverage has recently been used more and more synonymously with the concept of a single-payor health system, which has unfortunately started to gain some traction. However, I believe that the biggest event affecting healthcare in 2008 and beyond has yet to occur — the results of this year’s elections will truly impact the future of healthcare for many years to come.”

Jeff Fox, vice president at Tygris Commercial Finance Group, Inc., formerly MarCap, concurs: “The top issue for 2008 will have taken place on Nov. 4. The Presidential election will be the top issue for 2008 and 2009. Fox predicts further, “Healthcare will be one of the top items that a new administration will have to address and will have some impact on the ASC industry. This depends on any number of issues but certainly the expense of either candidate’s plan will have to come in line with the current administration’s aggressive plans to shore up the U.S. financial system. Both candidates has committed to some action plan to address the uninsured and the rising healthcare costs. Depending on where one stands on the issue, the federal government may not have the ability to react to the healthcare issues as it could have before the recent events that overtook the domestic and global banking systems. This may be viewed as a positive if you believe any change would be negative to our business. The credit crisis may be impacting some ASC projects being delayed, but it appears that this crisis shall pass.”

Looking to 2009

We asked those contacted for this piece to ponder the future of ASCs and specialty hospitals; here’s their take on what they believe will be the most critical issues for 2009.

Lorin Patterson: “The outlook for 2009 can perhaps best be described by two words — “fearful uncertainty.” Under the best of circumstances, the prospects of the election of a new administration with a different healthcare agenda, as well as the possibility of a significant change in the composition of Congress, would create nervousness in the market. The uncharted water that our economy is navigating at this time only amplifies this anxiety. While it is likely that the current financial crisis will impede the immediate implementation of either candidate’s healthcare agenda, some kind of change in the manner in which healthcare is delivered and paid for must be expected. Given the current financial stresses, 2009 would not be a good year for the industry to expect the implementation of any financial policies, such as an increase in reimbursement, which may favor it. On the other hand, government programs, which have historically actually made money for the government, such as fraud and abuse enforcement, should be expected to be even more aggressively pursued.”

Scott Becker: “On the ASC mergers and acquisitions front, the credit challenges have not yet had a real negative impact on transactions. However, as it is early in the most difficult part of this economic slowdown and loss of stock market wealth, it remains to be seen what impact will be had… will deals still close, will pricing for deals remain at solid levels, will buyers be able to finance acquisitions?”

Joshua Kaye: “With 5,500-plus ASCs across the country, surgeons and proceduralists in many geographic markets are already invested in or otherwise have a financial relationship with an existing ASC. As a result, 2009 could very well see quite a bit of mergers and acquisitions, as existing ASCs and ASC management companies look to increase revenue and decrease expenses by consolidating existing ASC facilities. The critical issue will be the impact that the consolidation will have on the multiples being paid and how to continue to attract new physician investors. Additionally, recent changes to the Stark law that become effective on Oct. 1, 2009 will require either the restructuring or unwinding of a number of physician/hospital ASC joint ventures that were structured as ‘under arrangement’ or management arrangement transactions.”

Molly Sandvig: “In 2009, I believe lines will be drawn between the four major financial players in healthcare: government, insurance companies, hospitals and physicians. The events of next year could easily set the groundwork for the parties that will be in control for many years to follow. We must ensure that physicians, as the representatives of patients, keep a seat at the decision-making table and in fact, win the right to control the destiny of their profession. What occurs in 2009 could make the difference between an immediate future allowing the practice of proactive healthcare vs. “check-box” medicine.”

Bob Zasa: “With a new administration in the White House, there will be new national healthcare policies that affect insurance as it is now constituted. There will be more private insurance that is portable and less employer insurance. Look for more broad coverage of children under either administration, as well as tighter cost controls and fewer increases with payors. Payors will most likely continue to withhold monies owed to providers, causing more staffing to audit these claims and re-file them to get proper amounts of money owed to ASCs per the contracts. This will encourage more providers to stay out of network for a while longer with countermeasures by ASCs to collect on the front end with payors who pay claims directly to patients. There will be higher deductibles on insurance products until state insurance commissions and federal regulators within the insurance industry force more even pricing of individual policies so premiums don’t vary by state so much, in order to reduce adverse selection. I also believe we will see more attempts for payors to reduce or discourage out-of-network payments.”

Michael Kulczycki: ”It is likely that the close of 2008 may bring the release from CMS of the final version of the conditions for coverage applicable to Medicare-certified ASCs, with a short window to an effective or implementation date, perhaps as early as January 2009. While much of the industry coverage has focused on the important issue of the definition of overnight stays for ASCs, the industry should be making plans now for responding to potential increases in CFCs affecting governance oversight of patient safety issues, and increased prescriptive expectations for performance improvement and infection prevention. The Joint Commission’s analysis of the proposed CFCs show that accredited centers generally will be in compliance with the revised expectations. However, it is likely that the Nevada situation in early 2008 will heighten, even more, the prescriptiveness of infection control measures in the final release. Hopefully, the ASC industry will quickly respond in aiding its professionals, through education and published information, in timely responses. The second critical issue, probably coming to light mid-year, will be the CMS plans for requiring performance measurement by ASCs. While the industry has been out front in pushing through ASC-specific measures (via NQF endorsement of the ASC Quality Collaborative items), in 2008 CMS was reluctant to move forward. ASCs should expect CMS action in 2009, and The Joint Commission stands ready to partner with the ASC industry to provide support in performance measurement reporting. This topic was among the items discussed earlier this summer in a briefing between Kathy Bryant, president of the ASC Association, and Mark Chassin, MD, MPP, MPN, president of The Joint Commission.”

Rick DeHart: “Politics! The elections and a new president will probably be the most critical issue for 2009. Even though the healthcare proposals from both political parties do not seem to impact the ASC environment, the concern is what could potentially materialize if one party corners the political market. I believe there is a lot of speculation of what might happen but, at this point, the crystal ball is not clear, which places us into a ‘wait and see’ mode.”

Reference:

Serbin, C.A. The Changing Face of ASC Reimbursement. today’s surgicenter. 7, 10: 14-16, October 2008. Accessed at: http://www.surgicenteronline.com/articles/changing-face-of-asc-reimbursement.html

Colonoscopy Billing

As a speaker at many national conferences, I find the question most frequently asked is, “What is the proper way to code a screening colonoscopy?” First, let’s talk about what is a screening colonoscopy. Physicians suggest a colorectal cancer screening (colonoscopy) typically when a healthy patient turns age 50. The procedure entails a colonoscope inserted in the anus moved through the colon past the splenic flexure in order to visualize the lumen of the rectum and the colon. It is used to provide an early diagnosis of colorectal cancer, diverticulosis, ulcerative colitis, Crohn’s disease, etc. The diagnosis code for the screening is selected from the V code section V76.51 (Special screening for malignant neoplasms, colon). The CPT code would be 45378 (Colonoscopy, flexible, proximal to splenic flexure, diagnostic).

Polypectomies

If during the screening a polyp is discovered and a polypectomy is performed, the ICD-9 coding sequence would be V76.51 as your primary diagnosis, and the polyp or abnormality as secondary. When choosing the procedure code, look at the technique used to remove the polyps. (Note: This is not all-inclusive list; please see the current edition of CPT for a complete list of polypectomy codes). Here are some examples:

• 45380-Colonoscopy, with biopsy, single or multiple. Hint: The physician may use the words “biopsy forceps,” or “Jumbo forceps.”
• 45385-Colonoscopy, with removal of tumor(s), polyp(s), lesion(s) by snare technique. Hint: This code covers both cold and hot snare.

Regardless of how many polyps are removed, you may only use each of these codes once.

Medicare Screenings

Medicare has slightly different code selections for colorectal screenings. Let’s talk about the ICD-9 code selections. For a Medicare patient, you would report V76.51 as the primary diagnosis. Then you must check if the patient is considered a high risk. There are specific criteria that CMS requires for a patient to be categorized as “high risk.” To establish the patient as “high risk,” the patient should exhibit one or more of the conditions found on the CMS list, which you should report as a secondary diagnosis to V76.51. Here are some examples:

• V10.05-Personal history of malignant neoplasm, large intestine
• V12.72-Personal history of colonic polyps
• 556.0-Ulcerative (chronic) enterocolitis

NOTE: This is not all-inclusive. Please review the complete list at http://www.cms.hhs.gov/ as well as local carriers, as they may have specific requirements. As a facility coder, it is advised that you check the patient’s chart, specifically the history and physical as well as the operative report, to ensure proper documentation supports the criteria. If the patient does not meet any of the criteria, then the patient is considered at average risk for colorectal cancer.

The risk factor will determine the procedure code. You should choose one of the following: orectal cancer screening; colonoscopy for an individual not meeting criterion for high risk (average risk):

• G0105-Colorectal cancer screening; colonoscopy for an individual at high risk.

Incomplete Colonoscopies

For coding purposes, the colonoscope must pass the splenic flexure. If this is not achieved, it is an incomplete colonoscopy. In these instances, you should use the CPT code for the procedure intended and append one of the following modifiers:

• Modifier 73-Discontinued procedure due to extenuating circumstances or those threatening the well being of the patient prior to the administration of anesthesia. The physician may cancel or discontinue the procedure subsequent to the patient’s surgical preparation (including sedation, and being taken to the room where the procedure is to be performed).
• Modifier 74-Discontinued procedure due to extenuating circumstances or those threatening the well being of the patient after the administration of anesthesia, or after the procedure was started.

When using these modifiers, it is important to have supporting documentation that clearly states how far the scope was inserted and the reason for the discontinuation. This information should be sent with the claim form for proper reimbursement.

Donna SanGiovanni, CPC, CHI, is a clinical practice specialist in the Department of Digestive Diseases at Yale University. She can be contacted at donna.sangiovanni@yale.edu.

Virgo Publishing Brings a New Face and Focus to today’s surgicenter

PHOENIX – Virgo Publishing LLC, announces a new editorial direction for today’s surgicenter magazine beginning with the name, SurgiStrategies, starting in January 2009. The scope of coverage will expand to deliver relevant, timely, ahead-of-the-curve content to help readers analyze and act upon information that can make them more competitive in the fast-paced and ever-evolving outpatient healthcare industry.

“We are rebuilding and relaunching the magazine to better reflect the changes taking place in the ambulatory surgery industry as well as to serve more effectively our readers in the C-suite, the back office, and in the operating room arena,” says Kelly Pyrek, editor-in-chief of the publication. Pyrek has worked in the newspaper and magazine publishing industry for more than 23 years. “We will be working closely with key industry thought leaders to identify the trends impacting our readers’ bottom lines.”

Gabe Molina, who has seven years of experience in newspapers and magazines, including the past two years in health-related media, will continue as associate editor. Dana Armitstead, who serves as the publisher, has been with Virgo Publishing for more than 11 years and has a background in trade shows and telcom publications.

The January issue of SurgiStrategies will reach subscribers the second week of December 2008. The current Web site www.surgicenteronline.com will be renewed to reflect the new look of SurgiStrategies, offering information and industry expertise, educational Webinars, a free e-Newsletter, blogs such as The Suite Life, Dana’s Dish, SurgiScene and much more.

“I’m very excited about this fresh new dynamic resource we’re providing to the industry.  The readers will love the invaluable content as well as the updated look. Since its inception, this publication has been a relied upon, must read for the outpatient community and with this re-launch, we are solidifying that status,” says Dana Armitstead.

Hospital-Owned Ambulatory Surgery Centers as a Hospital Outpatient Department

Healthcare Venture Professionals (HVP) remains committed to facilitating and supporting the physician-hospital ASC collaboration. At the same time, we are becoming more routinely involved in working with hospital-owned ASCs operating as hospital outpatient departments (HOPD).

There are two basic variations when it comes to the development of HOPD ASCs: new ASCs that are being developed as an HOPD; and existing equity-based ASCs (either physician-owned or hospital-physician joint ventures) that are being converted to a HOPD.

Based on the ASC literature, we are not alone in seeing this phenomenon. Others have recently commented on the growth of the HOPD approach to the development of ASCs. Depending on the specific situation, there are a number of reasons why this trend may be occurring:

• The increasing numbers of “maturing” physician-owned or joint venture ASCs. Many physician owners are reaching the point where they are looking to “cash out” on their ASC investments, and the local hospital is more frequently serving as a friendly alternative (vs. selling out to a for-profit company) to accomplish this goal.
• Increasing costs and greater risks entailed for physicians to meaningfully participate in equity-based ASCs (either physician-owned or joint ventures). This includes burgeoning construction and related materials costs, as well as tightening (and more demanding) lenders when it comes to financing ASC projects.
• The predicted or actual increased scrutiny by state and federal regulators of physician ownership in ASCs. A lot of people think that physician ASC ownership is bound to come under the same fire, sooner or later, that physician ownership in hospitals has been undergoing for the past several years.
• Increasing reimbursement pressures on freestanding ASCs from managed care payors. This has been true for some time in the highly-penetrated managed care markets. There is growing evidence that this trend is quickly spreading into markets that have been historically considered as “friendly” when it comes to the negotiation of favorable reimbursement contracts. This is having a direct impact on the profitability, cash flow and ROI/distributions from equity-based ASCs.
• The recent changes to the Medicare facility payment system which began a four-year phase-in program beginning this year. There’s been a lot of misinformation about these changes and their negative impact on freestanding ASC reimbursement and profitability. The facts are that, with the exception of a few specialties, this new system should be beneficial to freestanding ASC reimbursement. Even those specialties that are being hit (i.e., G.I., ophthalmology and pain management — where Medicare spends most of its freestanding ASC dollars) can still do well under the new Medicare system, with the proper attention to cost containment and operational efficiency. Despite these facts, there is at least anecdotal evidence that these Medicare changes have made some hospital or physician investors less willing to consider an equity-based approach to ASC development.
• The increased efficiency and effectiveness of in-hospital and HOPD ambulatory surgery operations. Hospitals are even turning to professional ASC management companies to ensure that their HOPD ASC is operated, to the highest degree possible, like a freestanding ASC. In some markets, this has obviated the “need” to consider an equity-based approach to new ASC development since existing or capacity is being better utilized to the satisfaction of physicians and their patients.
• Increasing reimbursement pressures being felt by hospitals and healthcare systems. Hospitals are becoming even more reticent to share in the technical/facility component by creating a joint venture ASC with physicians, due to the negative impact such a venture will have on the hospital’s increasingly fragile bottom line.

Making the Decision — Steps to Consider

Despite strong belief in the collaborative model, an equity-based ASC joint venture is not for everyone. There can be political, practical, regulatory or other overriding reasons why a joint venture approach is not merited in a specific situation. The reasons listed above are among the numerous factors that may lead to a decision that a well-designed and professionally managed ASC, of the HOPD variety, becomes the best solution in a given market.

Nevertheless, any decision to take the HOPD approach to ASC development should be made in a thorough and thoughtful manner. There can be negative political, practical and interpersonal consequences of deciding to go the HOPD route when, in fact, a more collaborative or equity-based approach is still seen as desirable from a physician perspective.

As the movement toward the HOPD form of ASC development continues, the process used to make the decision about the need and corporate structure for any ASC (planned or existing) becomes even more critical. More than ever, the ASC business-planning and decision-making methodology must include:

• Education for hospital representatives (including the hospital board of directors) and physicians on alternative models available for the development of an ASC, together with an effective description of all steps and the specific roles of all key players in the decision making process.
• Open communications between hospitals and physicians to include the identification of formal “leaders” or “champions,” who will represent and more actively participate in all subsequent ASC discussions and deliberations on behalf of their respective constituencies.
• A professionally conducted feasibility analysis that thoroughly considers and presents the quantitative and qualitative benefits of each approach to ASC development for both the hospital and physicians.

The above approach should optimally position both the hospital and its physicians when it comes to making the critical “Go / No Go” decision for subsequent ASC development. This same approach, with only minor modifications, will also work quite well in situations where the option of converting or “flipping” an existing equity-based ASC into an HOPD is being considered.

The Best of Both Worlds

If the decision is made to go with the HOPD ASC model, the goal should be to obtain “the “best of both worlds.” From a hospital perspective, the benefits of an HOPD model should include:

• More attractive reimbursement and retention of all outpatient surgery revenues that may have been reduced in a joint venture model. An HOPD ASC, regardless of location, will operate under the hospital license and usually receive hospital payment levels from governmental and managed care payors for outpatient surgery procedures.
• Better utilization of existing operating room capacity. It is also possible to “free up” other space currently dedicated to the provision of ambulatory surgery for alternative or improved revenue generating services.
• Providing patients/family and physicians with a much improved ambulatory surgery experience. By removing this service from a hospital environment, a dedicated HOPD ASC should avoid most staffing, scheduling and logistical problems which are inevitable in even the best run hospital OR settings, due to the “mixing” of inpatient and outpatient cases, and the unpredictability and inefficiencies resulting from emergency cases. An HOPD ASC can also be designed and located to minimize traffic congestion and directional confusion, and to maximize convenience and accessibility for the public.
• “Built-in” administrative and support services for the ASC such as human resources, maintenance, biomedical engineering and housekeeping.
• “Built-in” availability of hospital systems for support of the ASC (e.g., information systems).
• Direct access to needed clinical service arrangements for the ASC, such as anesthesiology, pathology and radiology.

Achieving the Best of Both Worlds

Achieving the “best of both worlds” is directly premised on operating the ASC as if it were a “freestanding” entity vs. a hospital department. This is best done by having:

• A facility designed, equipped and staffed for efficiency and effectiveness.
• Excellent professional management with experience in the operation of a freestanding ASC. As a side note, the engagement of a professional ASC management company can make the difference in gaining physician support for an HOPD ASC model. Physicians frequently express the “fear” (for a variety of reasons) that the new ASC “will be run like the hospital operating room.”
• Commitment to providing both utilizing physicians and their patients with a “Five-Star Experience,” usually best found in a freestanding ASC setting.
• Meaningful physician input and influence on all ASC clinical matters.
• ASC control of staffing, scheduling, pre-certification, registration and billing, product standardization, credentialing, quality improvement and other key functions to the greatest extent possible.
• Establishment of quality, operational and patient satisfaction benchmarks similar to those seen in the freestanding ASC sector.

Summary

Achieving the “best of both worlds” can be a challenge, especially for the hospital. There must be a willingness and flexibility to allow for a greater degree of autonomy for the ASC vs. the typical hospital department. This must be balanced by recognizing that the ASC, as an HOPD, must be fully integrated into the hospital organizational structure. Finding this balance is very important to the ultimate success of the HOPD ASC. If the right balance is not found, the hospital can become a bureaucratic burden that works against the goal of having the ASC function in a freestanding-like fashion.

A well-planned and operated HOPD ASC should result in significant benefits for patients, physicians, hospital and the community. With the appropriate amount of communication, expertise and patience, this goal of having the “best of both worlds” with an HOPD ASC can certainly be accomplished.

John A. Smalley (jsmalley@hvpros.com) is a principal and co-founder of Healthcare Venture Professionals, LLC, a full-service ASC management, development and consulting company with special emphasis on physician/hospital joint ventures.

What’s New in Minimally Invasive Surgery

Minimally invasive surgery seems to be a big buzz word in the ambulatory surgery center industry. Everyone wants to know what’s new and what’s coming soon to an ASC near you. Here are a couple of items — one a new piece of equipment to make the surgeon’s (and staff’s) lives in the operating room a little easier; the other … (1053 words)

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