ASC vs. In-Office Procedures WITHOUT ASC ownership

[Got Em]

95% of attendings I've spoken to said in-office procedures are better financially for you if you don't own ASC shares, but one attending I recently spoke to said the opposite. His reasons are that without in-office fluoro, you have less overhead/staff, less renting costs, less equipment, and increased efficiency. While you may be compensated less per procedure by professional fees, you can do more procedures in a shorter amount of time. The example he gave was doing 20-25 procedures in 5 hours in an ASC (and then seeing clinic patients in the afternoon) vs. doing 20-25 procedures in office for the whole day.

Anyone done these calculations and have any thoughts?

I know there is a similar thread, but the other one asks just for reimbursement info, which can be found on ASIPP's website. Also did not want to hi-jack that thread.

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[cowboydoc]

95% of attendings I've spoken to said in-office procedures are better financially for you if you don't own ASC shares, but one attending I recently spoke to said the opposite. His reasons are that without in-office fluoro, you have less overhead/staff, less renting costs, less equipment, and increased efficiency. While you may be compensated less per procedure by professional fees, you can do more procedures in a shorter amount of time. The example he gave was doing 20-25 procedures in 5 hours in an ASC (and then seeing clinic patients in the afternoon) vs. doing 20-25 procedures in office for the whole day.

Anyone done these calculations and have any thoughts?

I know there is a similar thread, but the other one asks just for reimbursement info, which can be found on ASIPP's website. Also did not want to hi-jack that thread.

The overhead point is valid. If you are low volume, owning the space, equipment and paying staff to run fluoro may not be cost effective. One has much more control of workflow in an in-office setting, so you should absolutely be able to be more efficient in clinic than the ASC, not to mention more flexible.

My ASC books cases on the half hour. I'm finally moving to in-office for all non-sedation cases. I'm going to do cases q15 min pretty easily. Unless you own the ASC, it's pretty obvious which is better in this case, unless you don't have the volume to support the in-clinic expense. This is where the suggestion for starting a practice using an ASC comes from. You can start off cheap and minimize overhead. Not a great long-term play, but potentially a good plan out of the gate in a new practice.

 

[gdub25]

The one attending is wrong, plain and simple, the rest are correct in saying you’ll make more money doing injections in your office. Cowboydoc’s point about being low volume could be the only way an ASC makes sense but you’d have to be so low volume that you only have part time clinic staff. That’s the only way you can cut costs enough for it to make sense. If you’re at an ASC doin cases you’ll do less per hour than you can in the office and while you’re at the ASC your staff is going to be sitting around getting paid to do busy work. Get a c-arm, see patients and do shots all at the same time. Even if you’re slow starting out and only have 10 patients a day in clinic and do 5 injections you’re better off in the clinic.

 

[drusso]

Completely different games/gambles. More overhead and responsibility in the clinic with the in-office procedure suite, but you don't have to deal with partners and politics so you've got autonomy on your side. The sweet spot is being part of a very profitable multi-specialty ASC with good contracts, productive partners, etc. But, pain doesn't bring home the bacon in those situations so the most you'll get for ownership is between 5-10%, sometimes much less. Then, you've got to pay the TAX: Management companies, real-estate owners/landlords (some of whom might be your business partners and thus have "competing commitment" ), admin, etc. Sure, you'll get the vig on the SOS arbitrage, facility fees, and juicy OON contracts, but that stuff is not "built to last." You're about 12-15 years too late to cash in those chips. Go do your own things and tell the parasites to go pound sand.

Your attendings are book smart, but street stupid.

 

[Got Em]

The one attending is wrong, plain and simple, the rest are correct in saying you’ll make more money doing injections in your office. Cowboydoc’s point about being low volume could be the only way an ASC makes sense but you’d have to be so low volume that you only have part time clinic staff. That’s the only way you can cut costs enough for it to make sense. If you’re at an ASC doin cases you’ll do less per hour than you can in the office and while you’re at the ASC your staff is going to be sitting around getting paid to do busy work. Get a c-arm, see patients and do shots all at the same time. Even if you’re slow starting out and only have 10 patients a day in clinic and do 5 injections you’re better off in the clinic.

I plan to initially start working 2 days per week on the pain practice as I build it up while working locums in my primary specialty. I will set aside some time for marketing. In this arrangement, how long does it typically take for someone to go to 3 days, then full time? I know it's highly variable, but I'm just looking for a range.

I plan to have 1 day devoted to clinic and 1 for procedures each week. You think it would still be worth it if I see 10 clinic patients and 10 injections each week initially while I build it up slowly?

In my calculations, I would need at least 400k for buildout, rent (2500 sq ft, 4-5 reg rooms w/ 1 procedure room), equipment, furniture, meds, and salary for the 1st year. Without C-arm, this goes down to 200-250k as need less space, staff, and equipment.

Thanks for your info!

 

[Got Em]

The overhead point is valid. If you are low volume, owning the space, equipment and paying staff to run fluoro may not be cost effective. One has much more control of workflow in an in-office setting, so you should absolutely be able to be more efficient in clinic than the ASC, not to mention more flexible.

My ASC books cases on the half hour. I'm finally moving to in-office for all non-sedation cases. I'm going to do cases q15 min pretty easily. Unless you own the ASC, it's pretty obvious which is better in this case, unless you don't have the volume to support the in-clinic expense. This is where the suggestion for starting a practice using an ASC comes from. You can start off cheap and minimize overhead. Not a great long-term play, but potentially a good plan out of the gate in a new practice.

Hello, thank you for the reply. What exactly does this mean to minimize overhead? Hire 1 MA when I start? Wait to buy C-arm until volume is sufficient? OR to actually rent a small space first, do procedures at ASC, and then move to bigger space when volume increases?

 

[cowboydoc]

Hello, thank you for the reply. What exactly does this mean to minimize overhead? Hire 1 MA when I start? Wait to buy C-arm until volume is sufficient? OR to actually rent a small space first, do procedures at ASC, and then move to bigger space when volume increases?

Some have recommended renting a small space and hiring a smaller staff...a rad tech can learn to check in patients, etc. If you do procedures at an ASC in which you don’t have ownership, you don’t make as much, but you don’t have as much initial cost in c-arm, staff, space, etc.

The thought process is choosing where to start small and grow the practice vs. go big, more overhead, but more earning potential. Varies by market, your risk tolerance, your cash on hand, loan rates and other factors. Many threads delve into this. Good luck!