Keep Surgeons From Leaving Your Hospital

There's been a dark cloud on the horizon for many hospitals for a number of years, and its initials are ASC. More and more surgeons are considering moving at least some of their cases to freestanding ambulatory surgery centers, preferring the convenience, efficiency, environment and sometimes the income opportunities they afford.

But if the research we've done is any indication, within that dark cloud is a silver lining-a way for hospitals to turn what appears to be a threat into an opportunity. While it's true that some of your surgeons may be considering an ASC, it's also true that they might respond very favorably if you meet them halfway, by proactively proposing a joint-venture ASC. At least that's the conclusion we've reached after interviewing more than 3,000 hospital-based surgeons. To follow, we provide an overview of what they told us.

Surgeons' Concerns
Most of the surgeons we talk to are frustrated with the hospital environment, from top-down management policies, to the day-to-day hassles that interfere with their surgical time.

Some key complaints that physicians have with hospitals include:

"First come, first served" OR time scheduling (instead of block time scheduling):
Says one stymied surgeon, "Being new to the staff, I am forced to take half of my surgical schedule to another hospital because I cannot get time at my primary hospital. Everyone loses ????-??? the hospital, myself and my patients."

Slow turnaround times:
" I spend more time waiting between my cases than my entire operating time for the day!" says another frustrated interviewee.

Being bumped from ORs when emergent cases arrive:"
My time is much more predictable in an ASC," is a common observation.

Inflexible equipment, supply, and scheduling policies:
"Do not tell me that I cannot book a case after 2:00 PM!" declares one surgeon. "I want to hand-pick staff that has incentives to jump up and say ????-??Lets go!' when a case is added."

Gross inefficiency:
"There is nothing more frustrating to me to have a hospital VP or director tell me that they cannot open another room so my elective cases can be done before midnight while they are sitting in the lounge chatting with the rest of the staff," complains one physician.

Non-responsive hospital administrations: "We have been begging the hospital to do a center with us!" says one surgeon. "After a certain number of years you give up trying. We are now doing it on our own!"

Many surgeons have heard wonderful success stories from peers who own their own surgery centers. They are not inclined to believe everything they hear, but they do believe they can achieve four objectives by building their own:

Control:
Surgeons are trained to be in charge of and liable for anything that happens to their patients in the OR. They hate any real or perceived loss of control, and they often believe that going to an ASC will help them regain some of the control that they lost in the hospital.

This does not mean that surgeons want to micro-manage. Rather, they want to be involved in the initial policy and procedure setting and take part in management of the medical affairs of the center, usually by sitting on a surgeon-controlled medical advisory board. They want to feel that this board has real power, and is not going to be overruled by the hospital.

Efficiency:
More than 75% of physicians state "obtaining improved efficiency" as their number one reason for considering owning (or using) a freestanding surgery center. Because of the absence of emergent cases and the focus on efficiency in ASCs, surgeons believe that they can achieve OR turnover times of 10 minutes or less in a surgery center (vs. 45 minutes in a hospital). They are convinced that this can save them up to a half day per week. Also, the high-volume surgeons feel that ASCs offer more flexible and convenient OR scheduling, allowing them to block out surgery times, especially the coveted early-morning hours.

Quality:
Most surgeons are aware of the studies that show that patients overwhelmingly prefer surgery centers over hospitals. They believe that, with the help of a consistent, efficiency-oriented nursing staff, an easy-to-access, pleasant facility, and the opportunity to procure the equipment and instruments they want, they will be able to achieve a level of quality and patient satisfaction that they cannot in a hospital. Extra Income: Even though many of the surgeons we interviewed stressed that extra income is not important (only 15% say it is their primary motivation to move to a surgery center) they usually kept coming back to this issue. One surgeon said it best: "The income from an investment in an ASC won't change my life, but, it may put one of my kids through a state college. If I really utilize the ASC and work to make it successful, that same kid may be able to go to an Ivy League college."

What the Hospital Can Provide
Fortunately for hospitals, surgeons also harbor many reservations about building their own ASCs. Very few of the surgeons with whom we spoke felt they had the time, resources, or the interest to handle the day-to-day management or administration of a surgery center. Most said that they would actually prefer outside management and would welcome the shared risk, combined expertise, and financial resources that a hospital partnership could provide.

We refer to the services surgeons want from a hospital partner as the "Four C's."

Cash:
Developing and building a surgery center can easily run into the millions of dollars. Surgeons, and even groups of surgeons, rarely have those kinds of financial resources and fewer still are willing to take out large loans to finance start-up costs. They want to know that when it is time to sell their interest in the center that they have a "deep pocket" partner that is still going to be around to buy it. They are often fearful of some corporate chains or startup regional companies that may or may not sell out or go public within a few years.

Credibility: Physicians feel that being associated with a hospital brings more credibility than if they were building the center alone. Very successful independent centers do exist, but physicians generally feel that if the hospital is involved with the project that they have a greater sense of success, both financially and politically

Contracting ability:
Forming new relationships with managed care providers is difficult for any new facility. Having the local hospital as a competitor for managed care contracts is a hassle that many surgeons would rather not deal with. The physician's perception is that a partnership with the local hospital will enable from having to compete for contracts.

Certificate of need (if one is required).
The CON process in many states is very complicated. Often a hospital may have an existing CON that it can sell to the new partnership or can "trade" ORs with the new venture. This can often save years and hundreds of thousands of dollars in a project. The majority of physicians feel that the hospital can make or break their approval process.

Creating a "Win-Win"
Physician-hospital joint ventures can provide all involved with extra revenue, give doctors a new measure of control, and potentially promote better patient care. Surgeons tell us that when they have a stake in their facilities, they are more willing to "do without" to save resources, and are willing to be re-trained on their own efficiency to ensure success.

If your hospital has surgeons who are interested in forming an ASC, chances are they need you as much as you need them. If you are proactive in learning what they want and working with them, you have an excellent chance to not only stabilize but grow your surgical cases and make your surgeons and patients significantly happier in the process.