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1. Determine your break-even number
The break-even refers to the number of cases (and their concomitant revenues) needed to cover your center's fixed costs and debt service. Every additional case beyond this number is increasingly more profitable.

It is important to spell out this concept to your current partners because this is the first place to sow your seeds of change. I have often heard the case volumes of the existing partners referred to as "the low-hanging fruit," and it's apt: Logically, if a physician is an owner in an ASC, why wouldn’t he/she bring every eligible case to the center? Without delving into the various political or logistical reasons certain partners' case volumes may be less than initially projected, I will instead lay out a strategy to improve this situation.

2. Capturing partners' cases
If the physician partners are agreeable, start by meeting with each of their surgical schedulers to examine the partners' surgical calendars for the past few months to determine which cases were brought to your center and which ones were done elsewhere. Initially, this may seem like a touchy subject, but once you explain that this exercise is designed to better accommodate them and not to point a finger, even the most obstinate of office staff seem to soften.

For example, one center recognized that a particular physician needed more block time at the ASC to accommodate the overflow of his patients being booked at the hospital. In another case, an office didn't realize that the center had recently contracted with a particular payor; until the situation was brought to light, all patients with that insurer were being booked elsewhere. Yet another example: A general surgeon didn’t realize that a change in the Medicare fee schedule amended the size of lesions that could be excised in ASCs — a look at the surgical schedule showed cases the ASC could be capturing.

Once the scheduling data from all the offices has been examined, you can choose the forum in which to communicate it to the physicians. Personal experience has shown the positive value of peer review at a monthly board meeting. Some older surgeons have been working with their schedulers for 20-plus years and simply go where they are told. Shining a light on this, with the added information of what just a few extra cases a month means to the center, can yield significant rewards.

I have worked at centers where this process is repeated quarterly. To facilitate this exercise in the future, creating a "patient exception form" is an easy way to keep track of which ambulatory patients don’t come to your facility. Simply have the physician's office surgical scheduler check off the physician, the procedure, the date and a reason your ASC was not the site of service. At the end of four months, you should have a (hopefully small) stack of forms for patients who could not be accommodated at your ASC. This will let you identify the reasons you are missing out on these cases and subsequently address the needs of a particular office, its patients and the surgeon. Surprise and disbelief are not uncommon when the data are presented; this is a very real and powerful tool to retain case volume.

Remember: Capturing cases begins with the surgical scheduler in your physicians' offices. There is no question that certain specialties transition more smoothly into the ambulatory setting. But the power rests with the schedulers, and you must communicate with them to ensure they think of your ASC first. I know of ASCs that hold monthly breakfast meetings for all surgical schedulers. It's an excellent way to update everyone on changes in contracting or policy; to provide an open forum to discuss the schedulers' questions and concerns; and, as a result, to form personal bonds beneficial to any working relationship.

3. Reach beyond the inner circle
Now that the surgical volume of your partners has been maximized, the next step is to examine unaffiliated community physicians. Beyond this point, recruitment efforts become a collaborative effort. If you can create synergies within your center, this is an easy way to increase volume.

It is true that the first and last sign-offs are in the hands of the physician owners, but there are many sources to be consulted when indentifying the best candidates. For example, physicians will know which individuals are a part of the big practices in your community, but when it comes to efficiency and OR behavior, they may not have a lot of insight. Rivalries and competition also exist among some specialties, so getting an unbiased assessment can be challenging.

I’ve found that the objective eye belongs to the anesthesiologists — they are the ones who can give you the straight facts. Who can do four cataracts in an hour? Who adjusts the drapes and tells jokes for 20 minutes before opening three shavers and proceeding to perform an arthroscopy that could have been timed with a sundial? Some surgeons are just better suited for life in a hospital.

Another good source is your nurses; they are another set of eyes and often have good, objective opinions about who would work well in your ASC.

Finally, equipment reps are a valuable source of information. Not only do they have the pulse of the community, but they are also the ones whose days are stretched into evenings when the hospital is taking 80 minutes to turn over a room. They feel the frustrations of inefficiency in the OR — and they can tell you who is fast and efficient and who uses a plethora of implants. The reps who have worked in your ASC for any period of time will know the surgeons and often have insights as to where their allegiances lie.

4. Be tenacious about following up
Once you have put together a wish list, it’s time to get these physicians into your center. Phone calls, faxes, letters, dinners and open houses should be last resorts. Instead, have your physician partners contact your candidates directly to help you get a foot in the door: Peer-to-peer interaction carries the most weight, and a personal invitation from a partner is often all it takes. At the very least, it cuts through a lot of the red tape when you visit their offices to follow up. Getting in touch with these busy practitioners is often the hardest part. Once they tour the center, get temporary privileges, and book their first cases, the biggest challenges have been overcome. Of course, following up after their first days is a good idea, and the aforementioned relationship with their surgical scheduler is important. But once the surgeon can see the significant benefits to an ASC, you should be well on your way.

Mr. Merrill ( This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ) is a vice president of business development for Ambulatory Surgical Centers of America. Learn more about ASCOA.