Anesthesiologist Shortages, Cardiology Procedures, and Reimbursement in the ASC w/ Bruce Feldman

Erik Sunset: [00:00:00] All right. Hello and welcome back. I’m Erik Sunset, your host of the DocBuddy Journal. Here at DocBuddy, we deliver healthcare solutions to take the pain and cost out of broken workflows. And today we’re joined by Bruce Feldman of BRF Consulting, Inc., which provides strategic planning, business development, and operational services for ASCs.

Erik Sunset: Bruce has extensive executive experience managing operations for practices, hospital departments, and surgery centers, and he’s done so for a variety of specialties, including cardiology, spine and pain, endoscopy, diagnostic imaging, and more. Thanks for joining us, Bruce. How are you

Erik Sunset: doing today?

Bruce Feldman: Sure. Fine. Thank you. Thanks for inviting me.

Erik Sunset: It’s our pleasure. Glad to get a little bit of ASC expertise onto the show. Hopefully we did you justice with that introduction there. Is there anything else our listeners should know about you

Erik Sunset: though?

Bruce Feldman: No, I’ve been in the healthcare administrative arena now for about 38 plus years predominantly in the [00:01:00] ambulatory care side of the equation. And as you mentioned managing outpatient article 28 facilities ambulatory surgery centers physician practices. Independent urgent care centers.

Bruce Feldman: So predominantly, mostly like I said, in the ambulatory care arena as well as both hospital based as well as private practice based.

Erik Sunset: So that’s a, a lot of different lenses to look through. Obviously we’re here today because of a Becker’s ASC article. It was titled ASCs offer anesthesiologist stipends as competition heats up. That’s been a recurring theme. If you’re paying attention to the news in any capacity, either focused in ASC, vertical, or broader healthcare, we know that there is a shortage of anesthesiologists out there. What do you do to solve for this

Erik Sunset: problem, Bruce?

Bruce Feldman: Well, I think the biggest thing that most ASCs and for that matter, hospitals are turning towards is the employment [00:02:00] of anesthetists. The problem is currently in many of the states, including New York and New Jersey in order to employ a certified registered nurse anesthetist in an ASC setting, there has to be a certified, board certified anesthesiologist on the premises, which obviously doesn’t solve the problem because that’s CRNAs in the first place.

Bruce Feldman: So, what was being pushed by ASCO, which is the Association of Surgery Centers, is to get all that legislation removed in a lot of states so that they can employ certified registered nurse anesthetists to take the place. The problem is that most CRNAs do not have the level and the skill set training that obviously anesthesiologists have.

Bruce Feldman: And the issue at hand is that as more and more complex procedures move from the hospital sector into the ASC [00:03:00] environment will some of these CNRAs have enough skill set and training to be able to do some of these more complex procedures, which typically require more deeper anesthesia longer recovery time, et cetera.

Bruce Feldman: So it’s somewhat of a double edged sword in that respects.

Erik Sunset: Well, and it’s certainly a double edged sword, but something has to give. You’re quoted in this Becker’s ASC article that the continued shortage of anesthesiologists had led to To many surgery procedures is having to be canceled and or postponed both in the hospital as well as the ASC setting. When you pair that with the broader cataclysm of not just the lack of anesthesiologists but a lack of providers, lack of doctors and of mid levels, they’re retiring earlier than they ever have.

Erik Sunset: They aren’t going through medical school as they historically have. Something’s got to give. So if you had a magic wand to wait, what

Erik Sunset: would you do?

Bruce Feldman: Well, unfortunately, I don’t have a magic wand to wave [00:04:00] and I think this problem is only going to get perpetually worse as time progresses. As you mentioned, many anesthesiologists have retired from the field. There’s a significant shortage of anesthesiologists. Many anesthesiologists that were covering ambulatory surgery centers, Now want a certain guaranteed minimum number of procedures to make it worthwhile to come to the center.

Bruce Feldman: They also don’t want to do procedures that don’t have, you know, higher revenue reimbursement rates such as like colonoscopies. Those are traditionally cases that are done under, you know, profofol. They’re quick cases, 15, 20 minutes. And the reimbursement from an anesthesia perspective is minimal.

Bruce Feldman: They would much rather come to an ASC and do a hip replacement or a joint replacement or a complex you know, general surgical procedure to make it worth their while. So that’s a problem that I don’t know how we’re going to really get to quickly fix that. A lot of [00:05:00] ASCs are now faced with the situation that anesthesiologists want to stipend to make sure that they’re guaranteed a certain amount of revenue.

Bruce Feldman: Beside the billing that they do. So they want to get paid a, a, a day rate or a case rate, plus have the ability to bill for their services. And that obviously becomes very costly to an ambulatory surgery center. Most ASCs usually employ a outside anesthesiology group to cover their services and the anesthesiology group basically just bills for their services, for their bill for the anesthesia services.

Bruce Feldman: very much. If they now have to get paid by the ambulatory surgery center, a stipend in order to provide services that is going to, you know, take away from the ASCs bottom line and it’s going to become more expensive for ASCs to do these you know, more complex procedures without having anesthesiologists.

Erik Sunset: Absolutely. [00:06:00] And obviously ASCs are not they’re, there’s, they’re walking a fine is what I’m trying to say here, that there’s not a whole lot of room to give on some of the margins for their procedures. So when you’re dealing with this scenario, where the anesthesia, which is external to the ASC as a business entity is either demanding or getting a stipend.

Erik Sunset: It seems to me that the ASC would need to be very clever in how it’s scheduling procedures. There can be no, no misses, essentially. Is

Erik Sunset: that the right way to look at it?

Bruce Feldman: Yeah, no, that’s absolutely correct. They have to make sure they have basically no gaps in the schedule. You know, you don’t want to have a two or three hour gap with no cases going on because obviously that’s going to hit your bottom line. So what a lot of ASCs have started to do now is they started consolidating their schedule.

Bruce Feldman: So instead of operating five days a week, they’re maybe now operating three days a week. And starting, you know, earlier, starting at seven, going maybe until six. Whereas before they would typically, you know, do six to three, five days a [00:07:00] week. So that is one thing that we’re starting to see happen, but you’re absolutely correct in that you have to be much smarter in terms of not only the length of time of your procedures, but the number of procedures that you’re scheduling in a given day.

Bruce Feldman: And if that means extending the time, like I said earlier and doing three days a week rather than five days a week then that, that can help because now you’ll basically have an anesthesiologist who comes you know, and is maximizing whatever stipend you’re giving them for the day. And they’re also getting a maximum amount of reimbursement from their end of the equation.

Erik Sunset: Yep, that’s obviously the optimal arrangement. Still, still tough sledding for those wearing the ASC hat. Although one spot that is a relatively bright spot is having more and more of these cardiologic procedures come off that inpatient only list. Lot of buzz going into 2024 around new cardiology procedures being [00:08:00] performed in the ASC.

Erik Sunset: Will you level set with the, the listeners of the show, why is that exciting? What do they need to do to be getting cardiology procedures on the schedule? And then if they’re already getting them, what could they be doing to get

Erik Sunset: more? What do you think?

Bruce Feldman: Sure. Well, I, I think it’s the next, you know, hot ticket amongst ASCs is cardiac procedures. We saw that, you know, two, three years ago with orthopedics with hip replacements and joint replacement surgery shifting from the hospital to the ASC. I think the new frontier is going to be cardiac procedures.

Bruce Feldman: Specifically things such as peripheral vascular stenting pacemaker battery changes, pacemaker implants implantation of ICDs, internal cardiac defibrillators and coronary angiography. Out Midwest, there’s actually a lot of cardiology groups that are developing single specialty ASCs just for cardiac procedures.

Bruce Feldman: You know, we saw that with GI with a lot of gastroenterology [00:09:00] groups building and developing their own endoscopy centers and now we’re seeing it, you know, with single specialty cardiac procedures. These procedures tend to have good reimbursement rates, at least for now, and I think that will eventually change as well as you know, everybody and the insurance companies get.

Bruce Feldman: But, you know, we all know that ASCs can offer a lower cost procedures than what the hospital can do. It’s a much more efficient environment, higher patient satisfaction, higher physician satisfaction. Turnover time is quicker. Patients can be home, you know, by a reasonable hour on the same day they’re less susceptible to developing a postoperative infection because they’re not exposed you know, to other patients like they are in a hospital setting.

Bruce Feldman: So I think we’re going to continue to see more and more procedures with cardiac. I think the big thing is to really have bigger [00:10:00] operating rooms because Typically, you need equipment that takes up more space, especially when it comes to doing angiography work. These cameras are typically, you know, quite expensive and it could be a very costly proposition.

Bruce Feldman: So, before you get into the cardiac arena, you have to make sure that you’re going to have enough of a volume to support the cost. for this equipment. And that’s why we’re seeing really basically out like in the Midwest and Arizona, you know, these big cardiac cardiology groups like Texas Heart developing their own cardiac ASCs, but specifically to doing cardiac procedures.

Bruce Feldman: But these are 15 to 20 man groups. So they can easily support, you know, doing, you know you know, 10, 15 cases a day. Yeah. Whereas, a typical multi specialty facility that’s just basically looking to bring in cardiac may not have the volume to be able to justify the cost of this equipment, which can be, as I mentioned [00:11:00] earlier inexpensive proposition.

Bruce Feldman: Even the disposables like the peripheral vascular stents that are required to have on board. To do some of these procedures, having onboard pacemakers having onboard, you know, internal defibrillators. And that’s why you’re seeing a lot of partnerships now being developed with companies like Medtronics that do a lot of work in the cardiac arena Smith and Nephew those kind of companies are now partnering with ASCs to basically provide the equipment.

Bruce Feldman: And then the ASCs pay for it on a, on a per procedure basis. So you don’t have this huge outlay. Stryker has done that many years ago with orthopedics. And now we’re seeing that, you know, like I said, with companies like Medtronix. They’re doing that with with cardiology.

Erik Sunset: What, as you said the ASC is the rare win win win in healthcare where you have. Patient provider and payer all in alignment. This is a good thing. We [00:12:00] want to do a bunch of procedures in this surgery center as opposed to a hospital outpatient department. As the year progresses, do you expect to see economies of scale realized for those ASCs wading into the world of cardiologic

Erik Sunset: procedures?

Bruce Feldman: Yeah, absolutely. And I think you’re gonna see more and more cardiac specialties. Shifting into the ASC and as such, you’re going to see a consolidation. You’re seeing that in the ASC management arena with companies like, you know, Optum buying SCA and tenant healthcare acquiring USPI.

Bruce Feldman: You’re seeing a consolidation there as well. And I think the same thing is going to hold true with ASCs. I think you’re not going to have the number of proliferation of ASCs that you have now because there has to be economies of scale. You can’t, you know, New Jersey and New York, for instance, are very heavily in terms of ASCs.

Bruce Feldman: There’s like one ASC. [00:13:00] For every, you know, two, two and a half miles. I don’t think that’s going to be able to continue. I think competition is going to become greater for these procedures as such. I think you’re going to see a greater consolidation. I also think you’re going to have to see ASCs that have a larger number of ORs.

Bruce Feldman: You’re going to. C A S C is getting away from the, just the two and three procedure room, you know, two and three O Rs having to go to like five O Rs, six O Rs, you know, seven O Rs and having maybe, you know one A S C in a given geographical area that can accommodate a larger volume and a larger diversity of types of patients.

Erik Sunset: Hard to argue to there. I saw some of that reporting the last couple of weeks that it’s obviously very expensive to build new facilities. Still expensive to add on to existing, but a little more bang for your buck to expand operations as to build.

Bruce Feldman: Yeah, the problem is that as you know there are several states that have a CON [00:14:00] Application process that is required to build a new ASC, New York being one, New Jersey being one That’s why you’re seeing a huge slowdown in ASCs in those states, I think there’s legislation now that ASCA is pushing for, for the CON requirement, many of these states to be lifted so that it is easier to build and also to expand an existing ASC, for instance, in New Jersey, the state of New Jersey in order to build a new ASC, there’s a moratorium on the development of new ASCs, you have to either partner with a hospital, or acquire an existing ASC license.

Bruce Feldman: So you’re seeing some ASCs that have not been doing well sell themselves to larger healthcare systems. And so I think that’s another, you know, development that you’re going to see within the next few months moving at a much faster pace.

Erik Sunset: Well, you’ve [00:15:00] invoked ASCA a couple of times. They’re good friends at ASCA. We will absolutely be in Orlando in April supporting the cause and hope to see you there, as well as

Erik Sunset: all of our

Bruce Feldman: Yes, I, I, I will be there.

Erik Sunset: Changing gears just a little bit because you’ve, you’ve been very popular with Becker’s ASC over the last handful of months.

Erik Sunset: This This point I with the ASC’s eye business growth, but headwinds persist. You’re quoted in this article that the other biggest issue is reimbursements. Getting the insurance companies to pay you the proper amount for the procedures you’re doing. Getting paid to contract seems like, you know, step one in the revenue cycle process. Obviously, that’s not always the case. What are your words to the wives for ASCs to be sure they’re making they’re collecting rather the money that they’re owed?

Bruce Feldman: Well, you know, the old adage isn’t how many cases you’re doing, it’s doing the right Types of cases and making sure that your reimbursement is up to par knowing your case per, you know, [00:16:00] your cost per case is very important. I think a lot of ASCs concentrate on just building volume, volume, volume, but they may not be necessarily you know, doing the types of cases that have the higher revenue producing a reimbursement.

Bruce Feldman: I think the biggest problem in this area is that hospital outpatient departments continue. To get paid higher reimbursement rates than ASCs. This is true with Medicare, and as you all know most insurance companies follow Medicare regulations. So whatever Medicare approves or doesn’t approve to be done in an ASC.

Bruce Feldman: Other commercial carriers follow suit. And right now that has not been par. So as we see this outward migration of more complex procedures moving into the ASC environment, what we’re not seeing is the reimbursement being on par with what it was if that same procedure was done in the hospital. And which is to [00:17:00] me kind of, you know, A little bit ironic because you would think that insurance companies would look to save money and therefore would be much willing to pay for a procedure that can be done in a much lower cost setting than a hospital.

Bruce Feldman: And yet we really have not seen that trend. Following at the same rate as we are seeing this outward migration of procedures. I think that’s one of the reasons why you’re seeing a large number of large healthcare systems acquiring or developing their own ASCs because they realize that they’re losing this volume that’s being traditionally done in the hospital and the revenue associated with it.

Bruce Feldman: And so they take a stake, an equity stake in developing an ASC so they don’t lose this volume. But. You know, again, it’s becoming more expensive to do these procedures in the ASC and yet the reimbursement has not followed suit. So I think it’s very [00:18:00] important that you monitor your, your revenue.

Bruce Feldman: I think it’s very important that you keep a close eye on your costs. You really have to know your cost per case. Not all cases are worthwhile doing. And an ASC because they’re just not revenue producing it. Let’s face it, ASCs are a business just as hospitals are a business. It is about the bottom line, especially ASCs that are owned by these you know, private equity firms that have a stake in the ASCs.

Bruce Feldman: They want to have a, you know, a fair return on investment for their stakeholders just like any other business. So it’s going to, you know, it’s really basically like I said keeping a close eye on reimbursement, but we really need to lobby more asker, I think is, is doing a great initiative in lobbying the CMS and the other commercial payers to make the pay equity [00:19:00] equivalent to what it has been traditionally for these procedures to be done in the hospital sector.

Bruce Feldman: And hopefully that will continue.

Erik Sunset: Bruce, I’m really curious about your thoughts on this. We had, we actually had Bill Prentice who who leads ASCA on the show last year. And one of the, One of the biggest hurdles that he shared that ASCA faces is just simply the awareness of what an ASC is, what it does, what it means for patients. I’m sure in your own life, I know this happens in mine, friends and family ask, you know, what’s an ASC?

Erik Sunset: Is that like getting a procedure at the hospital? And no, it’s not. Your outcome will be similar. You’ll have had a procedure done, but it’s cheaper. It’s less costly, less chance for infection, all these great pros. it sounds to me, bring us back to the point here, that when we talk about lobbying in Washington and being able to get an equivalent reimbursement for a procedure done at the ASC versus in that hospital setting, [00:20:00] is awareness the issue there as

Erik Sunset: well?

Bruce Feldman: Yes, certainly it is. And I know that ASCR and some of the the state ASC societies have been selling, you know, been sending delegates. I’ve gone, I went to Washington last year as part of my local chapters delegation to make congressmen and senators aware of how more cost effective It is to do these procedures.

Bruce Feldman: I think also what you’re seeing is a lot of ASCs are doing these open houses where they basically invite the public to come in and, you know, see an ASC and explain to them what the difference is in having their procedure done in a hospital. Versus having it done in an ASC. So awareness of what an ASC is just as it’s important to the legislative community it’s important to the general public as well.

Bruce Feldman: As you know, doctors basically drive the decision as to where the patient’s going to have their surgery. So, you [00:21:00] know, you don’t see patients basically saying, well, I want my surgery done at this center. It’s basically wherever their doctor goes. But doctors are all very well aware that it is more efficient.

Bruce Feldman: So I don’t, I don’t think we have to sell it to the doctors. I think we just have to get the reimbursement to want them to do their procedures more and more. In the A. S. C. Arena.

Erik Sunset: That’s it. You gotta have a economic rationale behind it and you can solve a lot of

Erik Sunset: problems that way.

Bruce Feldman: Yeah, absolutely. I think doing these, you know, these open houses where I know a lot of states you know, invite their local state congressmen and state legislative people to come to the center and get to experience firsthand. You know, one of the centers that I was involved with the, one of the local congressmen actually had his knee replacement done at the ASC and the next day, you know, he was promoting, you know, how great, you know ASCs are the fact that he was, you know, he was in at seven at home by [00:22:00] eight, you know, and ambulatory and you know, no pain discomfort and just all the advantages.

Bruce Feldman: I think the other thing that has really helped ASCs specifically is COVID. Because a lot of patients, you know, did not want to have their surgeries done in a hospital when COVID hit because of a, you know, fear that they’re going to contract COVID. And that same fear has now basically stayed with them.

Bruce Feldman: Patients would much rather have their procedure done in an ASC and not go to the hospital where the likelihood of contracting COVID is much greater. So COVID has in some way helped. Shift patient awareness on legislative awareness to these types of this type of environment.

Erik Sunset: Well, we certainly wish ASCA the best as it continues to fight the good fight. Folks like yourself, Bruce, who are going and traveling to Washington to make the voice of the community heard hugely appreciated.[00:23:00]

Erik Sunset: Before Before we conclude Bruce, we, we talked about this before we started recording AI and healthcare, you can run from it, but you sure can’t hide there’s an AI headline everywhere you turn now.

Erik Sunset: What kind of thoughts are you see the future of artificial intelligence or so called

Erik Sunset: artificial intelligence in healthcare?

Bruce Feldman: Well, I think AI is here to stay and it’s going to evolve at even a rapid rate So I think we have to embrace it and I think there are a lot of opportunities to use ai, AI to get the types of data that traditionally has been very difficult to obtain and very manually intensive. As an example determining if you know, physician a can do a procedure more efficiently and more cost effectively than physician B at the same surgery center.

Bruce Feldman: You know, that data typically, you know, you have to go in to the record and see how long it took Dr. A to do the procedure, how [00:24:00] long it took Dr. B you know, what equipment did Dr. A use versus Dr. B use. Artificial intelligence office platforms, where a lot of that can be, you know, automatically they can build a physician profile.

Bruce Feldman: Literally within a day, you know, within just two or three cases, whereas it can take, you know, 25 to 30 cases to get that type of data to make decisions. Things like utilization of physician block time, you know, is physician A utilizing their block time effectively? Those types of things and that gets back to one of your earlier statements about making, you know, the ASCs more efficient.

Bruce Feldman: Making sure that you’re maxing out the number of procedures that you’re doing in the day. AI can be a great asset and a great tool in that regard. So, yeah, I think AI is a good thing. Obviously, you know, there’s concerns that it’s evolving at a much quicker rate than we [00:25:00] really understand it.

Bruce Feldman: And that’s, that’s obviously a little bit of a concern. But I think that it’s going to give us the quality data and the information that we need to be able to make ASCs even more. Clinically sound and you know, more effective and is going to increase awareness to the benefits even greater than it is now.

Bruce Feldman: So I think AI is a good thing in that respect. And, you know, like I said, it’s, there’s no escaping it. So it’s here, whether we like it or not. And we just have to find out the best way to to utilize it to our advantage.

Erik Sunset: I’m with you, you know, you go back five or so, advent of a pen and paper in the medical practice, you know, writing down patient notes that was never going to treat the patient. AI the same way it can help you treat patients and help you be a more effective and profitable business, as you so rightly pointed out a little bit ago, I think that’s a pretty correct lens.

Erik Sunset: I wouldn’t recommend anybody run around [00:26:00] and try to get AI every nook and cranny of their facility or of their practice without a reason

Erik Sunset: to do it.

Bruce Feldman: No, absolutely. Like I said, it’s, it’s using it, but making sure. That you have the information of how you’re going to use it and why you’re going to use it you know, and what setting is it most appropriate to be used. But I think healthcare is, you know is a great environment. For AI to really make a difference in terms of patient outcomes to give physicians the information that they need to do procedures much more acutely it’s almost comparing it to when robots were introduced into the ASC environment, like the da Vinci you know, basically gave physicians the ability and the tools to do a procedure much more, not only cost effectively, but with a greater outcome in a shorter period of time, you know, less incisions, the outcomes.

Bruce Feldman: More precise surgery, which leads to better patient outcomes. AOI, I think, is a similar. [00:27:00] Comparison to you know, to the robot.

Erik Sunset: Well put. Well, before I ask you where our listeners can find you online, if you had one parting shot for everybody out there at an ASC, whether they’re a provider, administrator, somebody in the billing office, what’s one thing you think that all the winning or ahead of the curve ASCs should be doing for 2024?

Bruce Feldman: I think you always have to be one step ahead of the game. I think you always have to look ahead and see what’s coming down the pike and prepare your ASC to be able to accommodate that. So it’s sort of a moving target. And, you know, we can’t become stagnant. You can’t become content with, you know, what you’re doing now.

Bruce Feldman: You have to be looking at the horizon and seeing what’s coming down the pipe. So it’s really basically having sort of a crystal ball to some degree gathering the data and, and taking a jumpstart. You know, you don’t want to [00:28:00] be the ASC that missed the mark. And now the ASC down the road from you is doing those procedures.

Bruce Feldman: So you really have to basically. Be on top of your toes, you know, your toes, so to speak. And always be looking to refine things, make things better embrace new technology embrace you know, physicians bringing these types of cases to your facility and really basically Like I said, constantly evolving as the healthcare landscape evolves.

Erik Sunset: And I’m over here kind of laughing to myself. You provided the blueprint for what you just they all be doing in today’s show. Reimbursement data, being more efficient, cardiology procedures, and start to think about how AI can be impactful for you.

Bruce Feldman: Absolutely.

Erik Sunset: Well, Bruce, for those who would like to get in touch online, are there any social networks you can be found on? Are there any websites you want to point

Erik Sunset: anybody towards?

Bruce Feldman: I think Asker is very good. Becker’s you know, is very good for ASC [00:29:00] information. Personally, you can find me, you can find me on LinkedIn. So if you just pipe, you know, type my name into LinkedIn, I’m there and I have a lot of resource tools on available on my LinkedIn profile.

Erik Sunset: And we’ll get links to those sites into your profile, into show notes. Bruce want to thank you for your time and to our listener out there on behalf of the entire DocBuddy team, thank you for spending some of your podcast listening budget with us. Be sure you’re subscribed on Apple podcasts, Spotify, and YouTube, and we will catch you on the next episode of the DocBuddy journal.

Erik Sunset: Thanks everybody. Take care.

Bruce Feldman: Thank you.