10 Reasons Physicians Take Cases Out of Surgery Centers

Blayne Rush, MHP, MBA, president of Ambulatory Alliances, and Stuart Katz, MBA, FACHE, director of TMC Orthopaedic Outpatient Surgery in Tucson, Ariz., discuss 10 reasons physicians take ASC-eligible cases to other facilities.

1. Preferences for equipment or instruments not available at the surgery center. Mr. Rush says physicians may decide to take cases elsewhere because the surgery center does not stock the supplies or equipment they need. This may be a budgetary issue, but in all likelihood, it comes down to failed communication between your staff and the physician's office. "You have to have a relationship with everyone in the doctor's office — the practice manager, the scheduler, the doctor himself," he says. "If you have a relationship with all those people, you'll get to the heart of the issues." Talk regularly with your physicians' office staff and ask about supplies that are no longer used or any requests that have not been met.

2. Patients are inappropriate for surgery at the ASC.
Mr. Katz says sometimes cases go elsewhere simply because the surgery center can't perform them safely. "The biggest reason that physicians take patients out of surgery centers is the presence of co-morbidities," he says. Before every procedure is scheduled, his surgery center performs pre-anesthesia testing on the patient and scores them on an ASA scale of 1-4. "Anybody with more than ASA III doesn't come," he says.

He adds that patients also go to the hospital if they have had problems with anesthesia in the past. This is one issue that surgery center leaders can't do much about; just make sure the physician and ASC are on the same page about which patients are appropriate for ASC surgery and which aren't.

2. Investments in another facility or a treatment suite at their office.
Mr. Rush says it is becoming more common for physicians — especially pain and OB/GYN physicians — to house surgery and procedure suites in their offices. "They'll set up that procedure room in their office and then take what they can't do in their office to the ASC," he says.

He says he also sees physicians with investments or affiliations with multiple surgery centers and hospitals, meaning cases are divided among several facilities. "Sometimes the physician will have investment in an out-of-network center and an in-network center, and they'll bring any patients with out-of-network benefits to the out-of-network center and will bring Medicare and other lower-reimbursed insurance plans to the other ASC," he says. Mr. Rush says scheduling difficulties can easily drive a physician to another surgery center, so surgery center staffers must make sure that scheduling is easy.

3. Hospital politics and pressures. Mr. Rush says some physician offices are located on hospital campuses, meaning there's a hospital representative in their office multiple times a week. "The hospital rep will go and influence where the patients are referred, and sometimes it's the squeaky wheel that gets the grease," he says. He says while an ASC may not be able to compete in terms of proximity, ASC leaders can do their best to make the ASC an efficient, comfortable place to work. "Create positive pressure rather than negative pressure," Mr. Rush says. "Make sure they want to leave the hospital and drive down the street to your center because they're wanted there, the staff is happy and it's efficient in a way the hospital can't necessarily imitate," he says.

4. Cases that require after-hours treatment.
Most surgery centers are only open during normal business hours, meaning a midnight fracture will probably need to be treated at the local hospital or emergency care center. "If it's after hours on a weekend, the physician will probably take care of the problem at the hospital," he says. He says in some instances, a case can be delayed until Monday or Tuesday, but the priority here should be the safety and comfort of the patient.

5. Confusion about third party payor contracts. If a center is out-of-network, physicians may be hesitant to bring their cases to the center because of payor pressure. "Some insurance carriers have sent out letters to physicians and essentially made a soft threat that if they take a patient to an out-of-network facility, they're in technical violation of their agreement with the insurance company," Mr. Rush says. He adds that physicians may simply be confused about which patients can be treated at the center based on their insurance contracts.

If a patient comes to the surgery center and later receives an unexpected bill, he or she is likely to complain to the physician who performed the surgery. "If one irate patient comes to the physician's office about billing, then the physician starts getting upset," Mr. Rush says. Make sure to communicate clearly with the physician's office about which types of insurance the surgery center accepts, and communicate with patients about their predicted financial responsibility prior to the procedure.

6. Scheduling/block time non-compliance. Use of block time can cause conflicts among physicians, all of whom want their cases to start and end on time. Mr. Rush says sometimes one physician will start his cases late and bump into another surgeon's block time, effectively squeezing the latter surgeon's block time because he still has to finish to make room for the next provider. He says he has also seen surgery centers that split a block down the middle because two physicians wanted the time and could not agree. "That didn't solve the problem," he says. "You had two upset people because they tried to split the baby instead of accommodating both of them and creating an incentive for one of them to change block times."

7. Lack of adherence to start times. There are various reasons surgery can be delayed in the morning, including a late arrival from the physician or a late start by anesthesia. If the physician has to wait for other staff members to be ready to start his case, he will likely be annoyed and consider taking his cases elsewhere. Mr. Rush says the key is to isolate each problem causing late starts and deal with them individually, rather than just resolving to "start on time." "Only one issue is not a big issue, but when you add them all together, you often don't get the surgery started until 8:30 a.m.," he says."

8. Lack of familiarity or comfort with ASC staff.
It's simple: If a physician doesn't know or respect the surgery center staff, he is less likely to bring cases to the center. Try to match the same staff members with each physician on a regular basis to improve efficiency and physician satisfaction. An operating room where everyone knows each other will move faster than an OR full of strangers. In addition, physicians like to be comfortable with their staff and don't want to constantly work with new people who don't understand their preferences.

9. Lack of transparency — both financially and with executive decisions. If a center plays favorites with physician investors and discloses information to particular partners, other physicians are likely to be annoyed. "If you have a group of partners within a surgery center and one partner controls most of the center's stock, often the center will accommodate that physician in a certain way that no one else receives," Mr. Rush says.

Mr. Rush says all physicians should be invited to be involved in surgery center operations — a move that benefits the surgery center too, since dedicated physicians usually mean better outcomes and higher profits. Every significant decision at the surgery center should be run by the physician-investors, and no physician should be treated differently because of the amount of stock he owns in the center.

10. Lack of partner enthusiasm and partner frustration.
When partners initially join a surgery center, they will probably be excited to bring cases and get involved with surgery center projects, Mr. Rush says. Over time, however, they may notice that another partner who brings more cases to the center receives preferential treatment. He recommends treating every partner, even younger ones, with the same amount of respect, keeping in mind what the physician could do for the surgery center in the future. "The person who's doing 20 cases a month now could be doing 50 cases a month in five years," Mr. Rush says. "You need to look at them and see where they're going," he says.

He says that a lack of enthusiasm from physicians can be the death knell of a center, since someone else is almost certainly recruiting your physicians to another facility. Make sure to keep your partners excited about the opportunities at your center, even after they've been with you for a number of years.  

Related Articles on Surgery Center Cases:
20 New Statistics on Surgery Center Staffing Costs
4 Steps to Reduce Orthopedic ASC Supply Costs From ASC Administrator Stuart Katz
Orthopedic Surgery, Neurosurgery Drive High Out-of-Network Bills in New York

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