Facility fees/reimbursement

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doc1324

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Posting for a friend...pain is not my specialty, please forgive my ignorance.

If you are in private practice but perform a procedure in a hospital or ASC, and your compensation is a percentage of your collections, does the hospital/ASC facility fee typically count toward your collections? Or does the facility take 100% of it? It seems like the professional facility reimbursement can be significantly less than what the professional non-facility reimbursement would be if the same procedure were done in a clinic/office setting (at least with Medicare), so wondering how this all works. Thanks for any help.
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Generally if the physician is compensated by a percentage of their collections, they would only take a percentage of the pro fee.

And yes you are correct about the pro fee at a surgery center usually being significantly less than if the same procedure was done in office.
 
Ascs are not what they used to be. Many on here are fortunate to have a different experience, but I would almost beg to get my investment back at this point
 
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what has been the issue with your asc investment? I don’t own one so not poking fun. Just looking to reaffirm my office based practice decision.
 
ASC is a nice accessory if you do enough stim and have other like minded physicians involved. It doesn’t work for doing all procedures there financially. Slower turnover and high overhead kill the facility fee.
 
Dr. Ice said:
Ascs are not what they used to be. Many on here are fortunate to have a different experience, but I would almost beg to get my investment back at this point
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I have noticed this to be the norm rather than the exception
 
nvrsumr said:
what has been the issue with your asc investment? I don’t own one so not poking fun. Just looking to reaffirm my office based practice decision.
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A lot has to go right. A lot is out of your control.
 
Taus said:
Procedures in asc with pro fee only…. Might as well stick to peripheral joint injections in office and drop spine
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I am split actually. Office/asc. I’ve basically become 70% office and 30% asc. I own half
a share at the asc. Problem is the practice made a big mistake building a massive state of the art center with not enough bodies to provide volume. It’s now owned 55% by a health system cause we had no choice and now the partners are sitting around twittling thumbs waiting for the hospital to bring their own employed docs to the center to bolster it. They will obviously do it eventually but it’s not like they are in any rush.

Believe me, I have been a huge proponent of office procedures since I became an attending and even more so after my first job decided to screw me despite my overt altruism to them.

But at the same time always believed if a pain doc is going to perform any procedure in any type of facility, they should be getting a piece of it in some form be it shareholder or rvu..
 
Dr. Ice said:
But at the same time always believed if a pain doc is going to perform any procedure in any type of facility, they should be getting a piece of it in some form be it shareholder or rvu..
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100% agree. I used to be 50:50 office:asc. I’m now about 90% office, including rfa, scs, kypho.
 
I am in a hospital employed ortho group (paid by wrvu) and do all pain procedures in a multispeciality ASC- although primarily ortho. My practice is bread and butter pain with scs trials. ~27 injections a day and out by 4p (4 injections per hour). honestly I'm not sure how much faster I could do these in office.

It has been very lucrative for us- paying out between $70-90k per year for the owners/partners. Our center works nearly at full capacity with ortho/ joint surgeries.

So in the right setting, pain can be lucrative in an ASC.

Edit- I guess the post is referring to true private practice vs hospital employed. Obviously it can work for hospital employed but probably not pp.
 
afob100 said:
It has been very lucrative for us- paying out between $70-90k per year for the owners/partners. Our center works nearly at full capacity with ortho/ joint surgeries.
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Are there a ton of partners diluting out this payout? 70-90k/yr doesn't sound terribly lucrative. I'm assuming that the bulk of your income comes from elsewhere.
 
6-7 per hour in office isn’t difficult. I used to do 7.5 per hour in a hopd so there is plenty of room for them to speed up. 4/hr is better than 2-3 hour which is fairly common.

Your situation is different as your wrvu conversion factor is paying you more than your professional fees would be otherwise. So the hospital is sharing some of the ASC profit and ancillary profit that is assigned to them with you.

$90k is a nice extra bonus in this scenario but would be much, much less than you would make in a office setting for these procedures. $90k is less than the profit I will get off of only my scs trials this year. IBut you don’t have a way of accessing this side of the business in the employed setting.
 
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BobBarker said:
Your situation is different as your wrvu conversion factor is paying you more than your professional fees would be otherwise. So the hospital is sharing some of the ASC profit and ancillary profit that is assigned to them with you.

$90k is a nice extra bonus in this scenario but would be much, much less than you would make in a office setting for these procedures. $90k is less than the profit I will get off of only my scs trials this year. IBut you don’t have a way of accessing this side of the business in the employed setting.
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this. 70-90k more for a year of procedures would otherwise definitely not make up for the difference vs doing these all in office, even after your office overhead.
 
It's a very complex answer. Depends on:

-daily overhead differential between office vs ASC
-debt service differential for startup costs if you got in early
-efficiency
-cost per share (how much you invested and % ownership you got)
-professional contracts vs facility contracts

To make ASC favorable to office, you have to optimize each of these.

-staffing is minimally higher than if we did in office
-kept costs low as possible during build out
-efficiency is same as office
-FMV if you buy in early is more favorable as it is typically based on EBITDA. Break-even time should be <5 years.
-the higher % of MC the contracts the more favorable, especially if rates are better with facility contract
Example: ESI
Office: 250
Facility: 450 (100 pro, 350 facility)
At MC rate, 200 differential per case
If rate is 2x MC for both, 400 differential per case

If any of the above factors are unfavorable, it can really make it not worthwhile but generally I'm very pro ASC
 
BoardingDoc said:
Are there a ton of partners diluting out this payout? 70-90k/yr doesn't sound terribly lucrative. I'm assuming that the bulk of your income comes from elsewhere.
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I just bought into a newly built ASC. I know projections are often way off but they suggest we'll make about that on a 40k initial investment after a few years in. This is in addition to the usual hospital employed RVU income. I would be doing these procedures anyway in the hospital for the RVU only so hopefully it works out as "free money" so to speak.
 
Depends on how busy your partners are
I never calculated anything. Just went with feel and knowing decision was reversible. Best decision I’ve made but still early in it
 
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BobBarker said:
6-7 per hour in office isn’t difficult. I used to do 7.5 per hour in a hopd so there is plenty of room for them to speed up. 4/hr is better than 2-3 hour which is fairly common.

Your situation is different as your wrvu conversion factor is paying you more than your professional fees would be otherwise. So the hospital is sharing some of the ASC profit and ancillary profit that is assigned to them with you.

$90k is a nice extra bonus in this scenario but would be much, much less than you would make in a office setting for these procedures. $90k is less than the profit I will get off of only my scs trials this year. IBut you don’t have a way of accessing this side of the business in the employed setting.
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how were you doing 7-8 procedures per hr? did you have two fluoro rooms?
 
No, just one. It was a procedure room just outside the OR. So could leave the patient dressed normally. Preop rooms were right there. So they would quickly go from preop, hall outside the procedure room, procedure room, then back to the preop room they came from. I would usually prep and drape but staff did most everything else. Unilateral RFAs.
 
BobBarker said:
No, just one. It was a procedure room just outside the OR. So could leave the patient dressed normally. Preop rooms were right there. So they would quickly go from preop, hall outside the procedure room, procedure room, then back to the preop room they came from. I would usually prep and drape but staff did most everything else. Unilateral RFAs.
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Damn…. That’s a ton. I prep, drape, draw meds with X-ray tech, MA doing check in/discharge. Generally 4/hr. Occasionally 5. 6 gets hairy. I count RFA as 2 slots.
 
BobBarker said:
No, just one. It was a procedure room just outside the OR. So could leave the patient dressed normally. Preop rooms were right there. So they would quickly go from preop, hall outside the procedure room, procedure room, then back to the preop room they came from. I would usually prep and drape but staff did most everything else. Unilateral RFAs.
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I have similar set up.
How many preop rooms you had? Hard to do sedation as then they take up a preop room. I don’t have post procedure discharge room
With this, I can only do 4 in hour (nurses check in, position, check out).
 
We had 8 preop rooms. They would use the preop room like a pacu bay after the injection. Rn put monitors on and discharge the patient after 30 minutes or so. Usually, nothing else going on in the OR or just a random add on case from the night before.
 
BobBarker said:
We had 8 preop rooms. They would use the preop room like a pacu bay after the injection. Rn put monitors on and discharge the patient after 30 minutes or so. Usually, nothing else going on in the OR or just a random add on case from the night before.
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I only have 3 preop rooms, which is a limitation. So can only do 4/hour, max 5
 
Not all of them have to get sedation though. So I would do two procedures with sedation then 3 without and you could probably do 5 and have the post op bays empty by the time the next hour hits.
 
BobBarker said:
Not all of them have to get sedation though. So I would do two procedures with sedation then 3 without and you could probably do 5 and have the post op bays empty by the time the next hour hits.
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I’ve been in too many a fight with nursing management.
I don’t own the staff so hard to demand same type of production. The nursing manager states there are some questions nurses have to ask (COPD, liver disease, etc- none of which I use clinically).
Not worth the fight. I don’t use sedation so I can do 4/hour.
 
No sedation and only 4/hr? They can ask all of the questions out somewhere else and not in preop so you have infinite space for questions and then put them in preop for you to consent them and proceed directly to the procedure room.


An example of the important nursing questions that can’t be avoided.


“Ok, when did you last take your vitamin c gummy? No, give me a time. So was it before or after Matlock? And what time is matlock over? Ok, now how about your meloxicam? Meloxicam? Mobic? No, it is an arthritis pill. You took it last night? Ok, we will probably have to cancel your injection? I’m just going to stop right here for now.”

Nurse then proceeds to leave and hit vape pen in bathroom and get a snack.
 
BobBarker said:
No sedation and only 4/hr? They can ask all of the questions out somewhere else and not in preop so you have infinite space for questions and then put them in preop for you to consent them and proceed directly to the procedure room.


An example of the important nursing questions that can’t be avoided.


“Ok, when did you last take your vitamin c gummy? No, give me a time. So was it before or after Matlock? And what time is matlock over? Ok, now how about your meloxicam? Meloxicam? Mobic? No, it is an arthritis pill. You took it last night? Ok, we will probably have to cancel your injection? I’m just going to stop right here for now.”

Nurse then proceeds to leave and hit vape pen in bathroom and get a snack.
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No sedation and only 4/hour. Yep
Can’t think of way to make it faster. It’s a nursing manager giving me red tape and not providing solutions
Luckily whether I do 4 or 6 in an hour, my salary doesn’t change too much so I’m not fighting it but I have access issues as I’m booked out 5-6 weeks so it sucks for the patients and takes me forever to get through MBB/RFAs
 
Can you take the patients that have a life to live and want to get through their treatment plan back to your office?
 
BobBarker said:
No, just one. It was a procedure room just outside the OR. So could leave the patient dressed normally. Preop rooms were right there. So they would quickly go from preop, hall outside the procedure room, procedure room, then back to the preop room they came from. I would usually prep and drape but staff did most everything else. Unilateral RFAs.
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I'm having a hard time imagining the flow here.

I assume that because you're doing this in an area that's OR adjacent, you're wheeling patients in and out on a stretcher? That would honestly same a ton of time.

In my program the flow in clinic (typical office layout):
Patient is in pre-procedure room with RN getting vitals and having the aforementioned inane discussion --> walk to procedure room 10 feet away which can often take 5 full minutes because old --> get onto table which takes another 5 minutes --> I prep and drape --> I draw meds with the RN --> inject --> however long it takes to get off the damn table --> more inane questions +/- the occasional med refill --> start over.

3.5-4 PPH is about as fast as this circus gets, and that assumes they're basically all LESIs / SIJs / other quick injections.

During fellowship, I don't really care about trying to optimize seeing as I don't really have control over nursing or other staff in a way that can move the needle, but going forwards I would love to know how you optimized this process.

You said staff did everything else. Specific questions:
- Did the patient actually get wheeled in and out on a stretcher? That would fix a big time sink on my end
- Is there someone who is sterile drawing up meds for each procedure and setting out a tray/needles+syringes?
- Without sedation, how do you get patients from wanting to talk for like 5 minutes after each procedure? Wheel 'em out quick before they can start talking?

I could easily get 2 more PPH if I could just get patients on/off the table immediately and get them not to talk until their follow-up visit.
 
Yes, for patients with sedation we stretchered them into the room and left the stretcher in the room during the procedure and then rolled them back on.

Wheelchair in/out without sedation.
 
BobBarker said:
No sedation and only 4/hr? They can ask all of the questions out somewhere else and not in preop so you have infinite space for questions and then put them in preop for you to consent them and proceed directly to the procedure room.


An example of the important nursing questions that can’t be avoided.


“Ok, when did you last take your vitamin c gummy? No, give me a time. So was it before or after Matlock? And what time is matlock over? Ok, now how about your meloxicam? Meloxicam? Mobic? No, it is an arthritis pill. You took it last night? Ok, we will probably have to cancel your injection? I’m just going to stop right here for now.”

Nurse then proceeds to leave and hit vape pen in bathroom and get a snack.
Click to expand...
i do 3/hr in a hospital facility because nursing.....
 
BoardingDoc said:
I'm having a hard time imagining the flow here.

I assume that because you're doing this in an area that's OR adjacent, you're wheeling patients in and out on a stretcher? That would honestly same a ton of time.

In my program the flow in clinic (typical office layout):
Patient is in pre-procedure room with RN getting vitals and having the aforementioned inane discussion --> walk to procedure room 10 feet away which can often take 5 full minutes because old --> get onto table which takes another 5 minutes --> I prep and drape --> I draw meds with the RN --> inject --> however long it takes to get off the damn table --> more inane questions +/- the occasional med refill --> start over.

3.5-4 PPH is about as fast as this circus gets, and that assumes they're basically all LESIs / SIJs / other quick injections.

During fellowship, I don't really care about trying to optimize seeing as I don't really have control over nursing or other staff in a way that can move the needle, but going forwards I would love to know how you optimized this process.

You said staff did everything else. Specific questions:
- Did the patient actually get wheeled in and out on a stretcher? That would fix a big time sink on my end
- Is there someone who is sterile drawing up meds for each procedure and setting out a tray/needles+syringes?
- Without sedation, how do you get patients from wanting to talk for like 5 minutes after each procedure? Wheel 'em out quick before they can start talking?

I could easily get 2 more PPH if I could just get patients on/off the table immediately and get them not to talk until their follow-up visit.
Click to expand...

I’m now where Bob was. Depends on the procedure mix, I probably hit 6-6.5 an hour. I’m slowed down by the fact that I think I have one less staff member in the procedure room than he did, but mainly by the fact that there is an orthopedic surgeon operating on my procedure days, which occupies some of the intake/pre-op/recovery nurses enough to slow things down a little bit.

- Yes, wheeled in on stretcher for sedation cases. I have my MA come over from clinic for procedures, she is there waiting to wheel in the patient. 2 scrub techs in there drawing up meds and getting equipment ready, circulating nurse to place monitors and give sedation, plus fluoro tech. Reasonably efficient.
- You need to get good at redirecting the patient. Patient sitting in their wheelchair asking questions instead of getting on the table? “Please get on the table and I’ll talk as we get going”. Sometimes I’ll walk for a few seconds with my MA pushing them out to post-procedure bay if there’s anything else pertinent. If we can’t address it all in that time frame, I tell them just to bring it up next time in clinic. Establish expectations with them that procedure days are for procedures, it is not a clinic visit combined with a procedure. I tell them in clinic “I can get your procedure done soon because I do a bunch of injections every week, but in order to do that, we are just focusing on the injection that day. I wouldn’t be able to take care of your procedure or many others if I am doing a clinic visit with you too”. Most patients will understand and appreciate the honesty. And there’s plenty of patients out there that you don’t want the ones who don’t respect your time.
 
mdo1738 said:
I’m now where Bob was. Depends on the procedure mix, I probably hit 6-6.5 an hour. I’m slowed down by the fact that I think I have one less staff member in the procedure room than he did, but mainly by the fact that there is an orthopedic surgeon operating on my procedure days, which occupies some of the intake/pre-op/recovery nurses enough to slow things down a little bit.

- Yes, wheeled in on stretcher for sedation cases. I have my MA come over from clinic for procedures, she is there waiting to wheel in the patient. 2 scrub techs in there drawing up meds and getting equipment ready, circulating nurse to place monitors and give sedation, plus fluoro tech. Reasonably efficient.
- You need to get good at redirecting the patient. Patient sitting in their wheelchair asking questions instead of getting on the table? “Please get on the table and I’ll talk as we get going”. Sometimes I’ll walk for a few seconds with my MA pushing them out to post-procedure bay if there’s anything else pertinent. If we can’t address it all in that time frame, I tell them just to bring it up next time in clinic. Establish expectations with them that procedure days are for procedures, it is not a clinic visit combined with a procedure. I tell them in clinic “I can get your procedure done soon because I do a bunch of injections every week, but in order to do that, we are just focusing on the injection that day. I wouldn’t be able to take care of your procedure or many others if I am doing a clinic visit with you too”. Most patients will understand and appreciate the honesty. And there’s plenty of patients out there that you don’t want the ones who don’t respect your time.
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Sounds like you should send him a fancy bottle of booze this season as a thanks for his toil in greasing the skids to make that HOPD reasonably efficient!
 
It is ortho slowing you down for sure. The same thing would happen if they had much else going on as far as regular surgeries. It slows down check in, preop iv placement. I had one scrub, one rad, two nurses and I would help more if I was done with my notes. Usually for the first couple hours I would do a procedure, do a note from the day prior, then they were ready for the 2nd procedure. This was with the old emr.

We started doing procedures in an old cath lab/radiology unit. Nurses placing IV’s in a hallway and then doing recovery in an old office they blew the wall out of to connect to the radiology unit. Holes in the walls, roof leaking. lol. This was in 2015.
 
SpineandWine said:
Impressive.
I have 1 arm, 3 bays.
Can only get to q15 minutes max

Esp with HOPD with variable nursing
~~

How many you do in week then?
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50-60/week.

these are almost all patients i see myself and then send for injections.

also do EMGs 1/2-1 day/week.

the key is to not get bogged down with IVs, sedation, etc.
 
SSdoc33 said:
50-60/week.

these are almost all patients i see myself and then send for injections.

also do EMGs 1/2-1 day/week.

the key is to not get bogged down with IVs, sedation, etc.
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Do you enjoy EMGs? It became hard to justify doing them for me, despite wanting to keep the skill set.
 
cowboydoc said:
Do you enjoy EMGs? It became hard to justify doing them for me, despite wanting to keep the skill set.
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it is 100% not "worth" it from a $/time standpoint. even though im pretty fast

but it feels like i can jump off the hampster wheel once a week, which is nice. i also like the continuity for my patients,
 
SSdoc33 said:
50-60/week.

these are almost all patients i see myself and then send for injections.

also do EMGs 1/2-1 day/week.

the key is to not get bogged down with IVs, sedation, etc.
Click to expand...
Meaning you’re doing 10 hours of procedures
I’m going to get Flack on this but I do 90 procedures a week (3 whole days) and two days of consults, with APP help
I want to reduce procedure days down though (I do 4/hours)
 
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Office based. I have one procedure room. Pre/post adjacent, as is my office. 3 total staff today. Flexed to 7/hour rate for a bit today. 20 procedures total. 42 overall.

I’ve been booked out one day forever. Scheduling flexibility for my practices success has been key.

Made a concerted effort to get more efficient this year. Telehealth main driver but set volume expectations higher as well.

Left at 3 pm

Appreciate the insight of like minded docs on this forum.
 
SpineandWine said:
Meaning you’re doing 10 hours of procedures
I’m going to get Flack on this but I do 90 procedures a week (3 whole days) and two days of consults, with APP help
I want to reduce procedure days down though (I do 4/hours)
Click to expand...
90 procedures/week ! keep an eye on your radiation exposure! sometimes we ignore that this is cumulative over time
 
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