ReefTiger

Junior Member
10+ Year Member
5+ Year Member
Dec 1, 2005
89
0
Status (Visible)
  1. Attending Physician
Just curious as to what you think of them. I heard there is a trend towards these surgicenters expanding to small outpt/inpt hospitals. Furthermore I hear physicians are owning and running them. Some say it is better for pt and physician satisfaction and there is $ to be made.

What do you think? Is this something we should be looking into, or should we be hoping/trying to get into this type of situation?


I am hoping for some good open discussion on this!
 

EtherMD

Membership Revoked
Removed
10+ Year Member
Dec 25, 2006
389
0
Status (Visible)
  1. Attending Physician
Just curious as to what you think of them. I heard there is a trend towards these surgicenters expanding to small outpt/inpt hospitals. Furthermore I hear physicians are owning and running them. Some say it is better for pt and physician satisfaction and there is $ to be made.

What do you think? Is this something we should be looking into, or should we be hoping/trying to get into this type of situation?


I am hoping for some good open discussion on this!

If reimbursement remains like it is today (that is private insurance plus the government paying for our seniors) then SurgiCenters are here to stay. A busy surgi-center is a money making machine. The productivity is much higher than a hospital and patient satisfaction is usually higher as well.
The Physicians usually own and run the place. Throw in some MAC GI cases and you will be amazed at the revenue generation from the place.
How many No-Pay cases are done there? How many Medicaid cases?
Medicare is the only low payer for Anesthesia and these cases are usually just a portion of the very lucrative private insurance cases.

There is a good chance hospitals will end up being all ICU and Step-Down admissions. More and more of every type of surgery is being performed on an outpatient basis. Anesthesia Practices without Surgi-centers will be more reliant on hospital subsidies. Universal Health Care MAY change the situation a bit but overall the trend is to outpatient whenever possible.
 

ReefTiger

Junior Member
10+ Year Member
5+ Year Member
Dec 1, 2005
89
0
Status (Visible)
  1. Attending Physician
That's what I figured. It seems like physicians would have more control both in daily operations, and for price negotiations with suppliers and insurance etc.

The question is, how likely is it for anesthesiologists to be able to have equity/partial control in these type of operations? They sound like a win/win and also a gold mine. Are there many opportunities for anesthesiologists in this scenario?
 
About the Ads

EtherMD

Membership Revoked
Removed
10+ Year Member
Dec 25, 2006
389
0
Status (Visible)
  1. Attending Physician
That's what I figured. It seems like physicians would have more control both in daily operations, and for price negotiations with suppliers and insurance etc.

The question is, how likely is it for anesthesiologists to be able to have equity/partial control in these type of operations? They sound like a win/win and also a gold mine. Are there many opportunities for anesthesiologists in this scenario?


This is more "who you know" than "what you know." Usually, these centers are offered to Groups or Individuals (Anesthesiologists) that the surgeons have worked with in the past or currently work with at the hospital. The surgeons know the quality of the MD they are getting for their center. Sometimes you are offered ownership in the center as well (not always).

Obtaining ownership position right out of Residency is rare. Unless, your Dad, Uncle, etc. can assist you with 'who you know' in the surgery world the ownership in a center comes several years after working the surgeons.
 

ReefTiger

Junior Member
10+ Year Member
5+ Year Member
Dec 1, 2005
89
0
Status (Visible)
  1. Attending Physician
So, it sounds like it could be a really good career move to those lucky enough to get the opportunity. Of course the devil is in the details, but what sort of contractual details are ideal for an anesthesiologist in this type set up?

I have a lead on a possible situation like this straight out of residency with what I am led to believe is partial ownership. It seems like some risk, but probably profitable over the long term. It is definitely not a short term "feel it out" gig. I would just like to see what folks think about this, what would be key deciding factors in a contract etc. Either way, I'd still definitely have a contract lawyer review anything prior to signing.
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
20
Status (Visible)
  1. Attending Physician
Surgery centers can be owned by physicians or by corporations (hospital).

The physician owned ones tend to be very lucrative because the physicians refer their PAYING patients to the surgery centers...and send the poor paying ones to the hospitals....

Do you blame them?

However, most of the ones that I know of don't offer ownership to the anesthesiologists because, as an anesthesia provider, you don't bring business to the center.

There are exceptions...my mentor has ownership in a very successful surgery center in California ...his comment, "the single best investment I ever made"
 

Disciple

Senior Member
15+ Year Member
Oct 18, 2004
2,845
479
Status (Visible)
  1. Attending Physician
Just curious as to what you think of them. I heard there is a trend towards these surgicenters expanding to small outpt/inpt hospitals. Furthermore I hear physicians are owning and running them. Some say it is better for pt and physician satisfaction and there is $ to be made.

What do you think? Is this something we should be looking into, or should we be hoping/trying to get into this type of situation?


I am hoping for some good open discussion on this!

Congress recently allowed a moratorium on applications for new specialty hospitals to expire. However, in conjunction, CMS released recommendations on the issue this summer.

One of the recommendations was that payments to ACSs be brought more into line with those for HOPDs. This was supported by lobbying from the AHA.
Their position is based around the argument that ASCs divert all the lower risk better reimbursement cases from the hospital. Therefore, hospitals are able to bring in less revenue which was traditionally used to subsidize indigent care. Therefore physician ownership in ASCs hurts the community.

I don't know what's in the works for surgical or Anesthesia services, but ASC payments for interventional pain procedures in the ASC as slated to take a 8-10% hit next year. Several mentors have advised me against investing in a single specialty ASC for this very reason.

http://www.asipp.org/

The recommendations/findings by CMS were not all negative, however, and many are expecting the upcoming battles to be waged on the state level.
 

jwk

CAA, ASA-PAC Contributor
15+ Year Member
Apr 30, 2004
3,827
1,174
Atlanta, GA
The physician owned ones tend to be very lucrative because the physicians refer their PAYING patients to the surgery centers...and send the poor paying ones to the hospitals....

And that's a big problem. Hospitals are required to be open 24/7 and pretty much accept any patient that walks in, rolls in, or collapses in the lobby, regardless of their ability to pay. How do they stay profitable (well, actually most don't) and keep their doors open when many of the better paying patients get cherry-picked by surgeons running their own centers? Where are the conflict of interest regulations in all of this? (or are there any?)
 

johankriek

Membership Revoked
Removed
10+ Year Member
Jul 19, 2006
920
1
Status (Visible)
  1. Post Doc
. How do they stay profitable (well, actually most don't) and keep their doors open when many of the better paying patients get cherry-picked by surgeons running their own centers? Where are the conflict of interest regulations in all of this? (or are there any?)

. the thing hospitlas can't alienate the referring physician which i see so many hospitals doing. If i were a surgeon and i can get keep the facility fee and my fee if i opened up my center why wouldnt i. why would i give money to the hospital? unless there were something in it for me. It just simple business. If the hospitals want to stay profitable they have to change their business model.
 

ReefTiger

Junior Member
10+ Year Member
5+ Year Member
Dec 1, 2005
89
0
Status (Visible)
  1. Attending Physician
Well, it all goes back to people wanting care for free. I don't see a problem with physicians sending paying patients to a nicer facility with improved patient satisfaction. The business administrators have been using physicians as employees for their own benefit for long enough.
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
20
Status (Visible)
  1. Attending Physician
If Hiliary becomes president, there will be legislationn to prevent self-referrals......There is certainly potential for a major market upheaval.

That would be VERY interesting if it happened.
 

jwk

CAA, ASA-PAC Contributor
15+ Year Member
Apr 30, 2004
3,827
1,174
Atlanta, GA
. the thing hospitlas can't alienate the referring physician which i see so many hospitals doing. If i were a surgeon and i can get keep the facility fee and my fee if i opened up my center why wouldnt i. why would i give money to the hospital? unless there were something in it for me. It just simple business. If the hospitals want to stay profitable they have to change their business model.
But that same surgeon, who now only posts a couple of indigent or Medicare patients a month, still insists on having his ass kissed like he was bringing in cash-up-front patients, and expects a prime operating time ahead of all the surgeons who still are very happy bringing us their paying patients. Shouldn't the business model support those on the medical staff that still bring the bulk of their patients to a facility, and not worry so much about those who only bring in their indigent patients and act like they're doing the hospital a favor just by doing that?
 
About the Ads

johankriek

Membership Revoked
Removed
10+ Year Member
Jul 19, 2006
920
1
Status (Visible)
  1. Post Doc
If Hiliary becomes president, there will be legislationn to prevent self-referrals......There is certainly potential for a major market upheaval.

That would be VERY interesting if it happened.

what are talking about willis? what is a self referral?>
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
20
Status (Visible)
  1. Attending Physician
what are talking about willis? what is a self referral?>


Well, Arnold.......I'm talking about sending your patient to a surgery center that you own rather than where they would otherwise go.
 

johankriek

Membership Revoked
Removed
10+ Year Member
Jul 19, 2006
920
1
Status (Visible)
  1. Post Doc
Well, Arnold.......I'm talking about sending your patient to a surgery center that you own rather than where they would otherwise go.

that would be a ridiculous legislation.. thats like saying a dentist wouldnt be able to do work at his office.. She is not really trying to legislate that is she? where did you get that info? and what would be the point?
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
20
Status (Visible)
  1. Attending Physician
that would be a ridiculous legislation.. thats like saying a dentist wouldnt be able to do work at his office.. She is not really trying to legislate that is she? where did you get that info? and what would be the point?


Her or her cronies....essentially the Left slanted health care reform folks....

and this came from my "mentor".
 

VolatileAgent

Livin' the dream
15+ Year Member
Jul 6, 2005
1,049
13
Status (Visible)
If Hiliary becomes president, there will be legislationn to prevent self-referrals......

Well, Arnold.......I'm talking about sending your patient to a surgery center that you own rather than where they would otherwise go.

what do you mean "would be"? as you describe it, there already is. it's called the stark law. your "mentor" apparently doesn't, as you seem to believe, know everything. maybe time for a new mentor... when you're soon working for me...
 

VA Hopeful Dr

Senior Member
Volunteer Staff
15+ Year Member
Jul 28, 2004
24,763
42,246
Status (Visible)
  1. Attending Physician
what do you mean "would be"? as you describe it, there already is. it's called the stark law. your "mentor" apparently doesn't, as you seem to believe, know everything. maybe time for a new mentor... when you're soon working for me...

So its against the law to send patients to a surgery center that you own?
 

EtherMD

Membership Revoked
Removed
10+ Year Member
Dec 25, 2006
389
0
Status (Visible)
  1. Attending Physician
So its against the law to send patients to a surgery center that you own?

No. The surgeon explains to the patient in written form that he/she is an owner/has an interest in the facility. The patient is told that he/she can go elswhere for treatment. The patient signs a form acknowledging these facts.

As for what might happen when Obama or McCain wins the White House is anyone's guess.
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
20
Status (Visible)
  1. Attending Physician
what do you mean "would be"? as you describe it, there already is. it's called the stark law. your "mentor" apparently doesn't, as you seem to believe, know everything. maybe time for a new mentor... when you're soon working for me...

This will be my first response in VA's tone:


Go blow ...you Moe
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
20
Status (Visible)
  1. Attending Physician
No wait...I mean...

Go blow....you fat, double chinned, balding, big eared, sleep apneic, smelly Moe
 
About the Ads

Hawaiian Bruin

Breaking Good
15+ Year Member
Mar 13, 2003
2,180
1,197
Status (Visible)
  1. Attending Physician
Can we get the mods to start a "milmd vs. VA" forum? It'd be kinda like the web-based version of pro wrestling. You could even charge for pay-per-view access...

Seriously, every single potentially useful thread keeps degenerating into a pissing match, and young'uns like me who are trying to learn about the business end of our chosen profession from these kinds of useful threads lose out because of it.

We aren't taught diddly about this kind of stuff in med school, and it's obviously hugely important. More insight please, less trying to figure out whose e-peen is bigger.

Please?
 

SexPanther

This could be a problem
10+ Year Member
Feb 5, 2006
447
1
Status (Visible)
  1. Fellow [Any Field]
Can we get the mods to start a "milmd vs. VA" forum? It'd be kinda like the web-based version of pro wrestling. You could even charge for pay-per-view access...

Seriously, every single potentially useful thread keeps degenerating into a pissing match, and young'uns like me who are trying to learn about the business end of our chosen profession from these kinds of useful threads lose out because of it.

We aren't taught diddly about this kind of stuff in med school, and it's obviously hugely important. More insight please, less trying to figure out whose e-peen is bigger.

Please?


I tried, it was called "THE THREAD for Pissing contests, mine is bigger than yours, etc." However, the thread was removed from the forum in less than 12 hours (overnight).

I can tell you, they were already going at it pretty good prior to removal. Don't know why it was taken down, I had thought that it would keep this vitriol from permeating other threads (and it might be funny).

It does always seem to start with a comment from Volatile.
 

johankriek

Membership Revoked
Removed
10+ Year Member
Jul 19, 2006
920
1
Status (Visible)
  1. Post Doc
I tried, it was called "THE THREAD for Pissing contests, mine is bigger than yours, etc." However, the thread was removed from the forum in less than 12 hours (overnight).

I can tell you, they were already going at it pretty good prior to removal. Don't know why it was taken down, I had thought that it would keep this vitriol from permeating other threads (and it might be funny).

It does always seem to start with a comment from Volatile.

actually i wanted to post on that thread and i came back in a few hours it was gone. WHy did they take it away Isnt that un american to be stifling conversation. DIDNt socrates say truth comes in conversation or was that aristotle. I think the closing of threads should be banned. the thread will eventually die..
 

johankriek

Membership Revoked
Removed
10+ Year Member
Jul 19, 2006
920
1
Status (Visible)
  1. Post Doc
military md is a bully. he thinks becaus ehe donated 50 cents to the forum he can say or do waht he wants.. He thinks he knows everything. Im gonna go find his mentor and tell him to cancel you
 

johankriek

Membership Revoked
Removed
10+ Year Member
Jul 19, 2006
920
1
Status (Visible)
  1. Post Doc
\, and young'uns like me who are trying to learn about the business end of our chosen profession from these kinds of useful threads lose out because of it.

. More insight please,

Please?

you wanna mpre insight about the business end of medicine Ill sum it up

everyone is trying to screw you over. The insurance cos, the hospital, the group you are gonna work for, the nurses. everyone is trained to try to take away what you have or prevent you from getting what you deserve. See simple. You have to actively fight to make a living everyday. and when you are old have high blood pressure, dm, you are obese, have bph and cant hold it in for longer than 10 mins irritable bowel syndrome then you wont have the energy to fight anymore and the next guy will come in and take your place and he will go through the same thing. see simple i summed it up foryou
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
20
Status (Visible)
  1. Attending Physician
military md is a bully. he thinks becaus ehe donated 50 cents to the forum he can say or do waht he wants.. He thinks he knows everything. Im gonna go find his mentor and tell him to cancel you

yo...you clearly have a reading comprehension problem.

You claim I think I know everything.....Read the threads....I always claim that I'm learning everyday.....whereas the fat guy....always claims HE knows everything.....the resident ...the non boarded guy...the NO practice experience guy....

Read the threads.....the FAT guy always starts with name calling (kind of like you) when I simply state an opinion (right or wrong...it's my opinion that I'm entitled to)....people like the FAT guy starts calling me names.

I simply respond....

Don't start anything, and threads won't degenerate....you're welcome to your own opinion.....which you can state...but when you start pissing on me.....I'll respond in kind.
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
20
Status (Visible)
  1. Attending Physician
As for Stark, I believe it only applies to federally funded reimbursements...ie Medicare, Medicaid, and Tricare.....

Guess what?????? The surgery center owners DON'T want Medicare, Medicaid, and Tricare coming there.....

Anyone who knows better can correct me.....but not you Fat guy...because you clearly don't know any better.
 

sallyjoe

Full Member
10+ Year Member
Nov 6, 2006
73
0
Status (Visible)
  1. Attending Physician
As for Stark, I believe it only applies to federally funded reimbursements...ie Medicare, Medicaid, and Tricare.....

Guess what?????? The surgery center owners DON'T want Medicare, Medicaid, and Tricare coming there.....

Anyone who knows better can correct me.....but not you Fat guy...because you clearly don't know any better.

I heard of a new orthopedic surgery center that just opened in a large Texas city that did not allow Medicare, Medicaid patients so within a week or two of its opening one of the owner orthopedic surgeons tried to admit a Medicare patient. They convened an emergency meeting of the share holders and bought out the offending orthopedic surgeon and canceled his privileges.


Surgery centers can be good or bad for our profession. Many surgery center owners see anesthesia as a profit center and will put the anesthesia contract up for auction at a surgery center. How much would you pay for the excusive contract a surgery center for four years. I have heard of groups paying more than a million dollars to work in a surgery center for four years.


What about anesthesia coverage issues. If you work at a small town hospital where they get a new surgery center. The surgery center is only open 7 to 3 so the surgeons do their day time cases at the surgery center. The surgery center anesthesiologist do not take hospital call. So the hospital anesthesia group gets to take care of the Medicare, Medicaid patients and the percentage of daytime cases goes way down while the percentage of night and weekend cases goes up. I have worked a place that does almost no cases until noon then a noon case and then the start working from three to seven pm and then occasional cases overnight.
 

Disciple

Senior Member
15+ Year Member
Oct 18, 2004
2,845
479
Status (Visible)
  1. Attending Physician
As for Stark, I believe it only applies to federally funded reimbursements...ie Medicare, Medicaid, and Tricare.....

Guess what?????? The surgery center owners DON'T want Medicare, Medicaid, and Tricare coming there.....

Anyone who knows better can correct me.....but not you Fat guy...because you clearly don't know any better.

Stark does refer to to federally funded programs. However, some insurers have their own internal policies to stop physician self referral.

Hospitals also have methods to combat physician owned ASCs. Amongst these are "economic credentialing" and cutting deals with the insurance companies to have procedures for that carrier's patients performed at the hospital.
 

ReefTiger

Junior Member
10+ Year Member
5+ Year Member
Dec 1, 2005
89
0
Status (Visible)
  1. Attending Physician
So, I am curious as to the loopholes in these self referrals. For example, let's say you have a multi-specialty, multi-physician Surgicenter. Can a neurosurgeon refer a spine case to another surgeon at the surgicenter that both physicians own? Is this still self referral?

Is there a way around this by having ORs in a clinic setting and just do the procedure there? That way there is no referral to another center?

What is this economic credentialing by hospitals? Does anyone know what effect the push to have more medicare patients seen at ASC has had thus far?

For my own curiosity, what would be considered an excellent payor mix? average payor mix? Lowest payor mix you would accept in your practice/when looking for a job?
 
About the Ads

Duckie24

Totally Quackers!
10+ Year Member
5+ Year Member
May 28, 2004
161
0
Status (Visible)
No. The surgeon explains to the patient in written form that he/she is an owner/has an interest in the facility. The patient is told that he/she can go elswhere for treatment. The patient signs a form acknowledging these facts.
From what I understand, this isn't exactly correct either. I'm currently rotating with an ENT who owns a surgery center and he explained it thusly. He is part owner of the facility and operates there, so he can refer his own patients there without exception. However, someone else who has part ownership, but does not operate there, cannot refer their patients there.

So: own it, work there, no problems; own it, don't work there, problems.

That's how this doc explained it to me, and I assumed he knew what he was talking about since he's in the situation.

Great topic by the way. I had been wondering about this the very day the thread went up.
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
20
Status (Visible)
  1. Attending Physician
So, I am curious as to the loopholes in these self referrals. For example, let's say you have a multi-specialty, multi-physician Surgicenter. Can a neurosurgeon refer a spine case to another surgeon at the surgicenter that both physicians own? Is this still self referral?

Is there a way around this by having ORs in a clinic setting and just do the procedure there? That way there is no referral to another center?

What is this economic credentialing by hospitals? Does anyone know what effect the push to have more medicare patients seen at ASC has had thus far?

For my own curiosity, what would be considered an excellent payor mix? average payor mix? Lowest payor mix you would accept in your practice/when looking for a job?

Rather than looking at payor mix...looking at total revenue generated minus overhead costs....(billing, insurance, etc.)

Unfortunately, many practices will probably NOT allow you to scrutinize their books that closely.

So look at :

1) total revenue generated
2) how the revenue is divided
3) how many hours you have to work for your share of the revenue
4) are those hours when they are ok for you
5) find out if the revenue is subsidized by the hospital...either with employed physician extenders for the group...or with a direct payment to the group
 

EtherMD

Membership Revoked
Removed
10+ Year Member
Dec 25, 2006
389
0
Status (Visible)
  1. Attending Physician
From what I understand, this isn't exactly correct either. I'm currently rotating with an ENT who owns a surgery center and he explained it thusly. He is part owner of the facility and operates there, so he can refer his own patients there without exception. However, someone else who has part ownership, but does not operate there, cannot refer their patients there.

So: own it, work there, no problems; own it, don't work there, problems.

That's how this doc explained it to me, and I assumed he knew what he was talking about since he's in the situation.

Great topic by the way. I had been wondering about this the very day the thread went up.

I have the seen the forms that patients read regarding "surgeon ownership in the facility." The patients are aware their Physician is an owner in the facility and agrees to undergo the procedure at that facility."

Why would a facility want an owner who does not operate or do procedures at that facility? Why would a surgeon WHO DOES NOT do procedures at a facility refer his/her patients to that facility? Usually, the facility will issue shares of ownership ONLY to Physicians bringing cases to that place. Sometimes Anesthesiologists are offered shares as incentive to move cases along and increase productivity.

All surgeons in my area are required to have hospital privileges to operate at a surgi-center. Most of the time, this means the patient has the option (at least theoretically) to have that same procedure performed at a hospital.
 

ReefTiger

Junior Member
10+ Year Member
5+ Year Member
Dec 1, 2005
89
0
Status (Visible)
  1. Attending Physician
I just want to thank everyone who has contributed information to this thread. Other than the mild flame up, it has been a good thread. People are sooo touchy on these forum boards. It isn't just this one either. People do this stuff on every forum board I've ever read. The only positive benefit I see from it is that the thread gets bumped. I know that Ether probably feels like I was jumping on his case in a prior thread, but most of our dialogue is too difficult to infer intention. Nonverbal communication is key!

I think it is great that everyone still comes here to post for the benefit of those without any experience or knowledge. Especially since most people continue to do it DESPITE the flaming.

I'd love to keep this thread going, as I have not seen this much info on this topic on this board, and for selfish reasons previously stated.

Now, with all that said, I'll give you guys more info on the gig for more opinions on what info needs to be sought out, and of course I do enjoy gut feelings from people out in the "real world". By the way, what happened to Jet?

Ok, so this place is currently a 2 OR musculoskeletal institute with Neuro and ortho and pain management. They are expanding to 8 additional ORs (will initially run 4) and separate pain procedure rooms. There will be about 10-15 inpatient beds with infrastructure to expand to up to 20+ rooms in the future if needed. No ICU beds. This is somehow associated with one of the larger hospitals in town, but am unsure of exactly how. I am to understand it is to be physician run with "assumed debt" in the facility with contract signing. Currently there are 15+ physicians on staff with plans to expand. I do not fully understand all that "assumed debt" entails, as I did not get into total specifics with the business manager. I am still over a year to go before I'm in the real world, so talks are still very preliminary. This is why I am asking for you guys' help, advice, and I do appreciate it. I do think that this is very informative for other residents as we are not provided many details of such during training. (Ether, I know you've spoken about this plenty!)

Last two pieces of info I can give: total cost of new construction of ASC is about 15-18 million, and I asked about what he expects to generate. He said around 4-6 million/yr NET. Now, since this was a casual first meeting I was professional and didn't press the issue. So, I cannot be positive that NET means profit. I can find out in the future, but I want you guys to understand my situation.;)
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
20
Status (Visible)
  1. Attending Physician
Press the financial details.....otherwise how are you to make an informed decision.

1) where's the financing coming from? and what's the monthly note...over how long?

2) how many owners will there be?

3) how many percent to be owned by non-physicians ...ie manangment firm/hospital

4) expected monthly cashflow and where it's going....overhead, consumables, employees, utilities, etc.
 

EtherMD

Membership Revoked
Removed
10+ Year Member
Dec 25, 2006
389
0
Status (Visible)
  1. Attending Physician
I just want to thank everyone who has contributed information to this thread. Other than the mild flame up, it has been a good thread. People are sooo touchy on these forum boards. It isn't just this one either. People do this stuff on every forum board I've ever read. The only positive benefit I see from it is that the thread gets bumped. I know that Ether probably feels like I was jumping on his case in a prior thread, but most of our dialogue is too difficult to infer intention. Nonverbal communication is key!

I think it is great that everyone still comes here to post for the benefit of those without any experience or knowledge. Especially since most people continue to do it DESPITE the flaming.

I'd love to keep this thread going, as I have not seen this much info on this topic on this board, and for selfish reasons previously stated.

Now, with all that said, I'll give you guys more info on the gig for more opinions on what info needs to be sought out, and of course I do enjoy gut feelings from people out in the "real world". By the way, what happened to Jet?

Ok, so this place is currently a 2 OR musculoskeletal institute with Neuro and ortho and pain management. They are expanding to 8 additional ORs (will initially run 4) and separate pain procedure rooms. There will be about 10-15 inpatient beds with infrastructure to expand to up to 20+ rooms in the future if needed. No ICU beds. This is somehow associated with one of the larger hospitals in town, but am unsure of exactly how. I am to understand it is to be physician run with "assumed debt" in the facility with contract signing. Currently there are 15+ physicians on staff with plans to expand. I do not fully understand all that "assumed debt" entails, as I did not get into total specifics with the business manager. I am still over a year to go before I'm in the real world, so talks are still very preliminary. This is why I am asking for you guys' help, advice, and I do appreciate it. I do think that this is very informative for other residents as we are not provided many details of such during training. (Ether, I know you've spoken about this plenty!)

Last two pieces of info I can give: total cost of new construction of ASC is about 15-18 million, and I asked about what he expects to generate. He said around 4-6 million/yr NET. Now, since this was a casual first meeting I was professional and didn't press the issue. So, I cannot be positive that NET means profit. I can find out in the future, but I want you guys to understand my situation.;)


See Military MD's post for more financial information. But, based on the expansion you would do well in this facility assuming the surgeons are prompt, cost-conscious and plan on doing a lot of cases. You will need to run the place "lean and mean" with a minimum of Physician Anesthesiologists and CRNA's. The 'no fat' mode must be used as your income depends on it.
So, get the rest of the financial information and keep your options open about working in this facility.

Will you be the Physician Anesthesiologist in charge of the center? Or, will you be a 'junior' attending and owner in the place?
 

VA Hopeful Dr

Senior Member
Volunteer Staff
15+ Year Member
Jul 28, 2004
24,763
42,246
Status (Visible)
  1. Attending Physician
As for Stark, I believe it only applies to federally funded reimbursements...ie Medicare, Medicaid, and Tricare.....

Guess what?????? The surgery center owners DON'T want Medicare, Medicaid, and Tricare coming there.....

Anyone who knows better can correct me.....but not you Fat guy...because you clearly don't know any better.

See I wonder about this. I worked with an ophthalmologist who operated his own surgery center. As it was mainly cataracts, I'd think it was bunches of Medicare. Does this Stark law mean its illegal for him to send his own surgery patients over there?
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
20
Status (Visible)
  1. Attending Physician
See I wonder about this. I worked with an ophthalmologist who operated his own surgery center. As it was mainly cataracts, I'd think it was bunches of Medicare. Does this Stark law mean its illegal for him to send his own surgery patients over there?

Lots of exceptions to the law.....Loopholes exist also....

Imagine if Hillary and friends tighten up those loopholes.....there will be MAJOR upheaval in healthcare delivery for EVERYBODY.
 

Disciple

Senior Member
15+ Year Member
Oct 18, 2004
2,845
479
Status (Visible)
  1. Attending Physician
So, I am curious as to the loopholes in these self referrals. For example, let's say you have a multi-specialty, multi-physician Surgicenter. Can a neurosurgeon refer a spine case to another surgeon at the surgicenter that both physicians own? Is this still self referral?

Is there a way around this by having ORs in a clinic setting and just do the procedure there? That way there is no referral to another center?

What is this economic credentialing by hospitals? Does anyone know what effect the push to have more medicare patients seen at ASC has had thus far?

For my own curiosity, what would be considered an excellent payor mix? average payor mix? Lowest payor mix you would accept in your practice/when looking for a job?

The rule as I understand it is something like, If a physician is to have ownership in an ASC, then at least 1/3 of his/her total income must come from performing procedures at that facility.

"Economic credentialing" basically means that the hospital can find convenient ways to deny you priviledges if they think you may be sending cases to your surgery center rather than the hospital.
 

Disciple

Senior Member
15+ Year Member
Oct 18, 2004
2,845
479
Status (Visible)
  1. Attending Physician
Ok, so this place is currently a 2 OR musculoskeletal institute with Neuro and ortho and pain management. They are expanding to 8 additional ORs (will initially run 4) and separate pain procedure rooms. There will be about 10-15 inpatient beds with infrastructure to expand to up to 20+ rooms in the future if needed. No ICU beds.

Inpatient beds? ICU? That sounds more like a specialty hospital rather than an ASC. Different set of rules.

Current legislation is aimed at requiring new specialty hospitals to provide a certain amount of indigent services, emergency services, etc. By the lobbying of the AHA, of course.
 

ReefTiger

Junior Member
10+ Year Member
5+ Year Member
Dec 1, 2005
89
0
Status (Visible)
  1. Attending Physician
Alright, I've gotten some additional information about this scenario. This information comes from my friend who recommended me to this group. He is very trustworthy and hard working (was also the president of his medical school class, and is always professional).

1) This is going to be a specialty hospital.

2) Apparently the group also owns controlling interest in another regional hospital within 10 minutes from the specialty hospital. As of now the plans for that facility are not finalized, but enables additional future expansion of other services.

3) Both of the hospitals have an MRI machine

4) The business manager(s) I spoke with state they will be employees of the physicians. One of them has experience as a hospital business administrator, the other is a younger successful CPA from a respectable firm prior to joining this venture. These men are honest, hard working and from what I have gathered have great vision. I have heard some of this from my friend who originally recommended me to this group.

5) The total debt from the specialty hospital and other hospital is approximately 28 million.

6) Also, they plan on having nurses caring for no more than 3 patients in order to improve nursing and patient satisfaction.

7) As I understand things, a major tertiary hospital is also involved with financial backing, but I am unsure as to how exactly.

8) At this time, we are not sure how the contract would work with anesthesia, but for orthopeadics it is as follows: My friend recieved a stipend from the tertiary hospital until completion of residency and 1 year fellowship he begins in July. He will then work in the ASC/hospital for one year with a base salary of approximately $200,000. During the last quarter of the first year he will be able to receive payments from the revenue (he states they expect around $40-50K). Upon completion of the first year the board meets with him and decide to let him buy in to the group ($1 ceremony), or part ways. If he becomes partner the way he explained the debt payments on facilities are as follows: every month the hospital will generate x amount of dollars, from which you will pay back to the facility. This re-payment will always be less than the revenue. For a totally arbitrary example: At the end of the month his portion generated $1500, of which he owes 1000. So, he still recieves some additonal funds. Apparently this debt phase lasts for 3-4 years, at which time he will begin to receive the full $1500.

8) He told me that it was explained to him that his share after about 5 yrs would be around $500K not including salary.

9) Currently there are 17 physicians on staff.

10) No ICU beds in the expansion, but I believe there are some in the other hospital.

Now, I definitely understand his situation is different than what mine would be. I know they have at least 3-4 pain management physicians, 1 general anesthesiologist, 1 neurosurgeon, at least one physiatrist, and most of the rest are orthopods I believe. They will likely need more general anes. MDs in the future with the expansion which is where I come in.

At this point my main focus is to get all my ideas together prior to my next discussion with the business manager. I am actually very relieved that I would not have to sign a long term deal and assume debt without knowing how well the fit would be. Most of the physicians on the staff are older, church-going, pleasant people. My friend and I would be some of the new blood.

One of the major factors I would like in a contract would be membership on the board for integral participation regarding expansions, equipment, personnel etc. The folks I've spoken with say these two places will be run how we (MDs) want it to operate. Money is not the biggest lure in this set up for me, but it appears compensation has excellent potential.

They have already stated that their intention is to have CRNAs, but ultimately the decision would be up to physicians. Personally, I would prefer to have some CRNAs or some AAs to run the cases so I can be out doing blocks, spinals, preop etc. I do not have a problem with the care team model, especially if I have power to select who is hired.

What do you guys/girls think?
 

EtherMD

Membership Revoked
Removed
10+ Year Member
Dec 25, 2006
389
0
Status (Visible)
  1. Attending Physician
Alright, I've gotten some additional information about this scenario. This information comes from my friend who recommended me to this group. He is very trustworthy and hard working (was also the president of his medical school class, and is always professional).

1) This is going to be a specialty hospital.

2) Apparently the group also owns controlling interest in another regional hospital within 10 minutes from the specialty hospital. As of now the plans for that facility are not finalized, but enables additional future expansion of other services.

3) Both of the hospitals have an MRI machine

4) The business manager(s) I spoke with state they will be employees of the physicians. One of them has experience as a hospital business administrator, the other is a younger successful CPA from a respectable firm prior to joining this venture. These men are honest, hard working and from what I have gathered have great vision. I have heard some of this from my friend who originally recommended me to this group.

5) The total debt from the specialty hospital and other hospital is approximately 28 million.

6) Also, they plan on having nurses caring for no more than 3 patients in order to improve nursing and patient satisfaction.

7) As I understand things, a major tertiary hospital is also involved with financial backing, but I am unsure as to how exactly.

8) At this time, we are not sure how the contract would work with anesthesia, but for orthopeadics it is as follows: My friend recieved a stipend from the tertiary hospital until completion of residency and 1 year fellowship he begins in July. He will then work in the ASC/hospital for one year with a base salary of approximately $200,000. During the last quarter of the first year he will be able to receive payments from the revenue (he states they expect around $40-50K). Upon completion of the first year the board meets with him and decide to let him buy in to the group ($1 ceremony), or part ways. If he becomes partner the way he explained the debt payments on facilities are as follows: every month the hospital will generate x amount of dollars, from which you will pay back to the facility. This re-payment will always be less than the revenue. For a totally arbitrary example: At the end of the month his portion generated $1500, of which he owes 1000. So, he still recieves some additonal funds. Apparently this debt phase lasts for 3-4 years, at which time he will begin to receive the full $1500.

8) He told me that it was explained to him that his share after about 5 yrs would be around $500K not including salary.

9) Currently there are 17 physicians on staff.

10) No ICU beds in the expansion, but I believe there are some in the other hospital.

Now, I definitely understand his situation is different than what mine would be. I know they have at least 3-4 pain management physicians, 1 general anesthesiologist, 1 neurosurgeon, at least one physiatrist, and most of the rest are orthopods I believe. They will likely need more general anes. MDs in the future with the expansion which is where I come in.

At this point my main focus is to get all my ideas together prior to my next discussion with the business manager. I am actually very relieved that I would not have to sign a long term deal and assume debt without knowing how well the fit would be. Most of the physicians on the staff are older, church-going, pleasant people. My friend and I would be some of the new blood.

One of the major factors I would like in a contract would be membership on the board for integral participation regarding expansions, equipment, personnel etc. The folks I've spoken with say these two places will be run how we (MDs) want it to operate. Money is not the biggest lure in this set up for me, but it appears compensation has excellent potential.

They have already stated that their intention is to have CRNAs, but ultimately the decision would be up to physicians. Personally, I would prefer to have some CRNAs or some AAs to run the cases so I can be out doing blocks, spinals, preop etc. I do not have a problem with the care team model, especially if I have power to select who is hired.

What do you guys/girls think?

Sounds pretty good. What is your base salary? What is your final salary? How long to reach 'maximum salary? are you on the hook if things don't go well for the hospital/ASC? That is, will you owe money out of your salary to cover expenses for a bad month/year? THe devil is in the details and.or the fine print. Read over every document and get a good lawyer. The last thing you want is to be on the hook if things don't go as expected.

However, most likely you will make good money from this venture. So, as long as your base salary is fair and your final salary without hospital revenue bonus is decent ($300,000 or more plus benefits) it seems like a good deal.
 

VolatileAgent

Livin' the dream
15+ Year Member
Jul 6, 2005
1,049
13
Status (Visible)
Lots of exceptions to the law.....Loopholes exist also....

Imagine if Hillary and friends tighten up those loopholes.....there will be MAJOR upheaval in healthcare delivery for EVERYBODY.

why do you have such a bug up your ass about "hillary"? she didn't do a goddamn thing in the '90's (except benefit you by scaring a lot of people out of entering residency training in anesthesiology) and none of her part of the "clinton healthcare reform" happened. it was a colossal fart in church.

what makes you think she could do any better in 2008? do you actually think one person has that much power? what makes you think she has a snowball's chance getting elected in the first place? i hope they nominate hillary. that's a sure win for the republicans.

guess we need to add politics to the list of things you have little grasp of.
 

VA Hopeful Dr

Senior Member
Volunteer Staff
15+ Year Member
Jul 28, 2004
24,763
42,246
Status (Visible)
  1. Attending Physician
why do you have such a bug up your ass about "hillary"? she didn't do a goddamn thing in the '90's (except benefit you by scaring a lot of people out of entering residency training in anesthesiology) and none of her part of the "clinton healthcare reform" happened. it was a colossal fart in church.

what makes you think she could do any better in 2008? do you actually think one person has that much power? what makes you think she has a snowball's chance getting elected in the first place? i hope they nominate hillary. that's a sure win for the republicans.

guess we need to add politics to the list of things you have little grasp of.

Why were doctors terrified of John Edwards in 2004? He was only going to be the VP, yet folks were running around like he was going to single handedly sue every doctor into the poor house.

You're probably right about a Hillary nomination being a sure thing for Republican win. But given her views on national health care, I'd hate to be wrong.
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
20
Status (Visible)
  1. Attending Physician
Lots of exceptions to the law.....Loopholes exist also....

Imagine if Hillary and friends tighten up those loopholes.....there will be MAJOR upheaval in healthcare delivery for EVERYBODY.

why do you have such a bug up your ass about "hillary"? she didn't do a goddamn thing in the '90's (except benefit you by scaring a lot of people out of entering residency training in anesthesiology) and none of her part of the "clinton healthcare reform" happened. it was a colossal fart in church.

what makes you think she could do any better in 2008? do you actually think one person has that much power? what makes you think she has a snowball's chance getting elected in the first place? i hope they nominate hillary. that's a sure win for the republicans.

guess we need to add politics to the list of things you have little grasp of.

Hey Baldy.......Where in the definition of the word "imagine" implies fear?

Actually where in any of my posts show fear of Hiliary and Universal Health care reform.

I'm actually a physician with special qualifications in Critical Care medicine....They can shut down ALL of the ORs in the US, and I'll still have a job.....without even moving hospitals.

You, on the other hand, are just a resident who can't even read.

I hope that Universal Health care does come into play.....You can make your 5 dollars a unit sitting on a stool, charting vital signs, and moving the table for your surgeon...while you shout "I'm a doctor"...."only a doctor can do this"

Fatty, remember this....residents have no grasp of anything....and that's you...
 

nimbus

Member
15+ Year Member
Jan 14, 2006
7,364
10,233
Status (Visible)
Reeftiger,

Sounds like a potentially rewarding venture. It could be the opportunity of a lifetime, especially if you are in an early life stage and not saddled with mortgage/alimony/etc.

But...

Your friend's referral aside, why you? As a newly minted practitioner, what are you bringing to the table? Do you have management experience? Can you contribute capital to this project? Is it a geographically difficult recruiting area? Besides a fresh outlook and "trainability", why are they interested in you?

The principals (orthopods and pain docs) of this project must have existing relationships with anesthesiologists already in the community. In my neck of the woods, there would be multiple groups competing to get a piece of this action. Where are the anesthesiologists from the affiliated hospital? Are there other hospitals/anesthesia groups in the area? Were they invited to participate in this venture? I would talk to them to find out why they are not involved. They may be happy in their current situation and not want to anger management in their current hospital by participating in a competing specialty hospital. Or the anesthesiologists may have issues with the venture itself, especially with respect to volume and contracts. Surgeons always bring their best paying patients to their own facilities, but some health plans reimburse one party well at the expense of another. I would especially be wary of mandatory participation in health plans which may be favorable to surgeons and the facility but not to anesthesia. I would want to know why there is not much local anesthesia participation, keeping in mind that what may not be right for them may still be right for you.
 

EtherMD

Membership Revoked
Removed
10+ Year Member
Dec 25, 2006
389
0
Status (Visible)
  1. Attending Physician
Reeftiger,

Sounds like a potentially rewarding venture. It could be the opportunity of a lifetime, especially if you are in an early life stage and not saddled with mortgage/alimony/etc.

But...

Your friend's referral aside, why you? As a newly minted practitioner, what are you bringing to the table? Do you have management experience? Can you contribute capital to this project? Is it a geographically difficult recruiting area? Besides a fresh outlook and "trainability", why are they interested in you?

The principals (orthopods and pain docs) of this project must have existing relationships with anesthesiologists already in the community. In my neck of the woods, there would be multiple groups competing to get a piece of this action. Where are the anesthesiologists from the affiliated hospital? Are there other hospitals/anesthesia groups in the area? Were they invited to participate in this venture? I would talk to them to find out why they are not involved. They may be happy in their current situation and not want to anger management in their current hospital by participating in a competing specialty hospital. Or the anesthesiologists may have issues with the venture itself, especially with respect to volume and contracts. Surgeons always bring their best paying patients to their own facilities, but some health plans reimburse one party well at the expense of another. I would especially be wary of mandatory participation in health plans which may be favorable to surgeons and the facility but not to anesthesia. I would want to know why there is not much local anesthesia participation, keeping in mind that what may not be right for them may still be right for you.


Good Post. You hit many areas of concern.:thumbup:
 
About the Ads
This thread is more than 14 years old.

Your message may be considered spam for the following reasons:

  1. Your new thread title is very short, and likely is unhelpful.
  2. Your reply is very short and likely does not add anything to the thread.
  3. Your reply is very long and likely does not add anything to the thread.
  4. It is very likely that it does not need any further discussion and thus bumping it serves no purpose.
  5. Your message is mostly quotes or spoilers.
  6. Your reply has occurred very quickly after a previous reply and likely does not add anything to the thread.
  7. This thread is locked.