Physicians at the helm: creating a culture of gastroenterologist leadership in ASCs & endoscopy centers
Question: How can GI physicians become involved in endoscopy center and ASC leadership initiatives?
Lawrence R. Kosinski, MD, MBA, AGAF, AGA Institute Practice Councillor, Managing Partner, Illinois Gastroenterology Group (Elgin): Since most ASC governing boards and committees only function through the participation of multiple volunteer members, they represent a golden opportunity for younger physicians to involve themselves in governance/leadership. Committees are usually the first vehicle for young interested physicians who can work their way through the leadership up to governing boards.
James Lee, MD, AGAF, St. Joseph Hospital, Orange, Calif.: There has been increased utilization of ASCs driven by lower cost to the payer and patient preference of ASCs over hospital-based outpatient centers as well as physician preference. Colonoscopies and upper endoscopic procedures account for almost a third of Medicare ASC spending growth between 2000 and 2007. Therefore, gastroenterologists are in the unique position to become the leaders in establishing ASCs.
In order to establish an ASC, a physician has to delve into the business aspect of medicine. This process requires obtaining state licensure, becoming certified by payers groups and earning accreditation. In addition, a physician might want to get a pro forma for his or her practice. For example, on the average an endoscopic ASC has to perform 2,000 procedures [each year] to make ends meet. Depending on the reimbursement rate the number may fluctuate. Next step would be to decide whether to have a partner such as established corporate firm or the local hospital. It would depend on the specific relationship between physician and third party and if that relationship is necessary to get the ASC developed.
Michael Sciarra, DO, Ambulatory Center for Endoscopy (North Bergen, N.J.): Leadership initiatives in any organization are vital, especially when those leadership initiatives result in positive changes that positively impact efficiency, quality and profitability. A leader who also has a vested interest in the center tends to be more dedicated than one who "has no skin in the game" therefore it is beneficial to the center to cultivate and embrace such leadership when it presents itself. As for how can a physician become involved, the leader must lead by example.
Hardeep Singh, MD, St. Joseph Hospital, Orange, Calif.: I think that as the paradigm of medical care is changing, and we have been more focused on controlling costs of the delivery of medical care. There has been a new emphasis on ambulatory surgical centers. Getting involved is not always an easy undertaking because it often takes the GI physicians taking the initiative to form an ASC and partnering with other physicians to make it a viable center. Often it is best to partner with an established company that can help set up the ASC. They can also help strategize based on the area that you are working, about which specialties to include and what types of cases would be best to do in the ASC as opposed to the hospital
Christopher J. Vesy, MD, Texas Digestive Disease Consultants, Dallas Endoscopy Center: The first way physicians are going to get involved is by simply starting an endoscopy center or buying into one. As an owner, participation is necessary for success and getting physicians involved starts with requesting their leadership. It blossoms from there. I do think it's important to have the right leadership in the right place at the right time. For example, if your ASC has a surgical section, you want your surgeons to be involved in purchasing. Pick those people with a cost conscious mindset. Administrators can reach out to get physicians involved, but there is a lot of power in physician leadership reaching out to other physicians.
Q: What can gastroenterologists do to spark engagement in their fellow endoscopy center and ASC physicians?
MS: To spark engagement in a physicians fellow ASC/endoscopy center colleagues one must establish a "one-for-all, all-for-one" mentality. The focus must be about the business relation they share and not interpersonal issues they may share. Pure objectivity is the best one could strive for and anything less just translates to degrees of failure.
LK: The key to physician involvement is to create an environment in which their input is welcomed and valued. If an ASC is governed as a monarchy or an oligarchy, then there is no impetus for more physicians to engage in leadership. Democratic boards, with staggered terms for members, are the best model for building physician involvement. This will gradually elevate the knowledge of the members and create a platform for the better sharing of ideas.
JL: Gastroenterologists can spark engagement in fellow physicians by implementing a few steps. One is to increase control over their practices. In the ASC setting one can schedule procedures more conveniently and it is less likely to have cases delayed compared to the hospital-based outpatient centers due to emergencies. Also by assembling highly skilled staff and equipments specifically designed for a particular physician one can increase the productivity and efficiency of the individual practitioner. This will lead to increased job satisfaction and interest for continued utilization of the ASC.
HS: GI doctors need to partner with other gastroenterologists in the area. In order for an ASC to be viable, you need to generate enough volume of cases and access the right types of cases. That will require GI doctors banding together, sometimes with their competitors, as well as partnering with other specialties.
Q: Are there any specific ways you've been successful in physician engagement?
CV: There are a couple of different ways. I found this to be very successful: show physicians how their active involvement helps the ASC run smoothly. For instance, there is an issue with software. Offer physician exposure to different vendors and ask them what works best. Another example: younger physicians may be used to life in a hospital where they can pick and choose everything. Leadership needs to help them understand what things actually cost and how it affects the surgery center. This involvement fosters cost conscious efficiencies in behavior.
I've also found sparking engagement in younger physicians to be very important, especially when they gripe. In some settings, they may get their way by complaining — but that doesn't work in an ASC. You just create division. Talk to those physicians. Ask: "What would you do to make it better?" Sometimes you get a blank stare. Make them come up with a solution and then put them in charge of implementing it. Give them the power to make change. This is a really big learning tool.
Q: How can gastroenterologists inspire both physician owners and non-owners to actively work towards improved ASC operations?
JL: Gastroenterologists can inspire other physicians by continuing to strive towards improving efficiency and improving the quality of care. One example would be to increase efficiency of the room. A frequent complaint is that the room is not ready soon enough leading to delay of the next procedure. As gastroenterologists we have the expertise to recognize which steps are needed and not needed in the patient care. By improving efficiency gastroenterologists can inspire both physician owners and non-owners to work together to improve ASC operations.
MS: Improved ASC/endoscopy center operations should translate into improved profitability therefore the incentive will be inherent. The key to inspiring other physicians to contribute to improving operations is to make your partners understand the fundamental relationship between quality and profit.
LK: Again, the committee structure of most ASCs is designed to be the forum for the sharing of financial and operational information. Members of operations committees should do their homework, ask intelligent questions and attend meetings in order to maintain engagement.
CV: Ownership is partnership and non-owners need to understand that in order to become an owner, they need to demonstrate partnership skills. When I speak with GI fellows, I tell them that a business partnership is like a life partnership. You need to know how to communicate and work together. Give non-owners responsibility. See how they handle it.
Q: What skills do GI physicians need to succeed as both clinical and business leaders at an endoscopy center or ASC?
LK: There is plenty of educational material available for GI physicians to maintain a high level of business knowledge for their ASC. Becker’s ASC Review provides a steady flow of information that is timely and available online. Specialty GI societies, like the American Gastroenterological Association, American College of Gastroenterology and American Society of Gastrointestinal Endoscopy, are also great sources of information. Some of us have pursued MBAs through the course of our careers; this can be a significant investment of time and effort, but for some of us it has been career changing.
JL: One of the most important skills needed to succeed in ASCs is the decision making skill. Many decisions will have to be made prior to establishing the ASC. One is the specialties involved. Would other specialties benefit from participating in ASC such as orthopedics, ophthalmology, colorectal surgery or pain management? How can you maximize the utilization of the ASC among different specialties with different schedules? How many rooms will be needed and how many staff members would be needed to maximize efficiency of the center without sacrificing the quality of care? What equipment to purchase or lease? Most importantly what criteria are needed to hire staff?
The decision will involve the number of staff, qualification of each staff, compensation and benefits. Personnel will be the largest overhead for the ASC, but also the most important factor in deciding the level of quality provided by the ASC.
MS: Hard work, dedication to improving quality, smart business minded associates and willingness to anticipate market drift. Success also requires sacrifice at times in disproportionate occurrences, but sacrifice should be shared by all members at any given time to avoid resentment amongst partners, which is the death knell to success.
CV: The number one skill is common sense. Close behind is hard work. You need to understand that your actions affect everyone around you and alter the ASC's ability to appropriately and efficiently care for patients.
It is difficult to find people with a clinical and business mindset. Clinical minds are easy to find, business minds are not. Everyone wants to blame this on the fact that physicians aren't trained in business. Most physicians don't have time to gain a sense of business when they are spending 15 years to master the clinical. In a way, a business sense is innate. A lot of those skills are difficult to teach. Not everyone has to be the biggest and brightest clinical AND business leader. So an important part of having business partners is putting trust in their skill sets — whether it's great patient relationships, clinical expertise or business acumen.
HS: I think there has to be a focus on quality of care. If you are doing tremendous volume but patient care is compromised, the center cannot be successful. If quality and outcomes are kept at a high standard, and you can do an adequate volume, the center should remain busy. From a business standpoint, I think partnering with an established ASC company can really increase your opportunities for success. There are a few companies that have a proven track record in this arena. They know how to analyze your specific geography, they can help analyze who are the best and most efficient physicians in the area to partner with, and they can also offset some of the risk, as they will usually take on some of the financial risk of setting up an ASC.
Q: What are a few best strategies physician-driven endoscopy center success?
CV: You must always have a good administrator at your center. Even if you are there all day, you are primarily involved in the clinical work of the ASC during daytime hours. Without good administration, your employees will not come together to run a successful center.
Get involved outside of your center. State and national ASC associations are a great way to make contacts — and contacts will promote different and better ideas — and build relationships with people doing similar things. Local, state and national PACs or organizations like the American Society for Gastrointestinal Endoscopy, American Gastroenterological Association and American College of Gastroenterology are very meaningful and involvement in their activities is an advantage to your business.
LK: Involve your members in the leadership process. Don't allow the governance to be dominated by only a few. We are all very intelligent and educated physicians and most have useful ideas to share; we need a platform in which to do this.
JL: Strategies for ASC to succeed have to be based on the reasons why there has been steady increase of ASC utilization. The number of Medicare approved ASCs grew at an annual rate of 7.3 percent from 2000 to 2007 with Medicare payments to ASCs growing at 11.4 percent during the same period. One of the most important reasons for this is patient satisfaction, which is more than 92 percent.
ASCs offer more convenient locations, shorter waiting times, convenient scheduling and lower co-pays. Also due to high volume of the specific procedures, there is increased quality with less complication. The nature of procedures favored by ASCs includes the most up-to-date and minimally invasive procedures that will benefit the patients. All of these factors must be included in the strategy of establishing an ASC.
HS: The best strategy is to partner with an ASC company. Another option is to engage a local hospital, to see if they may be interested in creating a partnership with the doctors, to help establish an ASC. That model has also been successful around the country as it keeps the hospitals involved so that they are not in competition with their doctors.
Q: Why is GI physician leadership important in the endoscopy center setting?
LK: Leadership is not a skill shared by all. It requires passion, education and drive. If a center has a recognized leader, they should provide that physician the environment in which he/she can thrive. The leader may need some protected time and even some supplemental salary to facilitate their growth. In the end, this is what is good for the group and for the ASC. Don't be penny wise and dollar foolish.
JL: GI physician leadership is important in ASC setting for the opportunity for the growth of the center. Endoscopic procedures, colonoscopy and upper endoscopic procedures, were the largest drivers of the ASC growth accounting for 32 percent of the total charges in Medicare payments between 2000 and 2007. Colonoscopy has been firmly established as the preferred modality of colon cancer prevention.
As our population becomes more obese there has been a seven-fold increase in the incidence of esophageal cancer over the last few decades. This may lead to increase demand for upper endoscopic procedures in detection and treatment of esophageal cancers. As gastroenterologists we are in a unique position to contribute in providing the most efficient care at a lower cost to the society.
MS: Physician-driven strategies are vital to improvement in ASC/endoscopy centers because it is the physicians who are practicing everyday and have different perspectives on the industry than non-physician colleagues.
HS: GI cases tend to be very high volume and therefore it's important to have some of the GI doctors involved in the establishment of the center if possible.
CV: The special thing about an ASC is the physician leadership and ownership. Employees are going to be really focused on pleasing the physician and that attention to their bosses' needs means better care for their bosses' patients. When there is no physician leadership or ownership, I don't think you get that special touch.
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