Brad Lerner, MD, is a urologist, physician owner and medical director at Summit Ambulatory Surgical Centers, a group of 15 Urology ASCs in Maryland that performed more than 20,000 procedures last year. He is also a partner in Chesapeake Urology Associates and the chief of the division of urology for Union Memorial Hospital in Baltimore.
Dr. Lerner splits his time and works approximately 80 percent as a clinician and 20 percent as an ASC administrator. He's heavily involved with both the business and clinical operations of all the organizations he's affiliated with.
Here Dr. Lerner discusses what issues are at the forefront of his mind going into 2014 and where the year's biggest challenges — and opportunities for growth — will lie.
Question: What are you focused on going into the New Year?
Brad Lerner: The overriding issue is always achieving the highest possible level of patient care and safety. We are always looking for ways to improve patient care and stay current with changing state, Medicare and AAAHC regulations. A recurrent theme entering into a new year is to investigate ways to decrease expenses and/or to increase revenue while maintaining our focus on patient care. This involves multiple areas including critical review of existing and potential lines of service, vendor contracts, staffing models, supply costs, environmental services and more. Of course, we are looking at the potential changes related to the Affordable Care Act and what might be occurring in 2014. We are preparing ourselves for a larger patient population with higher deductible plans. We also know that we may be looking at bundled payments or outcomes-based compensation down the road as well.
Our organization is also looking more closely at the patient financial end of things, and we feel that it's becoming increasingly important to communicate with patients as far as their financial obligations prior to surgery so that there are no surprises at the time of their procedure. We actually experienced a higher cancellation rate this past year as compared to prior years related to this issue but feel strongly that there needs to be increased efforts to address this prior to performing any elective ASC procedure. Collecting the financial obligation upfront saves your billing staff the cycles of trying to collect from patients afterwards and improves cash flow.
We have looked at alternative financial plans to help patients that may have difficulty meeting their financial obligations for their procedures. We've engaged a third party financial provider that patients can look work with if desired especially when in a self pay situation. We have also incorporated a credit card payment option where patients will automatically pay a designated amount per month.
The times have certainly changed with a different environment related to insurance coverage options and potential changes coming from the government. We really do have to have a stronger focus on the business side of things and be more diligent from a collection aspect.
Q: How can you strive to be more efficient?
BL: We know that our physicians are their most efficient time-wise and from a revenue standpoint in the ASC as compared to the hospital or medical office. We predominately utilize block time sessions in our centers and are always looking at ways to allow our physicians to maximize their use of ASC time whether it be by changing length or numbers of sessions, providing the appropriate supportive staff as well as state of the art equipment and upgrading existing technology. We also are constantly evaluating additional lines of service that traditionally may have been performed in a hospital setting but may actually lend themselves appropriately to an ASC setting.
We also review historic case volumes as well as projected case volumes going forward for individuals and certain lines of service. Certainly, review of block time utilization with adjustments being made for under utilization as well as increasing available time for those that are maximizing their sessions takes place on a regular basis. There is huge difference between perception and reality and showing data to the physicians concerning utilization is a powerful tool.
Q: How will technology shape your business and your practice?
BL: One does have to look at committing a center to new or improved technologies as an investment. With improved technologies, there may be additional expenses but these same technologic advances will also likely improve patient care and safety and, potentially, revenues. We've been utilizing EMR for about seven years now. The electronic medical record is vital if you want to start measuring outcomes. We know the emphasis in the future may be more and more on outcomes. If you can show these positive outcomes, it's certainly something that could potentially be marketed to hospitals, other physicians, patients and insurance companies that may be seeking the safest option with the lowest complication rates at a lower cost.
Introducing new technologies and lines of service may help to increase case volumes and revenue. We are presently looking at adding new procedures including pediatric urology, ureteroscopy and expanding our genitourinary prosthetic program to include artificial urinary sphincters to treat incontinence.
One recent example involves trans-urethral resection surgeries, which has traditionally utilized a monopolar cautery technology. After an in-depth analysis of the clinical, financial and operational aspects of this new technology, we made the decision to bring in bipolar cautery and plasmavaporization, mainly for endoscopic the treatment of bladder cancer. It's safer for patients as the electrical current doesn't travel through the patient. There is less risk in stimulating regional nerves and interfering with implantable electronic devices such as pacemakers and defibrillators. It's also the scenario where there is an increased expense to our organization as it is more expensive technology with the same CPT code and reimbursement as the former technology. Our organization made the decision to invest in this technology to improve patient care and safety as well as the efficiency of our physicians. Now that we offer this technology, we are already seeing physicians moving cases from the hospital setting where this technology may not be offered to the ASC setting. By increasing the case volume, the increased expenses can be offset by the increased revenues and most importantly, patient care and safety are improved.
Interestingly, there was a commercial insurance carrier in Maryland that recently established a different professional fee schedule for ASC-based procedures. Historically, if you did a procedure in a hospital or in an ASC, the professional fee reimbursement was the same. The insurance company did this because they understand the value to the patient as well as to themselves. This is not just monetary. We know that procedures can done in a safe environment with a lower cost to them. They may serve as a potential incentive to certain physicians to do more cases in the ASC setting rather than in the hospital.
Q: What are some benefits of being a physician owner?
BL: As a physician and a fellow surgeon, I can understand my fellow surgeons and possible difficult situations better. On the flipside, it also takes a special kind of person to deal with your peers when it comes to disciplinary action or proprietary actions. I've been clear with physicians that we can't use 50 different types of gauze or gloves. I always tell my doctors, if you feel an existing product compromises patient care and safety, let me know. But if you want to change from brand A to brand B because you like it more but brand B is more expensive and doesn't bring better care, we would not want to make that change.
Physicians have their preference and idiosyncrasies. Part of working with other physicians is learning how to be a good communicator and to figure out the best way to communicate with them so they understand both sides of any situation. A lot of it is also being a troubleshooter. We want our physicians, nurses and staff members to be happy and for patients to be safe and get the highest level of quality care.
One of the more difficult issues is dealing with physician behavior issues. In every ASC, you deal with some physician behavior issues, and you have to deal with it immediately and directly. I try to work face-to-face and avoid emails as much as possible. Email is very open to interpretation and can be taken out of context. When you're face-to-face, you can hear them out and develop a corrective action plan that they agree to.
Q: What are some of your biggest challenges?
BL: My biggest challenge is how to balance my obligations to my patients in the office and in the hospital in addition to all the ambulatory surgery center issues including the clinical, operational, financial and regulatory issues. It's a balance. You have to figure out how to manage your time, and it's not easy to do. It is still an evolving process, trying to strike the proper balance. If you are going to be a practicing clinician and have an active role as a medical director, you have to be absolutely protective of your administrative time. One must be sure to set aside days or periods of time to devote yourself to your ASC duties. Trying to co-mingle ASC duties and clinical duties can be problematic at times.
A crucial part of my success is the support and hard work of our director of nursing and nurse managers. We all have great working relationships and meet weekly to go over any issues. All of our nurses, surgical technicians and other employees are also such a critical part of a successful ASC.
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