With anesthesiology reimbursements continuing to fall, anesthesiologists need to continuously find ways to grow to remain profitable. “When I came out of training in 1987, I did 700 cases a year and now I do 1,200-1,400 cases a year,” Dr. Konowitz says. “For that to happen, I’ve had to continually change the way I am doing things.”
Here are some ways Midwest Anesthesiologists has kept flexible and helped ensure the practice remained competitive.
1. Designate one partner as decision-maker. “As the managing partner of my group, I can make decisions fast, without having to take a vote,” Dr. Konowitz says. Flexibility is essential in such matters as negotiating contracts and signing up another practice site. When everyone has a vote, a practice tends to have an extremely hard time making any kind of management decision.
2. Directly manage the practice. Since physicians in the group take an active role in administration, they do not employ a practice administrator. “If you hire this function out, you won’t be able to follow cash flow on a daily basis,” Dr. Konowitz says. He personally runs the financial side, using Intuit QuickBooks software for a snapshot of practice finances at any moment. The group does, however, use an outside billing service and accountants that can handle all anesthesia venues, from hospital- to office-based practices, which most billing services cannot do.
3. Keep coming up with new ideas. Read everything from the clinical journals to the Wall Street Journal, Dr. Konowitz suggests. Go to national meetings and local events and just listen. Meet up with colleagues from other anesthesiology practices to get an idea how they are navigating the same problems you’re dealing with.
4. Diversify your business. Get the practice involved in a variety of venues, such as the hospital, ASCs, office-based practices and pain management. Midwest Anesthesiologists maintains a presence in all of these places, allowing it to survive shifts in reimbursements, regulations and other market conditions, Dr. Konowitz says.
5. Keep at the right size. “A large practice tends to maneuver like the Titanic, but when you have seven partners, as we do, you can get around like a small boat,” Dr. Konowitz says. On the other hand, groups that have just two or three partners don’t have enough resources to be in several different sites, obtain affordable malpractice insurance and try out other flexible options.
6. Always look for new sites. As the decision-maker for the practice, “I have to be out there finding the opportunities,” Dr. Konowitz says. Making speeches to the medical community is a good way to do this. He has made a lot of business connections when giving lectures on pain management techniques and workman’s comp.
7. Ride the circuit. Abraham Lincoln rode the Illinois county courthouse circuit as an attorney. Today, Midwest Anesthesiologists does the same thing in the Chicago suburbs, traveling between scattered sites to pick up more work. The partners limit travel to one hour each way to stay productive, but they are able to serve a wide swath of the Chicago area because they have three offices and can start the day from their homes in far-flung communities.
8. Develop a pain management practice. Dr. Konowitz and two other partners are boarded in pain management. They move between three pain offices. Only one site is open at a time, manned by a nurse practitioner who can order medications and MRIs but cannot provide injections. As part of the practice’s doctrine of diversifying, none of the three partners does pain full time. For example, pain management takes up about 40-60 percent of Dr. Konowitz’ time.
9. Hold on to hospital-based surgery. Though payments tend to be low, hospital surgery can deliver high volume and help pay fixed costs. Midwest Anesthesiologists’ base hospital, 250-bed Gottlieb Memorial in Melrose Park, was steadily losing surgery volume, forcing the group to find more work elsewhere. Gottlieb was at that time a self-standing hospital without much clout. But when it was acquired by Loyola University Medical Center in 2008, it gained access to more favorable malpractice coverage and some orthopedic patients from Loyola and its anesthesiology volume jumped. “We believe the pendulum will swing back to hospitals, in terms of better reimbursement than other sites,” Dr. Konowitz says.
10. Maintain a foothold in office-based anesthesia. Office-based opportunities in Illinois lost their luster in the past few years, as insurers stopped paying facility fees or covering supplies at surgery and procedure sites. With volume falling, Midwest Anesthesiologists has ended relationships with two such sites in recent years. Still, office-based anesthesia can be good “fill work” for anesthesiologists who have no other assignments at the moment. Partners currently work as anesthesiologists at five office-based sites, three of which are the practices own pain management sites.
11. Hold on to ASC-based anesthesia. Although the group recently bailed out of one ASC, it still works in two others and has seen higher volumes at one of them. The group is also involved in a dormant ASC that may be sold soon and regain its volume. Particular about which arrangements it will accept, Midwest Anesthesiologists recently stayed out of an attempt to revive another ASC in the area. Meanwhile, the practice’s doctrine of moving members from site to site does not apply to ASC assignments: one partner is assigned to one ASC to assure consistency.
12. Stay flexible with personnel. With so much going on at so many sites, it’s important to maintain flexibility in personnel and the amount of work each staff member performs. For example, one anesthesiologist in the group is a permanent night person who can also fill in during the day. She is a grandmother who wants to spend the day with her grandkids. This ability to run a flexible schedule helped the group land a contract with a fertility clinic that could only provide 72-hour notice for work.
13. Use nurse-anesthetists. “If you’re still in the mindset of ‘we can only do this with MDs,’ you can’t have a viable practice at the average site,” Dr. Konowitz says. “Sure, there are still some wealthy areas where you still get paid enough to do that, but the way reimbursements are going, that may change.” The group uses an anesthesia care team model for its 14 full- and part-time nurse anesthetists. Even though the practice is spread out, at least one anesthesiologist works with anesthetists at most sites. Senior nurse-anesthetists, however, practice at some non-hospital sites without physician supervision.
14. Use part-timers. The practice has been recruiting young anesthetists who become part-time when they start having children. Dr. Konowitz welcomes this. “With part-timers, we can flex extra staff on days when the need arises,” he says. Knowing when to bring in part-timers, however, means knowing the right number of workers needed, which involves maintaining a reliable schedule.
15. Be serious about the schedule. Fielding part-timers and orchestrating workers at many distant sites requires being on top of the schedule at all times. One partner keeps a close eye on scheduling, regularly sending e-mail updates to others. The schedule is set about two weeks in advance, but changes are needed when the day arrives. A surgeon might arrive late or the case could be delayed, which requires last minute changes. BlackBerrys have been issued to all staff who travel from site to site. When their schedules change, they send e-mail, instant messaging or phone calls to update everyone else.
Contact Dr. Konowitz at howardkonowitz@comcast.net.
