10 Ways to Improve Your Hospital's Orthopedic Program 24 Hospital ...

As acute care hospitals face growing com-petition, protecting their orthopedic surgery departments becomes increasing-

ly valuable. Not-for-profit acute care hospitalsdepend on that revenue to subsidize money-losing services and attract new patients.Reimbursements from public and private insurersfor orthopedic surgery remain high.

“If an orthopedics program isnot profitable, there areunderlying problems withoperations, cost containmentor other financials,” saysHarry Herkowitz, MD, chair-man of orthopedic surgery forWilliam Beaumont Hospitalsin Royal Oaks, Mich. “It’sunusual for an orthopedicsdepartment not to be prof-itable. It should be one of the most profitable service lines.”

The Hospital Review queried nine respected hospital

orthopedics professionals whose hospitals have garnered national and international fame for the qual-ity and success of their orthopedics programs. Here’stheir advice for improving the quality, patient satisfac-tion and profitability of hospital orthopedic programs.

1. Involve physicians.“Don’t just pay lip service. Real, meaningful physi-cian engagement is vital and should focus aroundstaffing, clinical patient, financial, operational andother issues,” advised Anna Silva, vice president forancillary services with 530-bed Our Lady of theLake Regional Medical Center in Baton Rouge, La.Their program controls a 45 percent market shareand ranks above the 90th percentile in patient satis-faction. “Our philosophy has been to try to buildthe best program in the state and invite them tobuild it with us. We make suggestions, but ultimate-ly the physicians assume the lead.”

Kellie Risser of Risser Consulting of Columbus,Ohio, and former CFO for the New Albany SurgicalHospital in New Albany, Ohio, says physicianinvolvement makes a much richer hospital orthope-

dics program and offers astronger patient continuumof care, from the physicianoffice through the hospitalstay and into physical thera-py and rehabilitation.

“The more involved thephysicians are in the wholecare and management of theprogram, the more success-ful it will be,” Ms. Rissersays. “It also sends a consis-tent message to patients.When doctors are engagedthey become aware of hospital costs and can helphospitals reduce unnecessarycosts.”

Fall 2008Vol. 2008 No. 1

10 Ways to ImproveYour Hospital’sOrthopedic ProgramBy Mark Taylor

INSIDE

2 Letter from the Editor

11 Hospital Physician Specialists: To Hire or Not to Hire

11 Minimal to Maximum Integration Models

12 Recapturing and Growing Your GI Business

13 Hospital Leader Shares Insight on Current State of Hospitals and Healthcare

15 Four Founding Sponsors of The Hospital Review

24 HospitalLeadersto KnowBy Scott Becker and Rob Kurtz

1. Jack Bovender Jr. — Jack Bovender Jr. isthe chairman and CEO of Hospital Corporation ofAmerica (HCA). He assumed this role in January2002. Prior to this position, Jack served as HCA’sexecutive vice president and COO for about tenyears, and was division president of HCA’s Atlantadivision and president of HCA’s Eastern GroupOperations. Prior to joining HCA, Jack served as alieutenant in the United States Navy, and as CEO ofMedical Center Hospital in Largo, Fla., and WestFlorida Regional Medical Center in Pensacola, bothowned at the time by HCA.

2. Irene Cumming — Irene Cumming hasserved as the president and CEO of UniversityHealthSystem Consortium (UHC) in Oak Brook,Ill., an alliance of 101 academic medical centers and178 of their affiliated hospitals representing approx-imately 90 percent of the nation’s non-profit aca-demic medical centers, for more than 12 years. She

continued on page 8

continued on page 5

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Letter from the Editor

Five Evolving Trends for Health Systems; Uwe Reinhardt to Keynote 15th Annual AmbulatorySurgery Center Conference

There are several interesting trends evolving in the healthcare and hospitalsystem area. These include the following issues:

1. Evolving towards employee models. We are seeing a substantial increasein systems establishing part time and full time employment models withphysicians. This is focused as much towards specialists as it is towardsinternists and primary care physicians.

2. Growing divide between the haves and have nots. In the hospital area,it is becoming clear that 20 percent to 25 percent of the nation’s hospitalsare thriving tremendously. At the same time, there is a great balance of hospitals that are struggling significantly. It continues to be a great split anddivide amongst hospitals.

3. Joint ventures can help, but not a panacea. Over the last five years, the strate-gy of joint venturing with physicians has remained a solid method for developingalliances with physicians. At the same time, many hospitals are finding that it isnot a strategy that fits all problems and all issues. This, in part, explains the move-ment towards employment models. In essence, systems find that they can use jointventures to solve a part of their physician and capital problems but find that it isalso necessary to engage and focus efforts around employment and other models.

4. Exponential uncrease in electronic health records and information systemsintegration. Over the past 12 to 18 months, we have witnessed tremendousgrowth in the implementation of models between physicians and hospitals relating to integration of medical records. We expect this to continue for the next24 to 36 months. Our next issue will include a significant article on nine thingsyou should know about the Stark Act rules related to electronic health recordsdonations to physician practices.

5. Recovery audit contractors are here to stay. Recovery audit contractorscontinue to demonstrate significant results in returning funds to theMedicare/Medicaid programs. Notwithstanding their lack of popularity,we expect this to continue as a strategy to help recover costs in the health-care sector.

The last quarter of the year should be a very exciting one. The election results,together with continued pressure on healthcare costs, should make the next several months and next year an interesting one in the healthcare sector.

For more information and updates on the hospital sector, please visit www.hospitalreviewmagazine.com.

Uwe Reinhardt to Keynote 15th Annual ASC Conference.For those interested in ambulatory surgery centers, we have the 15th AnnualAmbulatory Surgery Center Conference scheduled for October 23rd to 25th

at the Sheraton Hotel and Towers in Chicago. There, we will have Uwe Reinhardt giving the keynote address. We also have a great list of topicsand issues up for discussion.

Here are some of the sample topics that are being discussed at that meet-ing. Overall, there will be more than 75 presentations. We expect an out-standing turnout.

• Successful Structuring of Physician-Hospital ASC Joint Ventures — Joe Zasa, CEO, Woodrum ASD; Deanne Manchester, USPI; Amber Walsh, and Elissa Moore, McGuireWoods

• Orthopedics in ASCs: What Can You Expect in the Next Five Years — John Cherf, MD, Dept. of Orthopedics, The Neurological & Orthopedic Hospital of Chicago

• The State of the Union for ASCs — Kathy Bryant, President, ASC Association

• Can Two Centers Thrive by Merging? — Tom Yerden, CEO and Founder, TRY Health Care Solutions

• Gastroenterology, ENT, Ophthalmology, Pain Management and Bariatrics in ASC: What Works and What Doesn’t — Anne Roberts,


Engaging physicians also requires involving them in quality initiatives. “Oncedoctors see comparative utilization and peer-to-peer data, they respond,”observes Steve Thomas of the Indianapolis-based consulting firm HealthEvolutions. “There’s almost always an opportunity for improvement whenboth sides are interested, committed and truly engaged.”

Victor DiPilla, vice president of operations for The Christ Hospital inCincinnati, says his hospital needed to rebuild its orthopedics program sever-al years ago after losing a large orthopedics group over disputes on standardi-zation of implants and other devices and on-call coverage. By engaging thephysicians who remained, The Christ Hospital was able to reduce its patientlength of stay, cut costs and improve patient satisfaction through several physi-cian-initiated programs and purchases.

And that has grown the program as well. By implementing pre-operativescreening procedures, it has seen a 60 percent reduction in surgical site infections, and by launching a pain block program, The ChristHospital has decreased patient nausea, allowing patients to complete theirphysical therapy and rehabilitation on schedule. It has also improvedpatient satisfaction and allowed next-day discharges for many joint procedures, he says.

2. Create a dedicated orthopedics wing or building.“The physician-owned hospital debate has infused a degree of competi-tion into the marketplace,” says John Martin, CEO of Indiana’s largestorthopedics practice, 70-physician OrthoIndy. Mr. Martin also oversees the 37-bed Indiana Orthopaedic Hospital, ranked that state’s top orthopedics hospital.

“There are some real advantages to segmenting services, advantages in improving patient care and growing the bottom line,” Mr. Martin says.“When orthopedic patients come into a hospital and go to an area focused onorthopedic care, whether it’s a for-profit, physician-owned hospital or a not-for-profit acute care hospital, they know that they’re at the center of care.It really differentiates the very successful orthopedics programs from the not-so-successful programs.”

While the Indiana Orthopaedic Hospital only has a small number of theHoosier state capital’s hospital beds, it controls between 25 percent and 30percent of its orthopedics market.

“We’ve driven the marketplace in orthopedics,” says Mr. Martin. “A dedicat-ed, focused orthopedics facility offers patients a different kind of experience.”

For Mr. Martin, that translates not only to patient satisfaction, but increasedphysician approval as well.

“Doctors can come see patients in clinics, perform surgery and walk throughthe hospital to make rounds and place orders. They don’t waste that two-to-three hours in daily driving, parking and walking between sites. They can bemore efficient.”

Mr. Martin says streamlining management is another tool that has helped hishospital.

“We can solve problems and address physician concerns easier because therearen’t the layers of bureaucracy that slow down decision-making,” heexplained. “We can do in three or four weeks what takes most acute care hospitals a year to do. The bureaucracy is often what frustrates physicians andleads to disconnect.”

3. Focus on quality and profits will follow. John Reynolds, a consultant for Century City Doctors Hospital in LosAngeles and the former CEO for New York City’s Hospital for Special Surgery(HSS), says hospitals should follow the lead of Japanese carmakers whosefocus on quality improvement processes helped them to dominate the automobile industry.

10 Ways to Improve Your Hospital’s Orthopedic Program (continued from pg. 1)

ResourcesAnesthesia staffing and practice managementSomnia. Somnia is a physician-owned and managed leading provider of anesthesia services to hospitals, ASCs, and office-based surgical facilities nationwide. Visit Somnia at www.somniaanesthesiaservices.com or call (877) 476-6642, ext. 3538.

Superior Medical Services. Superior Medical Services is a full-service medical recruitmentfirm specializing in permanent and locum tenens placement of anesthesiologists, CRNAs and painmanagement physicians nationwide. Visit SMS at www.smsanesthesia.com or call (847) 816-9296

Back-office management, outsourcing and accountingMedHQ. MedHQ provides accounting, revenue cycle, human resources and credentialing services to clients in 10 states. Learn more at www.medhq.net or call (708) 492-0519.

Debt collectionsAffiliated Credit Services. Affiliated Credit Services is a Colorado-based professionalaccount receivables management firm which focuses on increasing businesses cash flow by pro-viding superior collection services. Learn more at www.acscollects.com or call (970) 867-8521.

Management, development and equity firmsPhysicians Endoscopy. Physicians Endoscopy develops and manages endoscopic ASCsin partnership with practicing GI physicians and hospitals. Visit the company on the Web atwww.endocenters.com, e-mail John Poisson at [email protected] or call him at (215) 589-9003.

Prexus Health. Prexus Health is a 100 percent physician-owned company that specializesin the development and management of multi-specialty, physician-owned ASCs and small hospitals. For more information, call (513) 454-1414, e-mail Prexus at [email protected] orvisit www.prexushealth.com.

ValuationHealthCare Appraisers. HealthCare Appraisers is a nationally recognized valuation andconsulting firm providing services exclusively to the healthcare industry. Visit HealthcareAppraisers’ Web site at www.healthcareappraisers.com or call the Delray Beach, Fla., office at(561) 330-3488 or the Denver, Colo., office at (303) 688-0700 to learn more.

Principle Valuation. Principle Valuation specializes in the valuation of all types of healthcare real estate including hospi-tals, independent-living communities,assisted living residences, skilled-nurs-ing facilities, continuing-care retire-ment communities, medical officebuildings, ASCs, pharmacies and rehabilitation facilities. To learn more,visit www.principlevaluation.com orcall (312) 422-1010.

VMG Health. VMG Health is rec-ognized by leading healthcareproviders as one of the most trustedvaluation and transaction advisors in the United States. For more information, visit VMG’s Web site at www.vmghealth.com, e-mail JonO’Sullivan at [email protected] or call (214) 369-4888.

Surgery Center of Reno; Steve Blom, San Antonio Surgery Center; John Poisson, Executive VP, Physicians Endoscopy; Dr. Douglas Hoisington

• Practical Case-Costing and Benchmarking for ASCs — Alsie Sydness-Fitzgerald• The Future of ASCs — Dr. Mark Koch, Somnia, Inc.; Tom Mallon, CEO and

Founder, Regent Surgical Health; Tony Taparo, Symbion, Inc.• Assessing the Profitability of Different Specialties in ASCs — Luke Lambert,

CEO, ASCOA• From ASC to Hospital: What are the Pros and Cons of a Conversion to a

Hospital? — Brett Gosney, CEO, Animas Surgical Hospital• Will the Stark Laws Close Down ASCs? — Amber Walsh and Melissa Szabad,

McGuireWoods• Safe Harbor, OIG Work Plan and Out-of-Network Issues — Scott Becker and

Scott Downing, McGuireWoods

Should you have any questions related to any of these issues, please contact me at(312) 750-6016 or at [email protected]; or contact The Hospital Review, Becker Healthcare Communications, at (800) 417-2035.

Very truly yours,

Scott Becker

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THAnnual ASC Conference & Exhibits

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CONFERENCE SPEAKERS TARGET AUDIENCEThis conference is designed to provide ASC physician owners and leaders,ASCadministrators,business-focused directors of nursing,surgeons,and all physicians involved in a single- or multi-specialty ASC the latest informationon business,legal and regulatory issues,and improving the profitability of andestablishing ASCs.

CONTINUINGEDUCATION CREDITS

CONTINUING MEDICAL EDUCATIONThis CME activity has been planned and implemented in accordance with theEssential Areas and Policies of the Accreditation Council for Continuing MedicalEducation (ACCME) through the Joint Sponsorship of the Institute for MedicalStudies (IMS) and ASC Communications,Inc.

IMS is accredited by the ACCME to provide continuing medical education forphysicians.

IMS designates this educational activity for a maximum of 13.5 AMA PRA Category1 Credits.

™Physicians should only claim credit commensurate with the extent of

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CASC CREDITThis program is approved for 13.5 hours of AEU credit by BASC Provider #3272.

CEUCREDITProvider approved by the California Board of Registered Nursing,Provider NumberCEP6949,for 13.3 contact hours.

For more information, call (800) 417-2035

or email [email protected] If you would like to sponsor or exhibit at the

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Ambulatory Surgery CentersImproving Profitability and Business and Legal Issues

T H E 1 5 t h A N N U A L C O N F E R E N C E F R O M A S C C O M M U N I C AT I O N S A N D T H E A M B U L AT O RY S U R G E RY F O U N D AT I O N

OCTOBER 23 – 25, 2008

S H E R A T O N H O T E L A N D T O W E R S • C H I C A G O , I L L I N O I S

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To register, contact the Ambulatory Surgery Foundation

(703) 836-5904 • Fax (703) [email protected]

Register Online:

https://www.ascassociation.org/chicagoOct2008.cfm

SAMPLE TOPICS INCLUDE:• Gastroenterology, ENT, Opthalmology, Pain Management and

Bariatrics in ASC — What Works and What Doesn’t• Successful Structuring of Physician-Hospital ASC Joint Ventures• Orthopedics in ASCs — What Can You Expect the Next Five Years• How to Reduce Staffing Hours Per Case• The State of the Union for ASCs• Spine and Bariatrics in ASCs• Making Urology a Success in Your ASC• How to Turn Around Your ASC• Can Two Centers Thrive by Merging?• Practical Case-Costing and Benchmarking for ASCs• The Future of ASCs• Assessing the Profitability of Different Specialties in ASCS • Orthopedics, Gynecology and Opthalmology in ASCs• Will the Stark Laws Close Down ASCs?• 10 Key Statistics You Should Review Each Week• How to Recruit and Retain Great Directors of Nursing and

Great Nursing Staff• Developing Strategies for Managed-Care Contracting• Key Practical Tips to Improving an ASC’s Coding Efforts• Safe Harbor, OIG Work Plan and Out-of-Network Issues• Key Steps to Establishing ASCs• Core Strategies to Succeed with Orthopedics and

Neurosurgery in ASCs

CONTINUING EDUCATION CREDITSCONTINUING MEDICAL EDUCATIONThis CME activity has been planned and implemented in accordancewith the Essential Areas and Policies of the Accreditation Council forContinuing Medical Education (ACCME) through the JointSponsorship of the Institute for Medical Studies (IMS) and ASCCommunications, Inc.

IMS is accredited by the ACCME to provide continuing medicaleducation for physicians.

IMS designates this educational activity for a maximum of 13.5 AMAPRA Category 1 Credits™. Physicians should only claim creditcommensurate with the extent of their participation in the activity.

CASC CREDITThis program is approved for 13.5 hours of AEU credit by BASCProvider #3272.

CEU CREDITProvider approved by the California Board of Registered Nursing,Provider Number CEP6949, for 13.3 contact hours.

For a full list of the speakers and theagenda visit www.BeckersASC.com.Sign up for the Becker’s ASC Review E-Weekly at www.BeckersASC.com.

AmbulatorySurgery Centers

Improving Profitability and Business and Legal Issues

THE 15thANNUAL CONFERENCEFROM ASC COMMUNICATIONS AND THEAMBULATORY SURGERY FOUNDATION

OCTOBER 23– 25, 2008

SHERATON HOTEL AND TOWERS •CHICAGO, ILLINOIS

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For more information, call (800) 417-2035

or email [email protected] you would like to sponsor or exhibit at the

program, please call (800) 417-2035.

Ambulatory Surgery CentersImproving Profitability and Business and Legal Issues

THE 15thANNUAL CONFERENCE FROM ASC COMMUNICATIONS AND THE AMBULATORY SURGERY FOUNDATION

OCTOBER 23– 25, 2008

SHERATON HOTEL AND TOWERS •CHICAGO, ILLINOIS

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TO REGISTER, CALL (703) 836-5904

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Bring a Group From Your Center and SAVE!

To register, contact the Ambulatory Surgery Foundation

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REGISTER BY SEPTEMBER 10, 2008, AND SAVE!

15 Great ReasonsT O AT T E N D T H E 1 5 t h A N N U A L A S C C O M M U N I C AT I O N S

A N D A M B U L AT O R Y S U R G E R Y F O U N D AT I O N FA L L C O N F E R E N C E

* * *1 Obtain practical guidance

you can apply to your ASC immediately.

2 Hear and think about big strategic ideas for your ASC.

3 Plan the future of your ASC.

4 Gain new insight on how to add cases and physicians to your ASC.

5 Hear great insight on many different specialties: orthopedics, bariatrics,

neurosurgery, general surgery,urology, ENT, ophthalmology and gynecology.

6 Hear how to improve case-costing and benchmarking.

7 Consider strategic options such as selling, merging or joint-venturing.

8 Learn new means to reduce costs, including implant and device costs.

9 Discuss great ideas with great colleagues from around the country.

10 Enjoy Chicago, Michigan Avenue and have fun.

11 Learn about new CMS rules on reimbursement.

12 Hear about the future of legislation and about ASCs.

13 Improve your coding and improve reimbursement.

14 Improve your managed care contracts.

15 Understand the value of your ASC.

Sami Abassi, CEONational Surgical CareKen Austin, MDRamapo Valley Surgical CenterLisa Austin, RN, CASC, VP of ASC ClinicalOperationsPinnacle IIIMark Beaugard, MD, andGeorge Trajtenberg, MDTurks Head Surgery CenterScott Becker and Scott DowningMcGuireWoodsChris Bishop, VP of Business DevelopmentAmbulatory Surgical Centers of AmericaSteve Blom, Executive DirectorSpecialty Surgery Center in San Antonio, NSCTom Bombardier, MD, ChairmanASCOAKathy Bryant, PresidentASC Association

Steve Burton, CEOION Healthcare

Jamie Carr, RN, PresidentCarr & AssociatesRobert Cates, National Director of ManagedCareNational Surgical CareRobert Carrera, PresidentPinnacle IIIJohn Caruso, MD, Neurosurgeon and President,Parkway Spine Surgery CenterJohn Cherf, MD, Dept. of OrthopedicsNeurological & Orthopedic Hospital of ChicagoDon Cook, President and CEOPacific Surgical Partners Lisa Cooper, AdministratorEl Camino Surgery CenterJohn Dipaola, MDEast Portland Surgery CenterSteve Dobias, CPA, PrincipalSomerset CPAsScott Downing, JDMcGuireWoodsStephanie Ellis, RN, CPC, PresidentEllis Medical ConsultingBrien Fausone, AdministratorMichigan Endoscopy CenterBoyd Faust, CPA, Chief Financial OfficerTitan Healthcare

Robyn Finnegan, VP of Managed CarePrexus Health Partners Jeff Fox, VP, Hospitals, Surgery and DialysisMarCapTom Galouzis, MD, PresidentLake Park SurgicareNap Gary, President Eastern RegionRegent Surgical HealthGeorge Goodwin, SVP and CDOSymbionBrett Gosney, CEOAnimas Surgical Hospital Mike Griffin, CFO, and Mary Ann Gellenbeck,RN, COOPrexus Health Partners Kenny Hancock, President and CDOMeridian Surgical PartnersEd Hetrick, PresidentFacility Development and ManagementDoug Hoisington, DO

Steve Holst, MD and Scott Bateman, MD,FoundersSheridan Surgical CenterScott Jackson, VP, Surgery Center DivisionMcKesson SurgicalTom Jacobs, President and CEOMedHQDon Jansen, VP of Marketing and DevelopmentPrexus HealthMarion Jenkins, PhD, CEOQSE TechnologiesNaya Kehayes, MPH, CEOEveia Health Consulting and ManagementBill Kennedy, SVP Business DevelopmentNovaMedMatt Kilton, COOEveia Health Consulting and ManagementMarc Koch, MD, President and CEOSomniaRick Kolsky, Professor of MarketingKellogg School of BusinessGreg Koonsman, CFA, FounderVMG HealthDonald Kramer, MD, PresidentNorthstar HealthcareLuke Lambert, CEOASCOALarry Lane, Supply Chain Management

Jeff Leland, Managing PartnerBlue Chip Surgical PartnersDoug Lewis, Managing DirectorPhysicians CapitalMike Lipomi, PresidentRMC MedstoneSteve Lloyd, MDMedical Endoscopy of South CarolinaJim Lynch, MD, Chairman, DirectorSpine Nevada and Surgery Center of Reno,Director of Spine ServicesRegent Surgical HealthTom Mallon, CEO and FounderRegent Surgical Health,Deann Manchester, VP of DevelopmentUnited Surgical Partners InternationalRoger Manning, PresidentManning Search GroupTyler Marsh, Director of BusinessDevelopmentAffiliated Credit ServicesTodd Mello, PrincipalHealth Care AppraisersEvie Miller, Director of AcquisitionsUSPIBill Mobley, MDUrological AssociatesRob Morris, VP of MarketingCare CreditJon O’Sullivan, Senior PrincipalVMG HealthRick Pence, President and COONational Surgical CareJeff Peo, VP of Business DevelopmentASCOAJohn Poisson, Executive VPPhysicians EndoscopyUwe ReinhardtJames Madison Professor of Political Economy andProfessor of Economics at Princeton University Herb Riemenschneider, MDKnightsbridge Surgery CenterAnne Roberts, RN, AdministratorSurgery Center of RenoJohn Seitz, CEOAmbulatory Surgical GroupCaryl Serbin, RN, BSN, LHRM, President and FounderSurgery Consultants of America;Serbin Surgery Center Billing

Jeff Simmons, President Western DivisionRegent Surgical HealthMichelle Smith, Director of Clinical OperationsNueterraBill Southwick, President and CEOHealthmark PartnersMary Sturm, SVP of Clinical OperationsSurgical Management ProfessionalsAlsie Sydness-Fitzgerald, RN, ChairpersonASC AssociationMelissa Szabad, JDMcGuireWoodsBarry Tanner, President and CEOPhysicians Endoscopy Tony Taparo, Group PresidentSymbion, Inc.Kimberly Taylor, PresidentTaylor & AssociatesLarry Taylor, President and CEOPractice Partners in HealthcarePhil Taylor, MDKnightsbridge Surgical CenterLarry Teuber, MD, PresidentMedical Facilities CorpManaging PhysicianNeurosurgical and Spinal Surgery AssociatesAmber Walsh, JD, and Elissa Moore, JDMcGuireWoods LLPEarl Walz, COOThe Urology GroupCathy Weaver, Senior ManagerSomerset CPAsMike Weaver, VP of Acquisitions andDevelopmentSymbionRob Welti, MD, Corporate Medical Directorand COO, Western RegionRegent Surgical HealthBob Wood, VP of Strategic PlanningAcclarentTom Yerden, CEO and FounderTRY SolutionsJoe Zasa, JD, CEOWoodrum/ASDBob Zasa, FounderWoodrum/ASDGreg Zoch, PartnerKaye/Bassman International Corp.

To Register Call (703) 836-5904

Strengthening the Future of Your ASC —Thrive Now and In the Future

This exclusive conference brings together surgeons,administrators and ASC business and clinical leaders todiscuss how to improve your ASC and its bottom line inthese challenging but opportunity-filled times.

The best minds in the ASC field will discuss newopportunities for ASCs plus provide practical andimmediately useful guidance on how to bring in morecases; improve reimbursement; manage, reduce andbenchmark costs; introduce new specialties; engineer aturnaround; work on joint-ventures with hospitals andmuch, much more.The ASC Communications — Ambulatory SurgeryFoundation difference:

1) Benefit from the combined efforts of ASC Commun-ications and the Ambulatory Surgery Foundation to attractattendees, as speakers and participants are the smartestpeople in the ASC industry today.

2) Take discussions and thinking to the highest levels, focusing on the physician-owners, medicaldirectors, ASC administrator and business-mindeddirectors of nursing.

3) Access expert views from all sides of the ASC world.


“They succeeded because the quality was there andthey used the target of achieving the highest quali-ty to attain profitability,” Mr. Reynolds says.“Doing it right the first time offers a better way tomove forward. In healthcare that means you don’thave to go back and do it again. Finding processesto cut infections and reduce complications meanscutting your costs, improving patient satisfactionand maximizing profitability.”

He says an orthopedics department can improveprofits by cutting length of stay by strictly followingquality regimens, protocols and processes, such asinfection control systems and clinical pathways.

“By focusing on quality, you improve profits,” Mr.Reynolds says. “There is nothing more valuable to aCEO than getting that bed back one day early.”

Before he retired from HSS, he said that hospital,which has been ranked by U.S. News & World Reportas America’s best orthopedic hospital, was asked tohelp the UK’s National Health Service replicate itssuccess with a hospital in London, the South WestLondon Elective Orthopaedic Centre.

“We showed them how, with the same resources,using our methods and efficiency measures, theycould achieve success. Now they do two or threetimes the previous volume with much shorterpatient waits,” Mr. Reynolds says.

4. Create and maintain a value analysisteam for equipment purchases.“Our team evaluates and assesses the implants andother devices, materials and equipment ordered andused in the hospital orthopedics department,”William Beaumont’s Dr. Herkowitz says. “We take apretty hard line and don’t put up with price gouging.We look at different companies with equivalent prod-ucts and do such a large volume that very few compa-nies won’t negotiate with us and want to be here.”

Dr. Herkowitz says Beaumont’s staff has commit-ted to cost containment and will switch companies if necessary.

“We have to make sure that the price is fair to ourhospitals so we can be profitable as well. Our teamcosts out and analyzes everything we buy, fromoperating room drapes to sutures and implants. Wedon’t necessarily go for the cheapest product avail-able, but the product with the highest quality at thebest cost,” he says. “We bid out everything.”

Dr. Thomas Sculco, surgeon-in-chief at New YorkCity’s HSS, says profit margins in the pharmaceuticaland device industries are high, while margins for mosthospitals and health systems remain flat and low.

“Implant costs eat up 30 percent to 40 percent oftotal reimbursements now for orthopedics,” Dr.Sculco says. “Those companies can’t achieve hugeprofit margins on our business. Orthopedics depart-ments need to look hard at those costs and negotiatehard. We evaluate all new technologies and manufac-turers have to demonstrate those technologies are bet-ter and more cost-effective to get our business.”

5. Contractually negotiate compliancewith quality protocols and initiativeswith public and private payors.Commercial payors and CMS are piloting pay-for-performance and best practices initiatives thatincentivize hospitals to adopt evidence-based practices proven to increase patient safety, reduceerrors and improve outcomes. Dr. Herkowitz sayshis system is cooperating with payors likeMichigan’s Blues programs on antibiotics andothers quality initiatives.

“By agreeing to administer antibiotics within 24hours, we’re improving patient care by reducingcomplications and infections,” he says. “That notonly saves us money down the road, but also savesinsurers money. And they reimburse us better forthe surgeries we perform at the same time we’reimproving patient safety.”

6. Adopt and follow effectiveclinical pathways programs. “Excellence in quality is a result of how you manageyour patients throughout the entire experience,”HSS’s Dr. Sculco says. “Our physicians have inputinto clinical pathways that offer consistent, qualitypatterns of care. We document what happens to thepatient every day, in some cases, almost everyminute. Patient expectations are fulfilled and thethroughput is very efficient as a result.”

7. Make patient education a profit center andmarketing tool.Century City’s Mr.Reynolds says his hospi-tal creates pre-admissionsplans for patients andoffers free classes at leastone week before admis-sion.

“We let them knowwhat’s going to happen tothem each day and tellthem what to expectthroughout their stay.When they have pain,they don’t panic. They’reprepared for what hap-pens and that leads to abetter, healthier attitude,”he says, noting that dis-charge processes are muchsmoother because thepatient is prepared.

He says the classes aretaught by nurses or physi-cal therapists and areviewed as marketingexpenses. “Our length ofstay has actually gonedown and we view theclasses as a revenue driver,”he says. “Patients aren’tmad or anxious about

going home a day or two earli-er, but happier.”

Our Lady of the Lake’s Ms.Silva says her hospital’s pre-surgery program includes test-ing and education, and hasresulted in fewer missedappointments and delays.

“We’ve found significantdecreases in cancellationsand have cut our length ofstay,” she says. “Our patients are readier for discharge and we work with physical therapy andhome health providers to ensure there’s no fallback in care.”

8. Pre-screen surgery candidates for infections. “Our pre-surgical screenings for MRSA and otherbacteria cost more, but if we find it early, we have path-ways for treating it and can reduce problems later,”says Ms. Silva. “We like to get upstream of issues, asopposed to waiting and reacting downstream.”

9. Align incentives.Consultant Mark Blessing of the Fort Wayne, Ind.,office of accounting firm BKD, says hospitalsneed to work closely with their surgeons to develop initiatives that benefit both parties.Blessing says sharing information with physiciansabout outcomes, lengths of stay, expenses and

Anna SilvaVice President forAncillary Services,Our Lady of the LakeRegional Medical Center


comparative performance data explains how doctors are doing and helps engage them.

“If the overall goal is to align incentives for hospitals, physicians and patients to get the bestoutcomes in the most efficient manner, hospitalscan work to keep surgery schedules efficient,block time in OR suites and open outpatient sur-gery centers in locations more convenient andaccessible to physicians and patients alike, insteadof in distant hospital interiors,” Mr. Blessing says.

He says offering state of the art equipment andhelping physicians develop cutting edge servicescement physician loyalty and encourage them topractice at that hospital. Helping local orthope-dics groups recruit new surgeons mutually bene-fits hospitals and group practices.

Dr. Sculco says HSS physicians are encouraged toparticipate in cost-cutting programs and canshare in the savings incurred, but not individual-ly. At HSS, those savings support departmentresearch efforts. “And if the savings can be sharedwith the department, then that goes a long way toencourage greater participation.”

10. Don’t just improve market share,but expand and redefine your market. The Indiana Orthopaedic Hospital’s Mr. Martinadvises hospital executives to seek new areas andunmet needs for services. Martin says many rural or

community hospitals don’t perform enough proce-dures to justify purchasing expensive equipment andrecruiting high-priced specialists and says those facil-ities may be eager to open new relationships.

“Start looking to different parts of your regionwhere patients lack access to technology and cut-ting-edge services,” suggests Mr. Martin.

He says that while his group hasn’t marketedactively outside Central Indiana, he reported thatadmitted patients throughout the Midwest seekservices at OrthoIndy.

“They’re coming to us.”

Contact Mark Taylor at [email protected].

oversees corporate operations and performance, for-mulates and executes the organization’s strategy, andrepresents UHC to the business and healthcare com-munities and the public. Ms. Cumming joinedUHC after serving as president and CEO of theUniversity of Kansas Hospital Authority for 11 years.

3. Delos M. “Toby” Cosgrove — Dr. TobyCosgrove is the CEO of the Cleveland Clinic. He isa renowned heart surgeon and has numerouspatents filed for developing medical and clinicalproducts used in surgical procedures, including theCosgrove Mitral Valve Retractor, the Stentless AorticValve, Low Velocity Aortic Cannula, and theCosgrove-Baxter Annuloplasty System for use invalve repairs. He has published hundreds of articlesand many training and continuing medical educa-tion films covering such topics as blood conserva-tion in cardiac surgery and aortic valve repair.

4. Trevor Fetter — Trevor Fetter has served aspresident and CEO of Tenet HealthcareCorporation since September 2003 and also servesas a member of the company’s board of directors.During Mr. Fetter’s tenure, he has helped achieve apeace accord with organized labor and resolved allmajor litigation facing the company. Under his lead-ership, Tenet has worked to find solutions to thenational uninsurance challenge; Tenet’s CompactWith Uninsured Patients has become a model for

24 Hospital Leaders to Know (continued from pg. 1)


the industry as it provides managed care-type dis-counts to uninsured patients and ensures theyreceive treatment, regardless of their ability to pay.Mr. Fetter has also served as the chairman and CEOof Broadlane, a leading provider of cost manage-ment services to both investor-owned and non-prof-it hospitals, and currently serves on the board of theFederation of American Hospitals.

5. Alyson Giles — Alyson Giles is president andCEO of CMC Healthcare System and CatholicMedical Center, Manchester, N.H. She has beenpresident and CEO of CMC Healthcare Systemsince 2002 and president and CEO of CatholicMedical Center since 1999. She also serves as the2008-2009 immediate past chairman of theAmerican College of Healthcare Executives. Beforeher current position, Ms. Giles served as executivevice president and COO of Optima Healthcare;president and CEO of New London Hospital; andpresident and CEO of Lake Shore Hospital inManchester, N.H.

6. Larry Goodman — Dr. Larry Goodman isthe president and CEO of the Rush UniversityMedical Center. He also serves as president of RushUniversity and is a principal officer of the Rushboard of trustees. He is known as an exceptionalleader and has developed the system tremendouslyover the last several years. He has also published inprestigious publications such as the Journal of theAmerican Medical Association and the Journal ofInfectious Diseases. His research has focused on infec-tious diseases, particularly gastrointestinal infectionsin HIV-positive patients. He is also known for pro-moting innovation in medical education.

7. Brett Gosney — Brett Gosney is one of thefew people on the list that operates a physician-ownedhospital. He is the founder and CEO of the firstphysician-owned hospital in Colorado, the AnimasSurgical Hospital. He is the vice president and presi-dent elect of Physician Hospitals of America (PHA).He helped lead the efforts to develop the hospital andfought through a wide range of local and state battlesand handled a number of efforts to help make thehospital a terrific contributor to healthcare services inthe Durango community.

8. Jeff Hillebrand — Jeff Hillebrand is theextraordinary COO of the Evanston NorthwesternHealthcare (ENH) System. Mr. Hillebrand hasguided ENH through various and different challenges to become and remain one of the leadinghospitals and health systems in Illinois. He previ-ously served as executive vice president, president ofENH Medical Group, senior vice president, andpresident, of Glenbrook Hospital. He is a fellow of,and has served as a regent in, the American Collegeof Healthcare Executives, and is a member of theSociety of Hospital Planning of the AmericanHospital Association, Leadership Greater Chicagoand the Young Presidents Organization.

9. Chris Karam — Chris Karam is a regionalleader in CHRISTUS Health, one of the top 10Catholic health systems in the United States. Mr.

Karam serves as president and CEO of the CHRIS-TUS St. Michael Health System in Texarkana,Texas, one of the most dynamic regions in theCHRISTUS Health system. He serves on the boardof trustees of the Texas Hospital Association and isan officer for the Ark-La-Tex Health Network,which includes approximately 325 physicians and20 facilities with common goals.

10. Paul Levy — Paul Levy has served as thepresident and CEO of Beth Israel Deaconess MedicalCenter, a Harvard Medical School teaching hospital,since 2002. He is the executive dean of administrationat Harvard Medical School and previously was anadjunct professor of environmental policy at MIT. Healso publishes a blog called “Running a Hospital” inwhich he shares his thoughts about healthcare.

11. Ed Murphy — Dr. Ed Murphy is the CEOof the Carilion Health System. He is a proactiveleader who has helped to transform Carilion Systemfrom a traditional not-for-profit model into an inte-grated physician-driven delivery system. Before joining Carilion Health System and beginning in1994, he was president and CEO of Seton HealthSystem in Troy, NY. He is also on the board of man-agers for The Egg Factory, which creates and devel-ops innovations with an emphasis in the space ofoptics and ophthalmics. He is someone to continueto watch over the next several years.

12. Don Nestor — Don Nestor has served as thesenior vice president of finance for the AuroraHealthcare System for as long one can remember.He is responsible for the management of all ofAurora’s operations with the exception of thoselocated in the Milwaukee area. He is an unusuallygifted leader with a long history of driving thegrowth of the Aurora System.

13. Mark Newton — Mark Newton is the CEOof the Swedish Covenant Health System in Chicago.Mr. Newton took a leadership of the system approx-imately three years ago after he completed serving asthe president of Highland Park Hospital. Duringthese three years, he has carved out a position forSwedish Covenant as one of the leading systems inthe Chicago area and has helped develop and growthe system in a challenging area. Mark also serves onthe boards of the Illinois Hospital Association andthe Chicago Hospital Risk Pooling Program, and isa member of the advisory board at North ParkUniversity School of Business in Chicago.

14. Keith Pitts — Keith Pitts has served as vicechairman of Nashville-based Vanguard HealthSystems since 1999 and serves as the chair of theboard of the Federation of American Hospitals.Prior to joining Vanguard, Mr. Pitts was chair-man and CEO of Mariner Post-Acute Networkand its predecessor, Paragon Health Network. Hehas also served as OrNda HealthCorp’s executivevice president and CFO, and has spent more than15 years as a consultant to healthcare organiza-tions, most recently as a partner in Ernst &Young’s healthcare consulting practice.

15. Ron Reed — Ron Reed is the CEO of MercyHospital in Iowa City. He helped put together a joint-venture ASC between his hospital and local physi-cians and has been instrumental in ensuring corpo-rate support while at the same time preserving andcultivating the physician led entrepreneurial spirit ofthe project. Mr. Reed is on the board of directors forthe Iowa Healthcare Collaborative and has beennamed one of the most influential business leaders inthe Iowa City area by a local business publication.

16. John Rex-Waller —John Rex-Waller is thechairman, president and CEO of National SurgicalHospitals, which partners with local physicians todevelop freestanding surgical facilities. He has alsoserved as the CFO of Hawk Medical Supply, aprovider of disposable medical supplies to physi-cians and previously he was the CFO and a co-founder of National Surgery Centers which was onethe largest independent owner and operator of sur-gery centers in the country. He has also worked as aninvestment banker.

17. Michael Sachs — Michael Sachs is thefounder of Sg2, a premier provider of data andinformation to hospital and health system leaders. It generally works with some of the mostprestigious health systems in the country. Beforefounding Sg2, Michael was the chairman of SachsGroup, which provided healthcare planning andmarketing data to more than 1,000 institutions inthe United States. Michael is a revolutionarythinker and implementer of ideas and a tremendous provider of resources to hospitals and health systems.

18. Molly Sandvig, JD — Molly Sandvig, JDis the executive director of PHA. She has done anoutstanding job for physician-owned hospitals andher leadership on behalf of them has been instru-mental in the ongoing debate about the rights forphysicians to develop and hold ownership stakes inphysician-owned hospitals. She also serves as thepresident of the South Dakota Association ofSpecialty Care Providers, representing specialty hos-pitals and ambulatory surgery centers in SouthDakota. She is currently serving a second term as agovernor appointee to the South Dakota HealthcareCommission. Ms. Sandvig is also a co-chair of the governor-appointed subcommittee on UniversalHealthcare Access in South Dakota.

19. Nancy Schlichting — Nancy Schlichtingis president and CEO of the Henry Ford HealthSystem. She previously held the positions of execu-tive vice president and COO for the system and wasresponsible for its hospitals, community care servic-es, hospital joint ventures, physician practice devel-opment and integrated support services. She has alsoserved as the president and CEO of Henry FordHospital and was responsible for the operation ofthe Detroit campus. Before joining Henry FordHealth System in 1998, she was executive vice pres-ident and chief operating officer of Summa HealthSystem in Akron, Ohio. She has also served aspresident of the Eastern Region of Catholic


Health Initiatives, president and CEO ofRiverside Methodist Hospitals and executive vicepresident and COO of Akron City Hospital.

20. Wayne Smith — Wayne Smith is theCEO of Community Health Systems (CHS).CHS is the largest for-profit publicly tradedhealth system in the country. Since his arrival in1997, CHS has grown from $742 million in netrevenue to more than $4 billion in net revenue.He has done a remarkable job of guiding thecompany forward in changing times. He alsocompleted the large merger of the Triad Systemand is doing a terrific job from what we can tellof integrating the two systems together. He hasbecome one of the foremost leaders of hospitalsystems in the country.

21. Paul Summerside — Dr. Paul Summer-side is the chairman of the board of one of the most successful hospitals in Wisconsin, theAurora BayCare Medical Center in Green Bay.He has been a dynamic leader on behalf of thisorganization. Aurora BayCare Medical Center isowned in large part by the Aurora HealthcareSystem. Dr. Summerside is a dynamic and expe-rienced leader. He also serves as the chief medicalofficer for BayCare Clinic. In this role, he isresponsible for all physician relations, recruiting,quality assurance and physician contracting.

He is also a residency-trained and board-certifiedphysician in emergency medicine.

22. John Thomas — John Thomas is presi-dent and chief development officer of CirrusHealth. Headquartered in Trophy Club, Tex., Cirrusdevelops and manages specialty surgical hospitalsand ambulatory surgery centers. Before joiningCirrus Health, Mr. Thomas served as senior vicepresident and general counsel for Baylor HealthCare System. John has also served as general coun-sel/secretary with the Unity Health System, a divi-sion of Sisters of Mercy Health System in St. Louis,and as president of wholly-owned captive insurancecompanies Church University Insurance Companyand Health Care Insurance Company of Texas.

23. John Toussaint — Dr. John Toussaint isthe former president and CEO of ThedaCare inAppleton, Wis. He recently took the lead on theThedaCare Center for Creating Value inHealthcare, a new ThedaCare-sponsored effort topromote value-based purchasing. His tenure aspresident and CEO of ThedaCare was marked byimpressive growth as well as growing worldwidenotoriety for ThedaCare’s success in applying leanmanufacturing principles and the ToyotaProduction System to the delivery of patient care;the process and tools are called the “ThedaCareImprovement System.” He was the first chairman

of, the Wisconsin Collaborative for HealthcareQuality and he founded the Wisconsin HealthInformation Organization.

24. Daniel Wolterman — Daniel Wolter-man has served as the CEO of the MemorialHermann Healthcare System in Houston since2002. He has more than 25 years experience invarious executive positions in the healthcareindustry and served as the chairman of the TexasHospital Association. Mr. Wolterman has taken ahigh-profile role as an advocate for reducing thenumber of uninsured Texans. His leadership andadvocacy have raised the profile of the uninsuredissue and helped build momentum at the stateand national levels for meaningful action. In2007, he received the Partnership for ActionGrassroots Champion Award from the AmericanHospital Association.

Get new insight every day at

www.hospitalreviewmagazine.com

Edited byRob Kurtz and Stephanie Wasek


Hospital hiring of physician specialists ebbs andflows, driven by reimbursement climates.

According to the American Academy ofOrthopaedic Surgeons, hospital employment oforthopedic surgeons nearly doubled from 2.2 per-cent of surgeons in 1990 to as high as 4.3 percent in2003, but had dropped to 4 percent by 2005, themost recent year for which data was available.

Hospitals face great challenges in recruiting fromwithin a shrinking pool of physician specialists,according to hospital executives, orthopedic consult-ants and physician recruiters.

The American Medical Association reports that thereare only 22,375 practicing orthopedic specialists in theUnited States, but that figure has remained virtuallystatic. In 2007, 558 specialists completed orthopedicresidency programs, compared to 557 in 2008.

Cheryl DeVita, senior consultant with St. Louis-based recruiting firm Cejka Search, says there is ashortage of orthopedic surgeons that isn’t beingreplenished through residency programs. “Of that22,375, only 8,639 are under the age of 45. The can-didate pool is growing smaller. They are in greatdemand. And unless your hospital is located in aplace people want to be, recruiting orthopedic sur-geons is going to be difficult,” says Ms. DeVita, whopointed out that nearly as many orthopedic surgeonsretire annually as enter the field.

When existing arrangements won’t help hospitals inrecruiting orthopedic surgeons with income guaran-tees or other incentives, “sometimes hospitals justhave to bite the bullet and hire them at the marketrate,” Ms. DeVita says.

And that’s neither cheap nor easy.

In a 2007 compensation survey conducted by Cejka,the American Medical Group Association foundorthopedic surgeons, on average, commanded$436,481 annual salaries, with spine and jointreplacement sub-specialists reaping an average ofmore than $500,000.

Ms. DeVita says sometimes existing orthopedicgroups don’t want added competition and won’trecruit themselves or are reluctant to pay market rates.Many orthopedic groups won’t guarantee that therecruited surgeon will be able to pursue their chosensub-specialties and are only seeking on-call coverage.

Kellie Risser, a consultant specializing in orthopedicsin Columbus, Ohio, says there’s only one reason toemploy a specialist: “If you can’t get one into yourmarket any other way.”

Ms. Risser says she hasn’t seen hospital hiring oforthopedic surgeons work successfully, noting, “The

specialist who wants to be hired is probably not theone you want.”

Harry Herkowitz, MD, chairman of orthopedic sur-gery at Royal Oaks, Mich.-based William BeaumontHospitals, says it’s appropriate to hire physician spe-cialists in those sub-specialty positions not filled bycommunity-based orthopedics specialists.

“If local, private groups aren’t currently offering thoseservices, you might look at hiring someone to takeover a sub-specialty not currently covered in yourhospital,” says Dr. Herkowitz, who cited orthopediconcologists as an example of a sub-specialty indemand in urban markets.

“Most orthopedic surgeons won’t remove tumors, hesays. “Also, some smaller community hospitals havedifficulty covering trauma services and would other-wise have to send patients to other hospitals offeringthose services. Under those circumstances it might beadvisable to employ a sub-specialist.”

But Dr. Herkowitz, who says Beaumont hospitals donot hire orthopedic specialists, acknowledged thatthere can be drawbacks.

“Sometimes employed physicians have the mindsetthat they don’t have to push that extra bit becausethey are being paid regardless of how hard theywork,” he says. “Productivity can be an issue.Doctors on salary aren’t always as motivated as thosewho are paid for the procedures they do.”

Victor Dipilla, vice president of operations at TheChrist Hospital of Cincinnati, says hiring physicianspecialists can prove “to be a slippery slope. Once youdo it, you have to be prepared for the consequences.This is an issue we’re grappling with now.”

Mr. Dipilla says it’s appropriate for a hospital to hirea specialist when it requires those specialty services,but low reimbursements or high medical malpracticerates make survival difficult in that market.

“Some hospitals are beginning to hoard cardiolo-gists,” he says. “Another circumstance might bewhen you can’t otherwise attract those specialists toyour hospital and need them. In our case, we’restudying this issue.”

Anna Silva, vice president of ancillary services forOur Lady of the Lake Hospital in Baton Rouge, La.,says hiring specialists should be a last resort. “I per-sonally prefer working with existing community spe-cialists,” says Ms. Silva. “But if the quality is not therein the community, or if they exist, but are notengageable, you may have to look elsewhere. It’s notmy first step, but it is an idea.”

Contact Mark Taylor at [email protected].

Hospital Physician Specialists: To Hire or Not to HireBy Mark Taylor

This short article briefly outlines severalmethods by which hospitals attempt to aligninterests with physicians. Certain of these

options may be useful for different types of projects.Further, depending on whether examining an imaging venture, an ambulatory surgery center venture, a nuclear camera venture, a cardiac cathventure, or other type of venture, certain of the models may be more or less useful. Briefly stated,the core models are as follows:

I. Minimal Integration Models. We gener-ally view the following as minimal integrationmodels. This generally means that the arrange-ments are short term and generally do not requirethe development of partnership agreements orrequire extensive capital contributions.

1) Medical directorships. This involves an agree-ment with a physician or physician group who willprovide various services to the venture (i.e.,administrative services, training of employees andstaff, etc.) in exchange for a set fee.

2) Management contracts. These are situationswhere either the hospital would manage a physi-cian practice or a physician would manage adepartment of the hospital or some other efforton behalf of the hospital.

3) Gainsharing efforts. Gainsharing usuallyinvolves the hospital and physicians workingtogether to achieve cost savings in purchasing forcertain surgical procedures or other procedures andthen sharing those savings between each other.While a minimal integration model, these effortstake a great deal of time and effort to put together.

4) Under-arrangement joint-ventures. In the traditional under-arrangement joint-ventures, ahospital simply buys an existing service from aphysician group or similar entity and then billsfor the services. This is differentiated from themore extensive under-arrangement venturesbeing put together today and noted below.

5) Part-time employment arrangements. Here, thehospital or a related party employs physicians on apart time basis to provide services to the hospital.

6) Independent contractor. Here, like an employ-ment agreement, the hospital typically contractsdirectly with a physician and has him or her provideservices on the hospital’s behalf. In other independent contract arrangements, such as hospi-tal-based independent contractor arrangements, thephysician provides services and bills third parties.Often, there is very little economic difference.

Minimal toMaximum IntegrationModelsBy Scott Becker

12 visit www.hospitalreviewmagazine.com

II. Medium Integration Models. We gener-ally view the following as medium integration mod-els. They require more work and effort to puttogether than a minimum integration model andoften require capital contributions and the develop-ment of various partnership type agreements.

1) True joint-venture. Here, the physicians and hospital joint-venture to be the actual provider ofservices. The joint-venture provider is developedtogether. The provider of services bills third partypayors and Medicare. This is a typical or traditionalmodel for a surgery center.

2) Equipment, real estate or infrastructure joint-venture. Under these types of joint-ventures, thephysicians and hospital jointly invest in an equip-ment joint-venture or real estate joint venture.Then, this venture leases equipment or real estate toeither a physician group or a hospital group or both.

3) Under-arrangements joint-venture. Under thisscenario, the physicians and hospital will often puttogether a much fuller under-arrangements venturethan under the minimal integration under arrange-ments. Then, this joint-venture will include every-thing except the provider number and license.Rather than providing services to third parties andcommercial payors, it will provide its services to thehospital and the hospital will bill its services as hospi-tal outpatient department services to third parties.These types of under arrangements and joint-ven-tures involve several serious regulatory risks.

III. Full Integration Models. There are alsoseveral complete integration models, which includethe following:

1) Income and employment through hospitaldirectly. The typical full integration generallyincludes full and complete employment of thephysicians. Here, the hospital directly employsphysicians. This has the benefit of satisfying theFraud and Abuse Statute employment safe harborand the Stark Act employment exception.

2) Hospital employs the physicians through a sub-sidiary. Here, the hospital creates a subsidiary com-pany and employs the physicians through the sub-sidiary. Again, this provides the hospital withincreased control of its ability to provide servicesover time and to control the physicians’ services.

3) Professional corporation or foundationmodel. Under this type of scenario, the hospitalprovides services through a captive or related professional corporation that employs the physi-cians. Here, we note certain recent IRS private let-ter rulings regarding UBIT in practice corpora-tions owned by hospitals.

Note: This article is not a legal analysis of the models discussed herein. Rather, this is intended asan overview of certain of the options. As one movesforward with any of these options, one should consider the provision of more comprehensive legalguidance, as well as the review of different valuationissues that are involved in each model.

Hospitals have endured an undeniabledecline within their GI outpatient proce-dural volume in the past 10-plus years as

physicians sought alternate settings to perform theircases. This migration of GI procedures fromHOPDs to ambulatory surgery centers (ASCs) andGI professional practice settings typically results in adramatic decline in the overall GI service line mar-ket share once enjoyed by local hospitals. In addi-tion, the loss of these outpatient procedures has aripple effect within the hospital delivery system—numerous other ancillary services traditionally pro-vided by the hospital, such as pathology and radiol-ogy, frequently disappear as physicians select alter-native providers when their historical referral pat-tern (and loyalty) to the hospital is loosened.

The good news is that as ASC and office-based set-tings continue to experience increased regulatorypressures — as well as significant reimbursementchallenges — many physicians now seek a relation-ship with their local hospital. Hospital-physicianjoint ventures, once the exclusive domain of multi-specialty ASCs, are now increasing within the singlespecialty GI market. As a result, now may very wellbe the critical time to implement such a relationshipwithin your market.

In May 2007, a terrific example of just such a hos-pital-physician endoscopy center joint ventureopened its doors. Historically, the GI outpatientdepartment at Montefiore Medical Center (Bronx,N.Y.) performed more than 7,000 ambulatory GIprocedures. The 10 to 12 voluntary physicians onstaff at Montefiore historically performed morethan 6,000 office-based endoscopy procedureswithin their various professional practice offices,outside the hospital setting. These physicians hadleft the hospital over the past several years for a vari-ety of reasons, thereby converting much of their GIprocedural business to office-based endoscopy unitswithin their own professional practice spaces.

The joint venture between Montefiore and thesephysicians is called the Advanced EndoscopyCenter.

In 2008, the Advanced Endoscopy Center expectsto perform more than 10,000 GI procedures with-in its four-room unit located a few minutes from thehospital campus. Within the next several years, thevolume is expected to grow to more than 14,000procedures annually. Two of the board members ofthe facility help us understand why this projectmade sense to pursue.

Why the joint-venture makes sense: The hospital point of view“As we evaluated the concept of joint venturing withour voluntary physicians, we identified three

primary reasons to move forward with our project,”says Don Ashkenase, executive vice president atMontefiore, whose single-specialty GI ASC openedin May 2007.

1. Identifying core competencies “Our hospital needs to focus on developing, enhanc-ing and profiting from certain medical specialty corecompetencies,” says Mr. Ashkenase. “After a compre-hensive fiscal analysis, we made the strategic decisionthat our GI outpatient service is one area that can beeffectively managed as a freestanding unit off the hos-pital campus.”

2. Limited capital budgets“Our current GI unit’s physical plant needs seriousmodernization,” he says. “On our urban campus, capital improvements are extremely costly, while devel-oping space off-campus can save significant money.”

3. Enhanced physician loyalty“GI physicians in the Bronx (as is true anywhere inthe country) can effectively convert the vast majorityof their outpatient caseload to their existing profes-sional practices,” Mr. Ashkenase says. “‘Office-based’endoscopy in the New York City area is highly preva-lent. This had already happened right here in theBronx within our voluntary GI physician group. Bydeveloping a freestanding endoscopy center in part-nership with our local GI physicians, we effectivelyalign our goals and objectives directly with the physi-cians in a true partnership arrangement. In this casewe regain a portion of the profits from the outpatientprocedure business while enjoying increased utiliza-tion of our pathology department and other spin-offancillary business from the facility.”

Why the joint-venture makes sense: The physician point of view“Although many members of the voluntary staff atMontefiore Medical Center historically performed asignificant volume of office-based procedures in theirpractices, many of us felt that developing a high

Recapturing and GrowingYour GI BusinessBy John Poisson

Don Ashkenase,Executive Vice President, MontefioreMedical Center

“Over the past two years,we’ve been impressed withthe outcomes of our decisionto develop a joint ventureproject with our voluntaryphysicians. The facility isgood for the community,good for the physicians, andgood for the hospital,” saysDonald Ashkenase, execu-tive vice president atMontefiore Medical Center,who serves as a member ofthe board of directors for theAdvanced Endscopy Center.

(800) 417-2035

quality state-of-the-art endoscopic ASC would bestserve the needs of our patients, while in the longerterm ensure reasonable financial stability for our-selves,” stated Robert Sable, MD, who serves as the co-medical director at the Advanced Endoscopy Center.There were three primary motivations to develop ajoint venture expressed by the physician coalition:

1. Reduced personal riskSetting up and equipping a quality office-basedendoscopy unit is becoming more and more expensiveevery year. By joining a state-of-the-art endoscopy ASC,physicians can spread their financial risks across a broad-er spectrum of participants — not just themselves.

2. Reduced personal headachesManaging an office-based unit takes time and energy,both of which are often in short supply in a busy GIprofessional practice. By developing a joint venture,using outside expertise as a guide, physician timecommitments are reduced.

3. Enhanced relations with the hospitalThe traditional physician versus hospital challengesdon’t have to exist. In a properly structured joint ven-ture (with the right business terms), everyone can co-exist in harmony. Aligned incentives are a wonderfulconcept. In the case of Advanced Endoscopy Center,an outside management company was chosen to assistin the process, which creates a natural buffer betweenthe hospital and the physicians — an independentthird party focused on what is best for the ASC.

The Montefiore joint-venture endoscopy centerdemonstrates several important areas that are criticalto developing a highly successful joint venture.

• First and foremost, the ownership of the new facil-ity was strategically designed so that all participantshad aligned incentives. In this case, the aggregateequity of the individual voluntary physician coalitionwas set at the same level as that of the hospital — eachhad 40 percent ownership, with the remaining 20percent minority ownership held by the outside management company tasked with making the venture come together.

• Governance is aligned. Both the physician coalition and the hospital hold two board seats, withthe fifth seat held by the outside management

company. No single party has effective control overthe facility, a point which gives both the hospital andthe physicians much comfort.

• Each party brings value to the table. The voluntaryphysicians bring the vast majority of cases to the facility — in 2008, this is projected as approximately8,000 procedures. The hospital brings strong value tothe venture as well. Hospital-employed GI physiciansare expected to perform 2,000 cases at the center in2008. In addition, the hospital’s managed care profes-sionals, working with the outside management com-pany, were able to use the hospital’s leverage duringthird party payer negotiations for the new facility. Theend result is the center’s average collections per proce-dure is more than double what had been projected inthe original business plan.

• Medical leadership recognizes the two very differ-ent types of physicians using the facility. A co-med-ical director was selected by both the voluntary physi-cian coalition and by the hospital employed physiciangroup. In this way, the unique needs of both groupsare recognized so that the center works for all users.

• There is opportunity for physician buy-in. Today’sGI physicians coming out of fellowship programs arelooking to buy-into endoscopy centers as part of a hir-ing package. In many cases around the country,income from the endoscopy center distributionsexceeds that of the GI practice, primarily due to thedeclining professional fees within the practice.Although recruitment of new GI physicians was nota primary aspect of the Montefiore joint venturebecause of the existing GI fellowship program at thehospital, it is very important to many communityhospitals. For instance, at Saint Vincent’s MedicalCenter in Erie, Pa., hospital administration recog-nized the need to recruit new GI providers into thecommunity as their existing physician base growsolder. Accordingly, once the new St. Vincent’sEndoscopy Center opens in autumn 2008, the facili-ty will provide an important tool for the hospital toattract new GI talent to its staff — the opportunity tobuy into the new single specialty GI center.

• The GI specialty is an in-road to the healthcare system. GI physicians are typically double-boarded,both in gastroenterology as well as in internal medi-cine. As a result, a tremendous amount of radiology,pathology, laboratory services, oncology, and a fairnumber of inpatient admissions, are generated by atypical coalition of eight to 10 GI physicians annual-ly. This is the reason that an increasing number of hos-pitals are establishing joint venture single-specialty GIASCs in tandem with their GI physicians, many ofwhom may not currently consider the hospital their“home” institution. A joint-venture project can bonda physician coalition to the parent hospital, therebybenefiting the hospital through the capture (or insome cases the recapture) of this GI spin-off business.

A parting question to consider: Which would yourather own — 100 percent of the GI outpatient busi-ness — which is subject to serious erosion over timeas physicians move out of the hospital — or a 40 to50 percent position in a thriving and growing joint-

venture business in partnership with your GIproviders? This is the question many in hospitaladministration are asking in today’s evolving market-place. Now is the time to evaluate your strategy as youproactively plan for the future. The benefits of thejoint venture are many, and the downside is minimalif structured and planned carefully.

John Poisson serves as executive vice president and holdsa minority ownership position in Physicians Endoscopy, anational development and management companyfocused exclusively on single-specialty GI ASCs. The com-pany currently operates 15 endoscopy centers with another five projects in various stages of development. Six of these 20 facilities are hospital-physician joint-ventures. He can be reached at (215) 589-9003 or [email protected] for more information. Learn more about Physicians Endoscopy at www.endocenters.com.

In just eight years, BayCare Clinic has becomean extremely profitable, high-quality, physician-owned organization serving the Green Bay, Wis.,

community. The chief medical officer for BayCareis Paul Summerside, MD, FAAEM, who also servesas the president of the board of managers forAurora BayCare Medical Center, in Green Bay.

Dr. Summerside sat down with The Hospital Reviewand shared his thoughts on the major challenges currently facing hospitals, why many hospitals arestruggling to find sustainable success and what stillkeeps him excited about healthcare.

Government regulations hinder growth.Hospitals are eager to invest in growth opportunities,but the lack of predictability in how future govern-ment regulations may impact such ventures is forc-ing hospitals to limit their investments. Such invest-ments are not cheap, especially when considering theexpenses associated with hiring physicians and nurs-ing and technical staff.

“The role of government regulation … is a massivefactor that we have no control over and can change avery good investment into a bankrupt investmentwith a stroke of a pen,” Dr. Summerside says. “Itmakes us not invest in a lot of things that make senseand have longer payoff horizons because we’re notsure if the horizon will ever get there.”

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Robert Sable, MDCo-Medical Director,Advanced EndoscopyCenter

"The center allows a new par-adigm for the treatment of ouroutpatients using a state-of-the-art facility designed to be acenter of excellence for ourcommunity. I am proud thatwe were able to do this in away that strengthens the col-legial relationship betweenhospital based and non-hospi-tal based practices,” indicatedRobert Sable, MD, who servesas the facility’s co-medicaldirector as well as a memberof the board of directors for theAdvanced Endoscopy Center.

Hospital LeaderShares Insight on CurrentState ofHospitals and HealthcareBy Rob Kurtz

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Since a solution to the issue of rapidly changing reg-ulatory and payment rules is not in sight, hospitalswill struggle to reach their true potential, thusdepriving patients of the finest care possible, he says.

“You have a set of rules today that make it very smartto build this or that or develop this business line and ayear later, it’s bankrupt after you put all of the moneyinto it because someone decided to change the rules. Itis a very difficult business reality that I think ham-strings medicine from being as efficient as it could be.”

Failure to invest in the “right” physicianexecutives hurts integration. Too manyhospital administrative boards are viewing physicianexecutives and clinical leadership as political pander-ers to pacify their medical staffs, which is hurtingeffective integration of physicians and fails to encour-age collaboration between the hospitals and physi-cians, Dr. Summerside has observed.

Since physicians can easily move their practice toanother hospital or even potentially open a compet-ing practice, integration and collaboration withphysicians is crucial to a hospital’s success. Withmuch of the success tied to the effectiveness of clini-cal leadership, hospitals should take a fresh look atthe individuals hired to fill these roles and not shyaway from investing in these positions.

“I think the systems that will do well are the ones thatare able to engage highly competent physician exec-utives, recognize that value and employ them tomake the machine work better,” Dr. Summersidesays. “I would postulate that many healthcare sys-tems struggle because they don’t appreciate this.”

Hospitals are often looking to fill these leadership positions with less-qualified — and thus lower-paid — physicians. While such appoint-ments may result in financial savings for organiza-tions, when compared to the salary that may berequired to hire a physician coming from a moreprofitable specialty, these individuals brought in tofill these roles lack the experience necessary to bringabout positive changes and results.

“So you end up with poor physician leadership, ifthere’s any at all, which perpetuates this kind of laissez-faire medical environment where the specialists have very poor relationships with the hospitals and little integration and little creativitygoes on,” Dr. Summerside says.

The solution is for hospitals to view these positions for what they truly are: Leadership for thehospital’s most expensive and important investment — the physicians. To fill this responsibil-ity, hospitals should recruit a high-level physicians and reward them with appropriate com-pensation, training, freedom and authority to makethe hospital’s business work effectively.

“They should identify physicians that are familiarwith the high-tech, high-compensation world of atertiary hospital,” Dr. Summerside says. “Who is themost likely to sit down in a meeting with neurosur-geons and orthopods and ER docs that drive the rev-enue of the hospital and have any credibility?”

“The institutions that can harness executives at thatlevel — the richer will get richer and the poorer will get poorer, and fast. Medicine is way toomuch of a team game now. All the pieces have towork together very well.”

“Transparency” will fail with lack of standardization. “Transparency” in health-care has been a buzzword for several years now,with growing pressure on organizations to publi-cize their costs. Unfortunately for hospitals andpatients, such transparency could actually serve todeceive patients about what is truly importantunless the government develops standard weightsand measures for quality and safety.

Dr. Summerside correlates the need for such stan-dardization to that of the automobile industry a fewdecades ago, when manufacturers did not have tomeet extensive safety standards. Manufacturers werefree to sell whatever they could and the consumerwould purchase automobiles with a belief they werebuying good, safe cars.

Then came Ralph Nadar’s book, Unsafe at AnySpeed: The Designed-In Dangers of the AmericanAutomobile, which led to Consumer Reports andother third-party measurements, and eventuallygovernment crash safety tests.

“That’s a basic standardized weight and measure, and made the true quality [of automobiles] transparent to the consumer,” Dr. Summerside says.“Once that occurred, look at the radical changes inthe automobile industry. It had to start with that.”

Healthcare presently lacks such a weight and meas-ure, and if organizations merely publicize theirprices, and patients (consumers) base their decisionssolely on this information, they may be choosing acare provider for the wrong reason.

“If one guy is charging $700 for a hernia and theother guy is charging $5,000, and the $5,000 guyhas a 1 in 1/1000 infection rate and the other guy has10/100 rate, who is really cheaper? How transparentis the fact that you published just the price? That’s thefraud the insurance companies and their fee schedulepanels have perpetrated.

“I think that if we can truly have honesty about ourpractices with our patients and our outcomes, thatwill be the best thing for doctors and their systems,”Dr. Summerside says.

He believes the government must become involvedand start developing such weights and measuresslowly and carefully, even if it is one procedure at atime or just starting with tracking and reportingwound infection rates. Unfortunately, such effortswould require unglamorous grunt work, somethingpoliticians are typically eager to shy away from.

Specialties relying on government pay-ors to struggle. Dr. Summerside has seen anongoing struggle for hospitals to recruit physicians forall specialties, but the struggle is magnified for thoserelying primarily on government payors. And it is astruggle that will only get harder with continuedreimbursement cuts and regulatory restrictions.

“Medicare and Medicaid rates in our environmentare unsustainable for things like cardiology, pul-monary, critical care, ER,” he says. “If you’ve got asignificant portion of your practice in the govern-ment payor arena, you are really going to struggle, atleast in this area of the country.”

Need for staff forcing tough decisions.The best of anything is always in short supply, andsuch is the case with good nursing staff and otherhospital staff. Many hospitals are struggling to fillopenings and ultimately settling for whatever is avail-able, which is an unfortunate and dangerous trend tostart, Dr. Summerside observes.

“We’ve drawn a line on not accepting poor fits andthat can be a hard line, but I tell you, once you getoff that position, there is no bottom. If you acceptpoor performance, it drives all performance down.”

Payor consolidation another unfortu-nate trend. The damage caused by payor con-solidation over the past several years, which hasthe dwindled down the number of payors con-trolling most contracts to three, or four if youconsider Medicare, is terrible news for hospitalsand patients, Dr. Summerside says.

“Anybody who thinks the consolidation of theseinsurance companies is good for the patient or goodfor cost is nuts. That’s a concept that went out withTeddy Roosevelt. That’s why the anti-trust legislationwas initiated. But the current administration, theDepartment of Justice, has turned a completely blindeye to this stuff,” he says.

Effort and strive for excellence stillrewarded. Despite all of the challenges and badnews which seems to impact healthcare on a regularbasis, the opportunity for excellent patient careexcites Dr. Summerside.

“I still believe, in my heart, despite all of the regula-tory crap we go through in the United States ofAmerica, if you get up in the morning and you worka little bit harder and a little bit better than the otherguy, you will succeed.

Such enthusiasm toward his practice and organiza-tion is a significant qualification for anyone hired tojoin his staff and is the basis of a question he asksprospective physicians during interviews.

“I say, ‘if you get up every morning and look in themirror and you can ask yourself why should anypatient come to see me instead of somebody else, ifyou’ve got an answer for that, you’re going to do greatwith our group. But if you don’t know or you don’tcare, you shouldn’t come here.’ If we can keep theright group of guys who get up every morning andgive patients a reason to see them instead of some-body else, the patients will be better off.”

Dr. Paul Summerside is the chairman of the board of one ofthe most successful hospitals in Wisconsin, the AuroraBayCare Medical Center. He has been a dynamic leader onbehalf of this organization. Aurora BayCare Medical Centeris owned in large part by the Aurora Healthcare System andis located in Green Bay, Wis. He also serves as the chief med-ical officer for BayCare Clinic. In this role, he is responsiblefor all physician relations, recruiting, quality assurance andphysician contracting. He is also a residency-trained andboard-certified physician in emergency medicine.

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