Gastroenterologists are being asked to do more for less - and to take a longer time doing it. Talk about being caught between a rock and a hard place.

• Do more. As long as colon cancer screening continues to increase the rates of early identification of cancer's most preventable form, expect patient demand for screenings to remain high. Between 2000 (when Medicare would pay for colonoscopies only if patients were likely to have polyps and cancer) and 2002 (when it agreed to pay for the procedures as a screening test), the number of colonoscopies undergone by Medicare recipients increased by 42 percent, from 2.2 million to 3.2 million. Could higher co-payments slow patient demand? Effective Jan. 1, Medicare beneficiaries are required to pay a 25 percent co-pay for screening colonoscopies (HCPCS G0105, G0121), an increase of 5 percent. Only the co-pay for these two procedures is increased.
• For less. Medicare's proposed ASC payment policy was not kind to gastroenterology. The specialty will see a dramatic drop in revenue if Medicare's proposed ASC payment policy takes effect in 2008. Fourteen GI procedures would be reduced, including the five most commonly performed. The current ASC payment for diagnostic colonoscopy is $446. Medicare's proposed ASC payment for CPT 45378 is $350, less $96. Overall, the new payment policy would slash GI rates 23 percent after 2008.
• Take a longer time doing it. Doctors who spend more time examining the colon during the critical withdrawal phrase of the colonoscopy are better at detection than those who worked more quickly, according to a study published last month in The New England Journal of Medicine. The study, which not all GI docs necessarily agree with, looked at 12 experienced gastroenterologists and found that the ability to detect abnormal growths in the colon could vary widely from doctor to doctor. The one factor distinguishing the most and the least accurate was thoroughness.

"This amount of time will vary from patient to patient but should probably average eight minutes or more," says Robert L. Barclay, MD, of Rockford Gastroenterology Associates in Rockford, Ill., the lead author of the study. Physicians who spent six minutes or more on withdrawal had the best results, according to the study.

Elements of success
Given all this, how are you to run a high-volume endoscopy center? I'm the center director at Main Line Endoscopy Center, which runs two centers in suburban Philadelphia. We opened our first four years ago, the second nine months later. We're doing 6,000 to 7,000 procedures per year in each facility. Here are seven strategies that have worked for us.

1 Use short-acting anesthetics. Our physicians strongly prefer monitored anesthesia care to conscious sedation because it significantly reduces recovery time. A CRNA or an anesthesiologist usually administers propofol alone, without Versed or a narcotic that can have lingering side effects. With propofol, most patients come out of the procedure already awake and quite comfortable, generally meeting most of the discharge criteria. Patients are normally ready for discharge within 15 minutes after the procedure.

2 Create good flow. From the waiting area to the discharge area and everything in between, there needs to be enough room in each area to accommodate many moving people (patients and their escorts) in a short time. Your facility's layout should facilitate good patient flow. The scope cleaning area must accommodate all vital cleaning equipment. Your waiting room must be large enough to hold patients' rides. You want to have enough space to store supplies. Procedure rooms must be large enough to handle much equipment and yet remain safe to patients and staff. How else can you achieve rapid patient flow?

• Have patient change areas and lockers for each patient.
• Have enough stretchers and bays to accommodate patients in the pre-procedure area and recovery area.
• Dedicate an area for patients to wait after discharge from recovery, an area where physicians can review findings and discharge instructions. This clears the recovery area to accept more patients.

3 Commit to safety. Scope cleaning is probably the most important safety aspect in an endoscopy center. Quality control measures such as glutaraldehyde testing and maintaining logs on all cleaning equipment ensures accuracy. Chart checks ensure not only proper documentation but also documented proper care. Follow-up phone calls are another quality measure to ascertain vital information about such things as complications and satisfaction. They are a great way to identify areas of needed improvement or change.

4 Screen patients early. Screening patients' health histories as early as possible is vital in capturing full utilization of a procedure schedule. Fewer cancellations mean more procedures performed. Obtain a history at least a week in advance but start as early as two weeks out.

5 Schedule procedures wisely. Scheduling according to physicians' average times for their procedures lets each physician maximize the use of the schedule. Consider the type of procedure, as EGDs take less time than colonoscopies.

6 Keep your equipment in good working order. From stretchers to scopes, be sure you have enough equipment. Timely repair of equipment and immediate availability of loaners are the keys to sustaining a large volume of procedures. Maintenance contracts for our equipment as well as our bio-med contractor have aided in this task. Similarly, keep your supply inventory at par levels. Contracted suppliers should be able to deliver products quickly if needed.

7 Find the right staff. It's essential to have enough staff to be able to carry out all necessary duties safely and in a timely manner. Competence, speed and flexibility are prerequisites for working in a high-volume center.