Physicians Endoscopy

Maximizing Quality in Your Practice and Making it Pay Off

Posted on May 20, 2013 by PE Marketing

By David A. Johnson MD, FACG, FASGE

Traditional benchmarking has focused on cost and efficiency. Downward pricing pressure will drive continuation of such activities, but there will be an intense and ever-increasing focus on quality direction for value-based purchasing. Furthermore, the rising consumerism related to health care consumption will force defensive benchmarking with an eye to how the data will be perceived by an external audience.

Defensive benchmarking will evaluate the confluence of quality measures, patient satisfaction and price, in light of how these will be evaluated by the patient as well as the insurers. Traditional benchmarking can provide cost data to support pricing decisions, but well-defined and broadly accepted quality measures that can transcend single episodes of care and are applicable to complex patient care across specialties have yet to be developed.

Endoscopy has become enormously popular throughout the world because of its proven value in the diagnosis and treatment of digestive diseases. A major, perhaps limiting, problem is that the benefits are maximized only when procedures are performed at an optimal level of quality and safety, which is not always the case. Technical failures and adverse events can occur even in the best of hands, but are more likely when procedures are performed by endoscopists with inadequate training and experience. Practitioners, patients and payers should all be interested in enhancing the quality of endoscopy and documenting it. Furthermore, gastrointestinal professional organizations have increasingly embraced the quality improvement paradigm that is advancing through medicine.

Recognition and Measure Excellence of Endoscopists

There are some features of an endoscopist that make a good experience more likely. Formal endoscopic training and extensive experience do not guarantee quality practice, but they certainly make it more likely. Thus, documentation of these and related elements should be a part of any assessment of endoscopic performance. Appropriate metrics could include:

•   Specialty training and certification (place and dates)
•   Training and maintenance of competence in life support and sedation
•   Evidence for continuing education in endoscopy
•   For each procedure—lifetime numbers, total last year and spectrum of practice

The proof of quality comes from documentation of performance. There is no substitute for collecting relevant data. Trainees are now expected to maintain logbooks of their procedural activity during training, and many authorities have recommended that endoscopists should continue to collect data prospectively on their endoscopic practice and performance. This translates into “endoscopy report cards.”

The assurance that high-quality endoscopic procedures are performed has taken increased importance. A high-quality endoscopy ensures that the patient receives an indicated procedure, that correct and clinically relevant diagnoses are made (or excluded), therapy is properly performed, and all of these are accomplished with minimum risk. The motivation for developing quality indicators for endoscopy begins with the desire to provide patients with the best possible care. These indicators may then be used in programs to
improve the overall quality of endoscopic services.

In 2006, the ACG and ASGE Quality Task Force developed and published quality benchmarks intended to create rational quality indicators that any well-trained endoscopist committed to patient care should and would follow and exceed minimum frequency thresholds. These benchmarks, weighted by scientific evidence, were developed to identify poorly-trained individuals doing a disservice to their patients and the medical profession.

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Posted in Industry Information, News | Tagged asc development, Endoscopy, Physicians Endoscopy | Leave a comment

On The Move: Lessons Learned from Moving a Practice and an ASC to a New Space

Posted on May 10, 2013 by PE Marketing

By John T. Gleason

As Digestive Disease Associates (DDA), a physicians practice, and Berks Center for Digestive Health (BCDH), a surgery center owned by members of the practice, approached the end of their leases, the owners had to decide if they would stay in their current locations or move to a new building under one roof with the hopes of improving operations and the patient experience. Ultimately, the owners decided to capitalize on the opportunity to relocate. As their Executive Director, I will present the highlights of this move, including the decisions made, consequences and lessons learned…

For some time, the owners had discussed how patients and the business could both benefit from consolidation. They came to the conclusion that they could run more efficiently from one location, especially because of staffing; it was difficult for the owners to optimize staff resources. There was a need for excess staff to ensure coverage in both locations. In addition, there were duplicate utility bills (telephone, cable, electric, internet, etc.) that if merged, would have resulted in efficiencies and cost savings. Lastly, the change would enhance the patient experience. Oftentimes, patients were confused about which location to report for an appointment. They would come to one office only to be redirected to the other. Thus, the decision to consolidate was in many ways an easy one—getting there was the challenge.

The move began with a quick review of available properties. A preferred site was selected at the end of March 2012. A lease was signed in early June after negotiations with the landlord; the build-out of the shell facility began immediately upon signing. It was a short timeframe for accomplishing a great deal of work. The building was just that, a shell—walls and a roof. There were no floors, mechanicals, plumbing, etc. In some ways, this situation was good because demolition was virtually unnecessary. On the other hand, there was much to be done. Plus, the plan from the beginning was to be in the building and starting operations by the end of December of that same year.

Thanks to strong direction from our management partner, Physicians Endoscopy, a motivated architect, General Contractor (GC) and well-organized employees at all levels, we opened the new facility almost exactly on time. It was beneficial that a timeline was developed early on. So, all parties were held accountable for achieving the designated goals on the plan. The stakeholders met on a weekly conference call to ensure objectives were met. Unexpected glitches that could have easily prevented hitting targets did not occur because the parties handled them immediately in order to stay on track. The first patients were seen at the new facility on January 7, 2013, just one week after the original target date. Everything had been accomplished in a mere six months.

This new center is really something to be proud of in my opinion. It will have a positive impact on the quality of care provided to patients in the community for various reasons. For one, BCDH now offers even better state-of-the-art equipment and computer systems. The center upgraded endoscope equipment, vital signs monitors, light sources and processors. While the initial plan was not to upgrade the electronic record, the age of the system indicated the need for it. Therefore, it is in the process of upgrade. The timing was right to make these changes; the center had used its equipment and systems to full capacity. It helped that all of these costs could be rolled up into one financing vehicle for ease of payment and administration.

The new center benefits patients in a variety of ways too, besides being treated with enhanced equipment. Opening the center has improved standards, increased learning and strengthened teamwork. The new location meets all the current federal, state and local government regulations for patient care and facility design as well; the setup meets the highest standards of care in the industry. To prepare for the opening, management, vendors and Physicians Endoscopy trained the employees on the new equipment, systems, and protocols. The staff’s ability to grow by increasing their knowledge and engaging in planning will benefit the organization and patients in the long run. Our employees are some of the most educated in ambulatory endoscopy surgery centers because they have now been trained on the highest-quality equipment. Lastly, the coordination and planning involved in moving demanded tremendous teamwork. As a result, BCDH’s team is functioning at its strongest ever. All of these changes cumulatively will assure improved patient care at BCDH.

BCDH and DDA learned a lot in the process of this move.

Here are just a few worth noting… Click here for full article!

Posted in Industry Information, News | Tagged ambulatory surgery center, ASC, asc management | Leave a comment

Ohio Center Opens Second ASC Location

Posted on April 23, 2013 by PE Marketing

Physicians Endoscopy, joined by six physicians of University Suburban Hospital Center (USHC) in Chagrin Falls, OH, are pleased to announce the commencement of operations at their new 2-room endoscopic ambulatory surgery center located in South Euclid, OH.

University Suburban Endoscopy Center (USEC), the second facility owned by Drs. Robert B. Cameron, Michael Koehler, Kevin Geraci, Raymond Rozman, Eric Shapiro and Rami Abbass, is a state-of-the-art facility in every respect.

The physicians also have an ASC and practice in Chagrin Falls and also maintain a practice location in South Euclid. These six physicians’ reputations for quality and patient care have allowed them to grow their Chagrin Falls center from 300 patients per month in the first two years, to over 500 patients per month in 2012. We anticipate the South Euclid location will provide expanded service offerings to this community.

This new endoscopic ambulatory surgery facility is a partnership between USHC Gastroenterology, LLC (physician entity), Cedar-Brainard Surgery Center, Inc. (hospital entity) and Physicians Endoscopy, LLC (a management company). Robert B. Cameron, MD, Medical Director will lead the center.

“Our GI group, USHC GI has enjoyed a great partnership with Barry Tanner and his team since 2006. Together with PE, we have navigated the changes in health care while beginning two successful premier GI endoscopy centers on the east side of Cleveland. Both USHC GI and PE have broadened their partnership to include University Hospitals of Cleveland,” said Michael Koehler, MD.

“We have looked forward to the opening of this new facility for several years. We are very proud to be able to open this facility in partnership with the physicians of USHC Gastro and the UH Health System,” stated Barry Tanner, CEO, Physicians Endoscopy.

Posted in New Center, News | Tagged ASC, endoscopic ambulatory surgery center, PE new center | Leave a comment

Assessing an ASC Investment

Posted on April 23, 2013 by PE Marketing

By John Poisson, EVP of Strategic Partnerships, Physicians Endoscopy

Examining an investment in an ASC can be a challenging task. There are many elements to consider before electing to join the ownership ranks of a facility. Since most ASCs impose governance provisions that penalize an investor for electing an early redemption (withdrawal), it is important to carefully scrutinize the facts upfront. The purpose of this article is to outline some of the major questions to ask to fully understand in order to make a well-informed investment decision.

Reputation & History of the ASC

There is a story behind the development of every ASC in the country. It is up to you to understand the history of the facility as well as its reputation within the community. For starters, does the center enjoy positive word of mouth in the area? Although physicians and staff are the real drivers of patient satisfaction, often times patients more generically reference their encounter at the “facility.”

ASCs that earn a solid reputation during their early days of operations typically continue to enjoy favorable reviews over time. A facility that struggles with its image in its early days may never gain a positive reputation; the ghosts of the past can be quite haunting, particularly if they are related in any way to clinical quality issues in the early stages of operations.

Solid Operating History: It makes logical sense that a facility with a solid operating history is generally considered a more desirable investment. There are many facilities that have been temporarily shut down or have undergone major re-syndication of their ownership group—be extra cautious in these situations—remember, every facility has a story and some of them can be ugly. There’s an old adage: “You get what you pay for.”

Single-Specialty Preference: For a practicing GI physician, a single-specialty endoscopy center is generally viewed as a more desirable investment than a multi-specialty facility. Across Physicians Endoscopy’s 300+ physician partners, nearly 25% have, at one time, practiced at a multi-specialty ASC. The most common complaints were either: 1) The physician owner had high procedure volume but only had a very small ownership percentage; or, 2) Other specialties seemed to receive more favorable treatment from management.

The Physician Partners: Along these lines, understanding who your prospective physician partners will be in the venture is mission critical. Although joining an ASC doesn’t require you to merge your professional practice with the other physician owners, everyone does need to be able to play in the same sandbox. For instance, professional practices that have broken apart, yet each physician remains an owner in the ASC, can lead to high tensions at times as those historical ghosts can occasionally resurface.

The Strategic Growth-Focused Business Plan

Healthcare may be one of the most dynamic industries in the country, especially in these changing times of healthcare reform. As a result, a center that has a solid track record
doesn’t necessarily indicate that those same rosy results will continue ad infinitum. On the contrary, today’s ASCs need to develop and implement well-designed multi-year strategic
plans in order to continue to flourish. And that should be one of the hardest hitting questions you ask while “interviewing” management at a facility. Simply, what exactly is their strategic plan over the next three to five years, and how are they tracking towards the execution of all necessary milestones and timing.

Changing Reimbursement Methodology: The days of old, whereby an ASC could routinely operate “out-of-network,” have essentially ended in most of the country. Today’s current in-network, fee-for-service environment is transitioning into various value-based reimbursement methodologies. Whether bundling, ACOs, or capitation reappears in your region, your ASC’s management team needs to be ahead of the curve. In order to participate in risk sharing methodologies, it is vital that your facility understand its case costing. This means fully vetting your cost per procedure across every line item in your budget. This should be a critical part of the answer you should hear from management when discussing a strategic plan—the culture of measuring and reporting metrics for nearly anything and everything done at the facility. Data is king in tomorrow’s reimbursement landscape.

Growth Initiatives: Part of a strategic conversion should focus around the recruitment of new providers and new procedures. Within GI ASCs, we are seeing many of the traditional “hospital-only” procedures migrating into the endoscopy center. Gaining traction in centers is the performance of Endoscopic Ultrasounds (EUS). Newer technologies are finally starting to receive Medicare and commercial carrier coverage. Procedures such as the BARRX-Halo or Bravo capsule devices are now becoming common in most urban markets.

Minimizing Business Risks: One of the biggest threats to a successful center is physician discontent. The most common area of complaint stems around the concept of each physician living up to his or her obligations—treating staff well, arriving on time, being attentive to patients and their escorts. However, there is a darker side to these obligations. Each year the center develops a budget based on expected block time utilization assumptions. Occasionally, a physician does not live up to expectations to fill his or her block time—the common term in the industry is “dead wood.” Thus, when evaluating an ASC investment, ask about this: Does dead wood exist in the facility, and if so, how does management see this changing over time? Buying out non-productive physicians can be very costly and frustrating for the overall ownership group.

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Posted in Industry Information, News | Tagged ASC | Leave a comment

10th Annual NY Colon Cancer Challenge

Posted on April 12, 2013 by PE Marketing

Physicians Endoscopy, along with four affiliated centers in the New York City metro area, participated in the 10th Annual NY Colon Cancer Challenge in Central Park on April 7, 2013. These four ASCs were the sole representatives for GI ASCs to take part in this event. The event was not only a fundraiser, but an educational day. Thousands walked through the Rollin’ Colon exhibit and took the opportunity to speak with the health and wellness representatives from Physicians Endoscopy and other vendors in the educational tent.

For more information, visit http://www.coloncancerchallenge.org/2013-challenge

Posted in Colon Cancer Awareness, News, PE Events | Tagged Colon Cancer Awareness | Leave a comment

Selling Your Practice to a Hospital

Posted on April 8, 2013 by PE Marketing

By Daniel B. Frier, Esq.

Daniel B. Frier, Esq.

In the past year or two, hospitals have been in a feeding frenzy, buying medical practices one after the other. Primary care physicians, cardiologists, ob/gyns and a handful of other specialists have been the targets of these acquisitions. With increasing costs, and sideways or dropping reimbursement rates, hospital offers have been too tempting for some physicians to turn down, and many have made the choice to sell their practice assets and become hospital employees. This article discusses what factors are motivating hospitals, the long-term prospects of selling a practice to a hospital, and some of the critical terms to negotiate in the sale documents.

Why are Hospitals Buying Practices?

Let’s get one thing straight. The vast majority of hospitals lose money on the professional fees generated by acquired practices. Sometimes, they lose a lot of money. Break down the economics, and it makes perfect sense. Hospitals induce physicians to sell their practice assets in exchange for a lump-sum purchase price, plus a salary that is ten percent to more than twenty-five percent greater than what the physicians were previously earning, assuming their volume remains roughly the same. Hospitals are generally no better (and usually much worse) at billing and collecting professional fees than is the average physician-owned medical practice. Therefore, hospital-owned practices incur greater costs (higher salaries) and collect less money than their physician-owned counterparts. Since most medical practices do not have a year-end surplus (i.e., all profits are distributed as income to the physicians), there is really no extra “fat” that enables the hospital-acquirer to offset the loss. A medical practice’s balance sheet turns red, and usually stays red, from the moment it is bought by a hospital.

This begs the question, “if hospitals lose money when they buy medical practices, why are hospitals buying them?” One common answer is that hospitals make plenty of money on the inpatient facility fees generated by the practices they buy, and this more than offsets the loss in professional fees. While potentially true, this theory is debunked by the fact that most practices bought by hospitals already have a history of referring patients to that very same hospital. Hospitals are essentially buying what they already have.

In the case of some specialists, like cardiologists, hospitals can theoretically make more money billing certain diagnostic services through a hospital outpatient department than the practice could on its own. In practice, due to new rules governing HOPD (Hospital Outpatient Department) billing, the differential is much less than many hospitals originally anticipated, and most of us predict that the amount of the differential is probably short-lived.

The best explanation for the recent frenzy in medical practice acquisitions by hospitals is that hospitals are afraid that if they don’t do it, a competitor will. The battle is over market share. In a fight for market share, short-term profits are secondary and often insignificant. The loser in a battle for market share ceases to exist, and most businesses, hospitals included, will do just about anything to prevent their extinction, even lose lots of money.

The problem with the market share strategy is that once the feeding frenzy ends, many hospitals will be left with an assortment of money-losing practices. If they cannot parlay those practices into something that ultimately generates income (e.g., integration into a profitable Accountable Care Organization (ACO)), then the acquiring hospitals will become less profitable than before, and few hospitals can afford this in the long run.

Long-Term Factors

The likely response by those hospitals that continue to lose money will be to either shed the acquired practices after the initial employment terms run-out, or significantly reduce the compensation offered to employed physicians. Remember, the finances of most hospitals are run by bean-counters. In three to five years, those bean-counters may be brand new hospital employees who were completely removed from the original acquisition, and are unaware of the synergies that justified the hospital’s willingness to lose money on professional fees. All they will see is red, and they’ll want to turn it black any way they can.

One might think, if hospitals try to lower physician compensation, the physicians will simply run to the next hospital, continuing to play hospitals against each other. In order to avoid this possibility, hospitals traditionally include a restrictive covenant in their acquisition documents that prohibits physicians from selling to, or working for, a competing hospital for two or more years after the termination of the relationship. Many hospitals are beginning to extend the restriction to prevent physicians from joining an existing medical practice (e.g., a large group practice), leaving the physicians with only two practical choices – accept the compensation reduction or go back to their old practice and restart an engine that hasn’t been turned on for three to five years.

If you want to test the theory that hospitals are acquiring practices to prevent their competitors from gaining market share, try negotiating the restrictive covenant out of a physician contract. You will fail. You might squeeze out higher compensation, or a higher purchase price, but hospitals will protect the restrictive covenant provision like it’s a matter of life and death – and it is.

Critical Factors in Negotiating Sale Documents

There are dozens of important considerations physicians and their attorneys should make while negotiating documents related to a hospital acquisition. This article will not recite an exhaustive list of those considerations. Rather, it will focus on those that deal specifically with the aforementioned problems likely to confront physicians at the end of their initial employment terms. In this regard, there are two especially important contractual provisions that should be appropriately negotiated – the physicians’ right of repurchase, and the restrictive covenant.

A right of repurchase references the physicians’ right to buy-back the practice assets if and when the hospital contract ends. Without a right of repurchase, the physicians would have to start from scratch if they cannot negotiate a favorable renewal term with the hospital. This reduces the physicians’ negotiating leverage at the time of renewal. Negotiating leverage is everything, and having more and better choices increases negotiating leverage. A right of repurchase gives physicians the option of reconstituting their old practice if things don’t work out with the hospital. While this may not be optimal, it is better to have this option than not to have it.

The right to repurchase assets is actually a misnomer if it is properly negotiated, because there are more than assets at stake. The provision should also deal with what happens to the practice’s employees (who have since become employees of the hospital), newly-implemented EMR systems, post-termination billing and collections issues, the old practice entity, newly-purchased equipment, office leases that were assigned to the hospital, and the like. Another factor is how to set the price for the repurchase. If the hospital spent $300,000 on leasehold improvements, how will those improvements be appraised at the time of repurchase? One of the most important concerns relates to ownership of the patient charts. The ability of a physician to reconstitute their practice is seriously hampered if the practice does not own, or have copies of, its patient charts. This should include patients treated both before the hospital purchase and thereafter. All of these factors, and more, must be carefully negotiated in order to make the potential transition back to private practice as easy and inexpensive as possible.

Negotiating the restrictive covenant will be very challenging because, as discussed above, its purpose goes to the hospital’s core motivation for entering into the relationship. However, if the restrictive covenant cannot be pared down to the point at which it allows the physicians sufficient options to survive without the hospital at the end of the relationship, then serious thought should be given to walking away from the deal. The future of healthcare is too uncertain for physicians to limit their options so severely that they may not be able to survive without accepting whatever the hospital offers them after the expiration of the initial term.

It is not the goal of this article to dissuade every physician from selling their practice to a hospital. There are certainly instances when it makes sense to sell. For example, if a physician is very close to retirement, if the practice is not in a position to merge with a larger group practice, or where the practice is able to negotiate a reasonable exit strategy with the acquiring hospital. However, we fear that selling to a hospital is not the long-term solution that many physicians think it is, and the decision to sell should be done with a more realistic understanding of the risks, and more attention to the exit strategy.

Posted in Industry Information | Tagged ambulatory surgical facility, ASC, hospital | 2 Comments

Getting Pay For Performance Right

Posted on April 1, 2013 by PE Marketing

By Dr. Ashish K. Jha

Over the past decade, there has been yet another debate about whether pay-for-performance, the notion that the amount you get paid is tied to some measure of how you perform, “works” or not. It’s a silly debate, with proponents pointing to the logic that “you get what you pay for” and critics arguing that the evidence is not very encouraging. Both sides are right.

In really simple terms, pay-for-performance, or P4P, can be thought about in two buckets: the “pay” part (how much money is at stake) and the “performance” part (what are we paying for?). So, in this light, the proponents of P4P are right: you get what you pay for. The U.S. healthcare system has had a grand experiment with P4P: we currently pay based on volume of care and guess what? We get a lot of volume. Or, thinking about those two buckets, the current fee-for-service structure puts essentially 100% of the payments at risk (pay) and the performance part is simple: how much stuff can you do? When you put 100% of payments at risk and the performance measure is “stuff”, we end up with a healthcare system that does a tremendous amount of stuff to patients, whether they need it or not.

Against these incentives, new P4P programs have come in to alter the landscape. They suggest putting as much as 1% (though functionally much less than that) on a series of process measures. So, in this new world, 99%+ of the incentives are to do “stuff” to patients and a little less than 1% of the incentives are focused on adherence to “evidence-based care” (though the measures are often not very evidence-based, but let’s not get caught up in trivial details). There are other efforts that are even weaker. None of them seem to be working and the critics of P4P have seized on their failure, calling the entire approach of tying incentives to performance misguided.

The debate has been heightened by the new national “value-based purchasing” program that Congress authorized as part of the Affordable Care Act. Based on the best of intentions, Congress asked Medicare to run a program where 1% of a hospital’s payments (rising to 2% over several years) is tied to a series of process measures, patient experience measures, and eventually, mortality rates and efficiency measures. We tried a version of this for six years (the Premier Hospital Quality Incentives Demonstration) and it didn’t work. We will try again, with modest tweaks and changes. I really hope it improves patient outcomes, though one can understand why the skeptics aren’t convinced.

So what to do? In a recent issue of JAMA, I outline three principles that are really simple, not all that original or creative, and may be one way to think about correctly structuring P4P programs. First – focus on the “pay” part – if you really want hospitals and other provider organizations to change behavior, put real money at risk. I know that large incentives can have the perverse effect of reducing internal motivation, but that primarily happens to human beings (who have internal motivation), not organizations. In this case, organizations and corporations are not people. Large organizations focus primarily on incentives. If the incentives for meeting a performance goal are small, organizations will make small changes. Their Chief Quality Officer might put it on his “to do” list. If the incentives are large enough, it will get the attention of the CEO, who will make it her mission to get it done. Size of incentives matter.

Second, get the right metrics. Here, I think that we have to stop playing around with process measures. P4P programs can be way too prescriptive, and focusing on a small number of processes, no matter how “evidence-based” they might be, is not going to get us where we want to be. We need to focus on a small set of high value outcomes. Who chooses? In the ideal world, if patients actually influenced the healthcare system, providers would figure out what mattered to patients. Right now, the payers (government through CMS, private insurance companies) get to choose and I think they should focus on what likely matters most to patients. When patients are hospitalized, they generally prioritize walking out alive, not picking up a new infection along the way, and being treated with respect. Those sound like good metrics. Patients would also like, after they are discharged, to not come back to the hospital soon, though I suspect that that’s a lower priority than being alive.

Finally, we need transparency in the way we structure the incentives. Many of the P4P programs to date have been un-necessarily complicated. The VBP program, for instance, is quite complex. For instance, on patient experience measures, your financial reward depends on a combination of achievement (how well did you do), improvement (how much have you gotten better) and persistence (how often did you do well across a range of measures). For most hospitals, it’s very hard for them to know how well they will do. My take is a simpler approach: pick a goal (let’s say the 90^th percentile of performance across the nation) and then, set up a simple scheme. The closer you are to the goal, the bigger your payments. So, if the best (90^th percentile) hospitals have a mortality rate for pneumonia of 12%, then hospitals that are at 12.2% will get paid more than the hospital at 13% who will get paid more than the hospital at 14%. I know it sounds too simple – but it makes sense, avoids game playing, and rewards hospitals purely on performance.

At the end of the day, P4P has to be a tool we use to drive improvements in care. It’s intuitive, and we already have it in healthcare: we pay more to doctors and hospitals who do more stuff. It’s time to pay more for providers that achieve better outcomes. And the key to success? Don’t be overly prescriptive about the details of what people should do. Focus on high level metrics (outcomes), put real money on the table, and then, get out of the way and let providers innovate. How low can they drive infection rates? Let’s find out. Let’s make sure there’s enough money for providers and hospitals to innovate the way they deliver care so that they can do well when they do good.
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Dr. Ashish K. Jha is a practicing Internist physician and a health policy researcher at the Harvard School of Public Health. This article is published on his blog, An Ounce of Evidence and is used here with his permission. You can follow Dr. Jha on Twitter: @ashishkjha

Posted in Industry Information, News | Tagged ambulatory surgery center, ASC | Leave a comment

East Side Endoscopy Gastroenterologists Provide Free Colonoscopies to Uninsured New Yorkers

Posted on February 28, 2013 by PE Marketing

Dr Moushumi Sanghavi Dr. Sanghavi performs procedures at East Side Endoscopy (ESE) in New York. ESE has developed a robust charitable care program with a mission of providing free colorectal care screening and surveillance to uninsured individuals. Dr. Sanghavi has been involved with the program since its launch in July 2012, and she has significant plans to expand its outreach.

Community-wide Effort
East Side Endoscopy’s program got its start thanks to the charitable work of another endoscopy center in Manhattan. Physicians at Carnegie Hill Endoscopy had reached out to the William F. Ryan Community Health Network to arrange a charitable care service. The William F. Ryan Community Health Network is a family of nonprofit, federally-qualified health centers that deliver world-class medical care to diverse and under-served communities.

“Through the same physician liaisons, we were able to develop our program with the Ryan-NENA Community Health Center (a part of the William F. Ryan Community Health Network) on the lower east side of Manhattan,” Dr. Sanghavi says.

East Side Endoscopy provided the Ryan-NENA Center with guidance to help identify appropriate candidates for the charitable care program. Gastroenterologists and primary care physicians at the Ryan-NENA Center refer patient candidates, together with any relevant information regarding their overall health, to East Side Endoscopy. If the candidates are found suitable for the endoscopy center’s program, they are contacted directly by East Side Endoscopy to schedule the colonoscopies and discuss preparation.

Dr. Sanghavi, Associate Medical Director for the Endoscopy Center, performed the first of the program’s colonoscopies.

“During the first several months of the program, I personally performed each of the screening colonoscopies referred from the Ryan-NENA Center,” Dr. Sanghavi says.

A Vision to Help Even More
The free colonoscopies are now performed every Friday afternoon at East Side Endoscopy with all gastroenterologists from the center participating in the program on a rotating basis.

“At this time, we are fortunate to be able to provide the patients with free preparation coupons that have been donated to us by a pharmaceutical company,” Dr. Sanghavi says. “The entire service from anesthesia to pathology is free for the patients. Our goal is to initially perform at least 300 colonoscopies per year as part of this charitable care program.”

That’s not Dr. Sanghavi’s only goal for the program.

“I hope to expand this program in the near future by increasing our referral base and performing non-screening (i.e., diagnostic) procedures for uninsured patients,” she says. “In the next year, I also hope to add a patient education component. This will help spread
information about the need and value of colorectal cancer screening to the general public.”

About the Ryan Clinic
For more information about the Ryan Clinic, click here.

Posted in Industry Information, News | Tagged east side endoscopy, endoscopy center | Leave a comment

Should Gastroenterologists Join ACOs?

Posted on February 21, 2013 by PE Marketing

Accountable Care Organizations (ACOs) present a critical crossroads for gastroenterologists. Should you join an ACO to protect your referrals, and share in any savings that might come out of it? Or should you maintain an arms-length relationship, protecting yourself against possibly lower reimbursements?

These new entities, which attempt to reduce costs by integrating care, are starting up operations across the country. If one or more of them crops up in your area, you’ll need to pay close attention, according to John I. Allen, MD, Vice President of the American Gastroenterological Association. “Our biggest threat (and potential opportunity) is the emergence of ACOs,” Dr. Allen, a member of Minnesota Gastroenterology in St. Paul, wrote on the AGA website.

Will an ACO open near you?

The first group of Medicare ACOs began operations in January 2012. While they have yet to penetrate many parts of the country, their numbers are growing by leaps and bounds, and some are entering less populated areas. As federal authorities announce new rounds of approvals, the number of ACOs more than doubled in July 2012 and are expected to almost double again by January 2013, according to the Center for Medicare & Medicaid Innovation.

Leavitt Partners, a healthcare consultancy in Salt Lake City, reported that there were 328 ACOs in November 2012, and in 2012, more than half of hospital executives said they expected to start or join an ACO in the next two years, according to San Francisco-based Dignity Health.

Some gastroenterologists are wasting no time in joining ACOs and taking a leading role in setting them up. Scott Ketover, MD, President and CEO of Minnesota Gastroenterology in Minneapolis, told Gastroenterology & Endoscopy News in October 2011 that he had joined the board of a new ACO under development.

However, many gastroenterologists are holding back. ACOs are not expected to favor specialists because the arrangement emphasizes primary care and is often run by hospitals that have their own agendas. With Medicare reimbursements set below commercial rates, gastroenterologists with a full appointment book may not be interested in attracting more Medicare patients.

On the other hand, a growing number of private-pay patients are entering ACOs, sponsored by commercial insurers like Humana, Cigna, UnitedHealthcare and several Blues plans. These private ACOs are said to have less confusing requirements than Medicare ACOs.

One successful example of a private-payor ACO is AdvocateCare, which involves Blue Cross Blue Shield of Illinois and Advocate Health Care, an integrated system with 10 hospitals and 4,000 affiliated physicians, based in Oak Brook, IL.

Since it began in 2010, AdvocateCare has cared for more than 200,000 patients. In the first half of 2011, hospital admissions per member were 10.6% below 2010 levels and ED visits dropped by 5.4%. In July 2012, Advocate Health Partners, the system’s affiliated physicians group, was selected to run a Medicare ACO.

Will ACOs redirect GI referrals?

With ACOs still in their infancy, their impact on GI referrals is not yet fully understood. Unlike under the old gatekeeper-style HMO, ACO patients cannot be prevented from seeking outside specialists. However, the Stark Law has been loosened to allow primary care physicians in an ACO to direct referrals to particular specialists. ACOs have been given a “limited exception” to Stark, as long as the referral is “reasonably related” to the goals of the ACO program.

While primary care physicians within the ACO are expected to clamp down on specialty referrals, they may go easier on GI cases, according to Glenn Littenberg, MD, Managing Partner of Gastroenterology Associates in Pasadena, CA. “Because GI physicians aren’t big spenders, they don’t make a likely target for major changes,” he told Gastroenterology & Endoscopy News in October 2011. Furthermore, he did not think internists in an ACO would take over care of chronic GI diseases such as irritable bowel syndrome or inflammatory bowel disease.

“In the future, primary care physicians might use guidelines to determine GI referrals, but many ACOs won’t have this capability at first,” said Terry Spoleti, President of Glenridge HealthCare Solutions, a consultancy in Columbia, MD. “Because of the difficulties with setting up IT infrastructure, it is expected to take several years to move to a system that aligns with the most effective specialists,” Spoleti said in a recent issue of AIS Health.

Will ACOs be good for endoscopy centers?

Since self-standing endoscopy centers have lower costs than hospital-based centers, they would seem to be a perfect fit for ACOs. But this may not be the case for hospital-led ACOs, since they would have a strong financial interest in keeping volume high for their in-house operations.

However, keep in mind that hospital-led ACOs cannot prohibit outside referrals, and participating primary care physicians could refer to self-standing endoscopy centers to meet goals for savings.

How would endoscopy centers be paid? Michael Weinstein, MD, a GI Physician at Capital Digestive Care in Chevy Chase, MD, expected a bundled GI payment from some ACOs. “The payment would be available to the center and to GI specialists, pathologists and anesthesiologists involved in a single episode of care,” he told Becker’s ASC Review in 2010. “I think it’s really going to be the GI specialists that quarterback the episode of care,” he added.

If there were any complications, however, the set reimbursement for an episode of care might fall below costs. James Fox, Director and Senior CFO Consultant at New York-based Warbird Consulting Partners, counseled centers to put a cap on losses in their arrangements with ACOs. “One of the things to be concerned about is if the ACO is trying to shift too much of the risk or costs onto the surgery center,” Fox said in Becker’s ASC Review in 2012.

Why join an ACO?

There are two key reasons for gastroenterologists to become a full-fledged member of an ACO. The first is to participate in creating clinical pathways that caregivers in the ACO will use to refer and treat GI patients.

A specialist “would want to be there to help formulate the clinical pathways of care, including such things as the risk factors and the comorbidities,” said Paul Keckley, Director of the Deloitte Center for Health Solutions. “The specialists need to give primary care physicians the diagnostic queries for the patient,” he told Becker’s Hospital Review in 2011.

“Specialists who do not join the ACO would still receive referrals from it, but they might have to accept the ACO’s clinical guidelines,” said Mark Lutes, a healthcare attorney with Epstein Becker & Green in Washington, D.C. “The relationship might involve a contract or simply a “dialog” between the specialist and the ACO,” he said in the Becker’s article.

What sort of income would ACO savings provide?

The second key reason to join an ACO is to be eligible for a portion of the savings that the ACO might accrue. A Medicare ACO will continue to pay physicians a fee-for-service rate, but those who are ACO members would then also receive a portion of the savings, which would be calculated based on a comparison to the anticipated budget.

It is not clear, however, whether most ACOs will produce any savings to start with, and the poor-performing ones might never produce savings. To be eligible for any payments at all, a Medicare ACO with 5,000 to 60,000 beneficiaries must produce savings of at least 3.9%. The federal government would then take at least 40% of that figure and the ACO would distribute the rest among all providers.

“The organizations that currently call themselves ACOs fall short of being full-fledged ACOs,” stated a report by Oliver Wyman, a New York-based company that helps organizations set up ACOs. For example, of the 89 organizations that became Medicare ACOs in November 2012, only five are taking on both “upside” and “downside” risk, a level that could bring higher savings. The remaining 84 ACOs would “run as predominantly fee-for-service enterprises, and hope for the best,” the company said.

“If there are any savings, it is up to the leaders of the ACO to determine how they would be distributed. A typical breakdown for a hospital-led ACO would be 50 percent for the hospital, 40 percent for physicians and 10 percent to post-acute care,” said Akram Boutros, MD, President of BusinessFirst Healthcare Solutions, a hospital consultancy in Great Neck, NY. “However, the actual percentage a group of physicians receives would depend on how much they are integrated with the hospital,” he said in a 2012 interview with Becker’s Hospital Review. If hospital leadership sees the physicians as clear partners, they would get a bigger share than if they were seen only as a “cog in the wheel,” Dr. Boutros said.

Summing up

Many gastroenterologists have put off dealing with ACOs due to serious doubts that the Affordable Care Act would survive past 2012. The ACA has been highly unpopular with many Americans, a variety of lawsuits challenged the measure, and the House of Representatives tried many times during the year to repeal the law.

But in the wake of the U.S Supreme Court’s decision to uphold most of the ACA, and President Obama’s re-election, ACOs appear to be here to stay. ACOs are still in an experimental stage and gastroenterologists do not necessarily have to join them, but they do need to keep abreast of them, paying particular attention to how they are affecting referrals. In the long run, new methodologies incubated by ACOs could become the predominant methods of payment.

In short, you will then need to develop a plan to deal with ACOs. “Many believe this is simply another fad,” Dr. Allen wrote. “I would suggest that we not be fooled into complacency.”

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Posted in Industry Information, News | Tagged endoscopy center, gastroenterology, medicare | Leave a comment

Voted By Our 2012 Physician Partners…

Posted on February 14, 2013 by PE Marketing

Physicians Endoscopy (PE), already known as the leader in the development and management of new GI ASCs, has quickly become a major force in the GI acquisition market as well.

How have we positioned our company at this level?

FLEXIBILITY

Flexibility in Structuring the Acquisition Equity Model: Majority, Minority or a Combination
Flexibility in Crafting Deal Concepts and Business Terms Specific to Each Individual Transaction
Flexibility in Future Equity Restructuring Allowing for New Providers or Hospital Partner

With PE’s strong financial resources, we continue to seek ownership in select, high-quality licensed GI surgery centers. Coupled with the immediate equity purchase benefits, PE’s operational efficiencies and professional guidance will maximize your ongoing distributions.

If you have plans for opening a new center or selling equity in your existing GI center, you will want to talk to PE before you take action. I welcome the opportunity to speak with you and provide sound, practical advice that makes sense for your future and the growth of your center.

“Our partnership with Physicians Endoscopy provided us the flexibility necessary within our coalition that allows for strategic growth and a continued, sustainable, profitable business. While other companies wanted to buy a majority equity ownership in our center, only PE could accommodate the strategy we felt necessary to allow for future owners without the current physicians diluting further equity. PE’s flexibility all along the way was instrumental in solidifying the relationship, and we look forward to a long term partnership of continued growth and reward.”

Dr. Wayne Siegel

Ambulatory Center for Endoscopy

North Bergen, NJ

Posted in News | Tagged Ambulatory Center for Endoscopy, Endoscopy, GI Surgery Centers, PE Acquisition, Physicians Endoscopy | Leave a comment