31320 SLSA Cover - Advisory · impact of each stakeholder can vary. For example, as shown in one study, ophthalmology and dermatology have higher rates of self-referrals.8 Orthopedics

2445 M Street NW, Washington DC 20037 P 202.266.5600 | F 202.266.5700

advisory.com

Service Line Strategy Advisor

31320

How to Build ASC Referrals

Tactics for appealing to four ambulatory surgery center stakeholders

Look inside for:

• Proceduralist, primary care physician, payer, and consumer ASC preferences

• Lessons on appealing to each stakeholder to increase referrals and boost utilization

TOPIC

More in this membership

WHAT’S NEXT?

CREATING A PRIMARY CARE STRATEGY FOR SERVICE LINESTen imperatives for exceeding the service expectations of referring physicians

Read this brief to learn how activated consumers, value-conscious payers, and narrow networks are changing service line growth strategy, and what you’ll need to do to ensure future growth.

RECOMMENDED PREP

Stream or download the Ambulatory Surgery Investment: 2013 Outlook at advisory.com/mic/ambulatoryoutlookwebconference

LEARN HOW TO

Engage the four main stakeholders responsible for ASC referrals to increase utilization

Ambulatory surgery centers

BEST FOR

Business developers

READING TIME

45 min.LEARN MORE AT

advisory.com/slsa or email us at [email protected]

Now that you have learned about engaging four major ASC stakeholders, read Service Line Strategy Advisor’s upstream service line strategy research or commission a custom project.

©2015 The Advisory Board Company • 31320 1 advisory.com





Service Line Strategy Advisor Alicia Daugherty Managing Director

Haley David Consultant

Chelsea Tisosky Analyst

LEGAL CAVEAT The Advisory Board Company has made efforts to verify the accuracy of the information it provides to members. This report relies on data obtained from many sources, however, and The Advisory Board Company cannot guarantee the accuracy of the information provided or any analysis based thereon. In addition, The Advisory Board Company is not in the business of giving legal, medical, accounting, or other professional advice, and its reports should not be construed as professional advice. In particular, members should not rely on any legal commentary in this report as a basis for action, or assume that any tactics described herein would be permitted by applicable law or appropriate for a given member’s situation. Members are advised to consult with appropriate professionals concerning legal, medical, tax, or accounting issues, before implementing any of these tactics. Neither The Advisory Board Company nor its officers, directors, trustees, employees and agents shall be liable for any claims, liabilities, or expenses relating to (a) any errors or omissions in this report, whether caused by The Advisory Board Company or any of its employees or agents, or sources or other third parties, (b) any recommendation or graded ranking by The Advisory Board Company, or (c) failure of member and its employees and agents to abide by the terms set forth herein.

The Advisory Board is a registered trademark of The Advisory Board Company in the United States and other countries. Members are not permitted to use this trademark, or any other Advisory Board trademark, product name, service name, trade name, and logo, without the prior written consent of The Advisory Board Company. All other trademarks, product names, service names, trade names, and logos used within these pages are the property of their respective holders. Use of other company trademarks, product names, service names, trade names and logos or images of the same does not necessarily constitute (a) an endorsement by such company of The Advisory Board Company and its products and services, or (b) an endorsement of the company or its products or services by The Advisory Board Company. The Advisory Board Company is not affiliated with any such company.

IMPORTANT: Please read the following. The Advisory Board Company has prepared this reportfor the exclusive use of its members. Each member acknowledges and agrees that this report and the information contained herein (collectively, the “Report”) are confidential and proprietary to The Advisory Board Company. By accepting delivery of this Report, each member agrees to abide by the terms as stated herein, including the following:

1. The Advisory Board Company owns all right, title and interest in and to this Report. Except as stated herein, no right, license, permission or interest of any kind in this Report is intended to be given, transferred to or acquired by a member. Each member is authorized to use this Report only to the extent expressly authorized herein.

2. Each member shall not sell, license, or republish this Report. Each member shall not disseminate or permit the use of, and shall take reasonable precautions to prevent such dissemination or use of, this Report by (a) any of its employees and agents (except as stated below), or (b) any third party.

3. Each member may make this Report available solely to those of its employees and agents who (a) are registered for the workshop or membership program of which this Report is a part, (b) require access to this Report in order to learn from the information described herein, and (c) agree not to disclose this Report to other employees or agents or any third party. Each member shall use, and shall ensure that its employees and agents use, this Report for its internal use only. Each member may make a limited number of copies, solely as adequate for use by its employees and agents in accordance with the terms herein.

4. Each member shall not remove from this Report any confidential markings, copyright notices, and other similar indicia herein.

5. Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents.

6. If a member is unwilling to abide by any of the foregoing obligations, then such member shall promptly return this Report and all copies thereof to The Advisory Board Company.


Table of Contents Advisors to Our Work .............................................................................................................................. 4

The Impact of Four ASC Stakeholders .................................................................................................. 5

Proceduralists .......................................................................................................................................... 7

Tactic #1: Give Physicians a Fair Voice and Stake ........................................................................ 7 Tactic #2: Hone Specialist Convenience ........................................................................................ 8 Tactic #3: Communicate Efficiency to Recruit Physicians .............................................................. 9

Primary Care Physicians ....................................................................................................................... 11

Tactic #4: Demonstrate Service Quality to PCPs ......................................................................... 11 Tactic #5: Use PCP Office Proximity to Build Referral Base ........................................................ 12

Payers ...................................................................................................................................................... 13

Tactic #6: Demonstrate Low Costs and High Quality to Payers .................................................. 13

Consumers .............................................................................................................................................. 14

Tactic #7: Emphasize Patient Experience .................................................................................... 14


Advisors to Our Work

With Sincere Appreciation We are grateful to the individuals and organizations that shared their insights, analysis, and time with us. The research team would especially like to recognize the following individuals for being particularly generous with their time and expertise.

Robin Clinkenbeard Page Southerland Page, Inc. Austin, Texas

Carole Guinane Sentara Healthcare Norfolk, Virginia

Mark Hedberg Hunton & Williams LLP Richmond, VA

Matthew Jenkins Hunton & Williams LLP Richmond, VA

Paul Krakovitz Cleveland Clinic Cleveland, Ohio

Frank Lago Baptist Health South Florida Jacksonville, Florida

James Pinna Hunton & Williams LLP Richmond, VA

Barbara Zalewski Henry Ford Health System Detroit, Michigan


The Impact of Four ASC Stakeholders Health systems are increasingly focusing on ambulatory surgery centers (ASCs) as a means to increase OR capacity, gain market share, and offer a lower-cost site of service. In one Advisory Board survey, 52% of members plan to evaluate an ASC investment in the next three years.1

ASC Industry Maturation Has Led to Market Saturation

While ASCs may represent a new opportunity for some system leaders, the ASC industry itself is relatively mature, with growth leveling off overall. From 2009 to 2013, the number of Medicare-certified ASCs grew at a 1% annual rate, averaging 175 new facilities entering the market each year.2

Number of Medicare-Certified ASCs3

The consistently high growth rates seen a decade ago have saturated some markets. According to VMG Health’s 2011 survey of ASC value drivers, ASC developers and owners considered market saturation the number one challenge the industry faces.4

ASC Closures a Cause for Concern

Not only are fewer ASCs entering this saturated market, but many ASCs are closing. Since 2009, for approximately every two Medicare-certified ASCs that have opened, one has closed.5 While some ASCs “leave” the market due to hospital outpatient department (HOPD) conversion, many ASC closures are due to underperformance. In the VMG Health survey mentioned above, over one-half of ASC developers and owners in one survey were considering closing underperforming ASCs.

Costs and Underutilization Threaten ASC Viability

There are two primary causes of ASC closure: poor financial performance and underutilization. Declining reimbursement, poor case mix, and elevated costs contribute to poor ASC financials. Of the nearly 6,000 surgery centers in the United States, roughly

1) Planning 2020 Ambulatory Summary Report, Service Line Strategy Advisor, The Advisory Board Company, 2015. 2) 2015 Report to the Congress: Medicare Payment Policy, Chapter 5 – Ambulatory Services, Medicare Payment Advisory

Commission (MedPAC), http://www.medpac.gov/documents/reports/chapter-5-ambulatory-surgical-center-services-(march-2015-report).pdf?sfvrsn=0.

3) Ibid. 4) “2011 Value Driver ASC Survey,” VMG Health, http://www.vmghealth.com/Downloads/VMG_ValueDriver2011.pdf. 5) “2015 Report to the Congress: Medicare Payment Policy,” Chapter 5 – Ambulatory Services, Medicare Payment Advisory

Commission (MedPAC).

4,490 4,756 4,955 5,064 5,152 5,228 5,307 5,377

2006 2007 2008 2009 2010 2011 2012 2013

13% growth 4% growth

Since 2009, for approximately every two Medicare-certified ASCs that have opened, one has closed.

2:1


half are struggling financially or are only moderately profitable.6 To address these issues, ASC leaders deploy familiar cost-control strategies such as monitoring drug and medical supply costs, rationing technology investments, and better integrating ASCs into the supply chain.

Addressing underutilization is a more complex and uncharted territory for hospital leaders. Facility planners often overbuild, failing to accurately forecast volumes and placing too many operating rooms in the center.7 Planners may not select the appropriate procedures, choose the right physician partners, or locate ASCs in an optimal market, resulting in a lack of volumes. Once planners have established an ASC, however, they must solidify referrals to mitigate underutilization.

Four Major Stakeholders Influence ASC Referrals

To build referrals, ASCs have to appeal to four main stakeholders: proceduralists, primary care physicians, payers, and consumers. Depending on the services offered, the impact of each stakeholder can vary. For example, as shown in one study, ophthalmology and dermatology have higher rates of self-referrals.8 Orthopedics referrals, on the other hand, are more dependent on primary care physicians and proceduralists. Other specialties are also more susceptible to payer steerage, depending on cost.

While all four ASC referral stakeholders value quality, each has a unique set of preferences. Practicing specialists value efficient operations and convenient scheduling, whereas primary care physicians prioritize high clinical quality and quick appointment availability. Payers care about a center’s low costs, while consumers seek a pleasant patient experience. Administrators therefore face competing strategic priorities amid limited resources.

Stakeholder Influence on Common ASC Specialties

This white paper details seven tactics for engaging the four ASC stakeholders.

6) “Acquisitions & Turnarounds,” Blue Chip Surgical Partners, http://www.bluechipsurgical.com/acquisitions.html. 7) “Critical ASC Mistake: Overbuilding the Facility,” Becker’s ASC Review, http://www.beckersasc.com/asc-turnarounds-ideas-to-

improve-performance/critical-asc-mistake-overbuilding-the-facility.html. 8) Oluseyi A, et al., “Specialist Participation in Healthcare Delivery Transformation: Influence of Patient Self-Referral,” The American

Journal of Managed Care, 20, no. 1 (2014): e22-e26.

Low Impact Moderate Impact High Impact


Proceduralists Proceduralists are the primary source of an ASC’s quality care and growth. However, given the increasing employment trend, fewer physicians are available for recruitment. According to the aforementioned VMG Health survey, hospital-employed physicians were the third most commonly cited top threat to case volume growth and retention, after the economic landscape and external competitors. And, 87% of ASC operators believe this threat will increase moving forward.

Organizations can strengthen relationships with proceduralists by engaging them in the ASC planning process, maximizing convenience for both the surgeon and her staff, and leveraging loyal proceduralists to recruit peers.

Tactic #1: Give Physicians a Fair Voice and Stake By including surgeons in the strategic decision-making process, hospitals are more likely to ensure they remain invested in the center’s success. However, the lessons for physician engagement vary across the different ownership arrangements hospitals may enter.

Involving Physicians in ASC Shift Decisions Strengthens Buy-In

Physicians accustomed to performing cases at the hospital may bristle at shifting certain services to the ASC. As such, hospitals need to gain compliance among their employed or affiliated physicians to maintain sufficient volumes at their wholly owned ASCs.

Leaders at Burrowton Health9 noted that getting physicians to shift into their ASCs occurred organically over time. Leaders found that attempting to move all of a certain low-volume procedure (e.g., all laparoscopic cholecystectomies) into the ASC was not effective, as physicians balked at performing other types of cases at the hospital, and then driving 20 to 40 minutes to the ASC to perform one procedure. Burrowton found greater success by moving entire sub-service lines with a sufficient number of outpatient cases to the ASC and getting physicians to champion that shift. Lastly, administrators initiated and welcomed informal educational discussions with surgeons to identify opportunities to shift procedures and determine their willingness to do so.

Three Keys to Burrowton Health’s Approach to Shifting ASC Procedures

Shortsighted Inequitable Ownership Arrangements Syphon Profits

Hospitals considering a joint venture model should understand the impact of ownership distribution on referrals. Any ownership scenario in which one physician has a disproportionate share of profits is ill-advised. In these situations, other physicians may feel disenfranchised, dissuading them from acting as productive ASC participants.

9) Pseudonym.

Utilize physician champions

Target heavily outpatient, shifting specialties

Discuss shifting procedures with surgeons

“Waiting for our physicians to ask, ‘Is anything starting to move into the ASC?’ is much more effective than requiring that procedures be performed in the ASC.”

Vice Chairman, Surgical Operations


This risk is especially high as physicians leave an ASC. One in three practicing physicians in the United States is over the age of 55 and likely to retire soon,10 and 93% of ASC leaders in the VMG Health survey mentioned above believe the significant number of active physicians nearing retirement age presents a high risk to their centers’ value. As such, ASC leaders should ensure joint venture arrangements have physician-owner departure stipulations.

River’s Edge Outpatient Surgery Center,11 one of the first freestanding outpatient centers in New York, fell victim to this ownership pitfall. Though initially a high-quality and lucrative center, over time many of the original surgeons who were shareholders retired or changed facilities. Although these physicians ceased to bring revenue into the center, they continued to receive profit distributions. River’s Edge’s ownership model could not adapt to an increasingly competitive landscape and failed to attract new physicians to perform there. Eventually, the financial burden became too heavy, and the center failed.

Hospitals should include language in the contract stipulating that departing or retiring physicians relinquish operational income, giving everyone, including new physicians, equitable share.

Tactic #2: Hone Specialist Convenience At the outset of ASC development, planners should identify and prioritize physician preferences. Once the center is established, administrators should periodically check in on physician experience and identify improvements.

Close Proximity Appeals to Physician Routine

In the 2011 VMG Health survey, 67% of leaders indicated that physician convenience has at least a moderate effect on facility value. In planning the location of their ASCs, hospitals should evaluate existing centers or potential developments that are close to the hospital or physician offices.

Mountain Spring Health System,12 found that their physicians preferred to have offices inside a medical campus that included the ASC. This allowed them to travel back and forth between their offices and ASC as their cases and schedule required.

Optimized Block Time Suits Surgeons

While offering procedure block times for ASC physicians is a ubiquitous practice, ASC administrators should monitor block schedule utilization to ensure OR time is used effectively. Though block time use is contingent on the center’s utilization, the common

10) “Help Wanted: More U.S. Doctors Projections Indicate America Will Face Shortage of M.D.s by 2020,” Association of American

Medical Colleges (AAMC), https://www.aamc.org/download/82874/data/helpwanted.pdf. 11) Pseudonym. 12) Pseudonym.

“No matter how many cases [the physicians] did, they didn’t make any money. Almost 90% [of the center] was owned by people who were no longer practicing… The docs who stuck around [said], ‘It isn’t worth it. I’m busting my butt to put dollars in someone else’s pocket.’”

CDO Ambulatory Surgical Centers of America


benchmark is 70% to 90%.13 When surgeons are not using block time effectively, leaders should consider strategies to increase utilization, such as easing the scheduling process or shortening select block times to provide more time for other physicians.

At the Jackson Sports & Orthopedic Surgery Center,14 about 72 hours before a scheduled but unused block time, administrators will call a surgeon’s office to inquire whether he plans to add additional cases. If not, administrators will email news of a voluntary block release to all affiliated surgeon offices, encouraging them to fill the time with their own cases. This helps surgeons to schedule procedures when they find them most convenient. Moreover, if a given referral necessitates an earlier or later start time for a block-holder, ASC administrators will call the surgeons to ask for the favor, demonstrating willingness to accommodate special requests.

Jackson Sports & Orthopedics Surgery Center’s Block Time Optimization

Easy Scheduling Process Facilitates Referrals

If a surgeon’s office staff finds it difficult to schedule surgery, this could also impact utilization. Organizations should ensure a seamless scheduling process for physicians’ office staff by minimizing paperwork, reducing redundant calls, and ensuring a prompt response.

Some centers use technology to help streamline the scheduling process. For example, the Fair Lakes Surgery Center’s15 scheduling office avoids incomplete case information by providing the physician’s office staff with electronic surgery scheduling request forms. This HIPAA-compliant website lists required fields, such as patient demographics and procedure information. The easy-to-use portal not only improves the scheduling efficiency for the ASC, but also streamlines the referral process for the specialists’ offices by eliminating recurring phone calls.

Tactic #3: Communicate Efficiency to Recruit Physicians ASC administrators should promote efficiency to show physicians why they should choose to perform procedures at their particular ASC as opposed to competitors’ facilities.

13) Fields R, “6 Case Volume Metrics to Manage in a Surgery Center,” Becker’s ASC Review, http://www.beckersasc.com/asc-

turnarounds-ideas-to-improve-performance/6-case-volume-metrics-to-manage-in-a-surgery-center.html. 14) Pseudonym. 15) Pseudonym.

Verify Schedule

ASC accommodates surgeons who release block times with efficiency and attentiveness

72 hours before surgery, scheduler calls surgeon

If surgeon does not plan to add more cases, scheduler emails release information to other physicians

Reward surgeons Release Block Time Verify Schedule

“If…there are too many hoops for [surgeons’ offices] to jump through, they will go to a different surgery center.”

Director of Operations

Top 50 ASC Surgery Development and

Management Company


Efficiency Attracts New Physicians

Disseminating operational data is an effective way to attract physicians to a surgery center.16 On-time starts, quick staff, and short turnover times show physicians that the center’s operations run smoothly, bolstering physicians’ confidence that they will be able to perform all relevant cases there.17

Peer Conversations Leverage Professional Trust

Unaffiliated surgeons who are evaluating an ASC’s clinical, operational, and financial benefits will likely feel most comfortable discussing these issues with other practitioners. Such peer-to-peer conversations may prove more successful than other marketing efforts in attracting new physicians, as ASC surgeons understand best what new recruits prefer.18

Hangleton Health19 has a very active physician and business development group for their five ASCs. In fact, each hospital in the system has its own group dedicated to promoting ambulatory services; the group markets ASC services in conjunction with outpatient imaging, urgent care, and sleep centers. These individuals also check in with loyal proceduralists to ensure that they are happy. If so, they encourage the proceduralists to call their peers and share their satisfaction. To foster these professional peer discussions, the ambulatory business development committees host social events for physicians to informally network.

16) Vaidya A, “Improve Physician Referrals: 7 Fundamental Tips,” Becker’s ASC Review, http://www.beckersasc.com/asc-turnarounds-

ideas-to-improve-performance/improve-physician-referrals-7-fundamental-tips.html. 17) Fields R, “6 Proven Strategies for Physicians Recruitment,” Becker’s ASC Review, http://www.beckersasc.com/asc-turnarounds-

ideas-to-improve-performance/6-proven-strategies-for-physician-recruitment.html. 18) Dyrda L, “5 Tactics to Attract New Physicians to ASCs,” Becker’s ASC Review, http://www.beckersasc.com/asc-turnarounds-ideas-

to-improve-performance/5-tactics-to-attract-new-physicians-to-ascs.html. 19) Pseudonym.

“We tell our physicians: ‘If you’re happy, please call your peers and tell them!’ They are better than salespeople.”

ASC Director Hangleton Health


Primary Care Physicians Primary care physicians are a crucial referral source and provide significant downstream revenue for many ASC specialties, such as orthopedics and gastroenterology. However, there is a projected shortage of 31,000 primary care physicians by 2025.20 Further, health systems are increasingly employing primary care physicians, leaving fewer PCPs available for ASC alignment.

With this shrinking PCP pool, health system leaders must understand what motivates PCP referral decisions and prioritize tactics to secure those cases.

Tactic #4: Demonstrate Service Quality to PCPs Referring physicians value not just clinical quality but also service quality. In a 2004 survey in Annals of Family Medicine, PCPs ranked medical skill as most important when referring to a specialist, followed by patient access, communication quality, and patient experience.21 ASC administrators should prioritize these attributes when educating primary care physicians on their center’s offerings to garner referrals.

Top Four Factors When Choosing a Specialist22 Ratings of “Moderate” or “Major” Importance, n=553

Quick Patient Access Influences PCP Referral Decision

As an example, the Permanente Medical Group, an 8,000-provider-led medical group, pools specialists when scheduling cases to offer patients a choice between waiting to see their first-choice physician or getting to see another high-performing physician immediately. This streamlined scheduling system not only fosters satisfaction among referring physicians and patients, it also reduces capacity bottlenecks. Though this example is not from an ASC, it shows how administrators can accommodate preferences on access to support referring physician needs.

Effective PCP Communication Bolsters Future Referrals

As shown in the chart above, 95% of PCPs rate the quality of communication with a specialist as important to their referral decision. In fact, another study showed that primary care physicians are 1.5 times more likely to refer to a specialist based on ease

20) Dyer B, Strong T, “How to Tackle America’s Physician Shortage,” Fortune, August 10, 2015. 21) Kinchen KS, et al., “Referral of Patients to Specialists: Factors Affecting Choice of Specialist by Primary Care Physicians,” Annals of

Family Medicine, 2, no. 3, (2004): 245-52. 22) Ibid.

100% 96% 95% 94%

Medical Skill Time to FirstAvailable

Appointment

Quality ofCommunication

PatientExperience with

Specialist


of communication.23 As a result, hardwiring consistent communication between ASC proceduralists and referring physicians about a patient’s status and follow-up care plans through email or phone calls is a critical component of attracting referrals.

Tactic #5: Use PCP Office Proximity to Build Referral Base In the survey from Annals of Family Medicine, mentioned above, 60% of primary care physicians considered a specialist’s location to be important when referring a patient. Placing an ASC near primary care offices naturally grows a referral base and may boost referrals.

Mountain Spring Health System, mentioned earlier, built an ASC next to an existing successful family health outpatient clinic, hoping that clinic’s high volumes would bode well for the ASC. When the clinic failed to provide referrals, however, the ASC could not grow surgical volume. In hindsight, leaders realized that the clinic’s specialties were too different from those in the ASC and that primary care would have been a better referral source.

Blaiken Health,24 however, established a more successful ASC by leveraging its primary care base. Having reached OR capacity at one hospital, executives sought to shift procedures to an ASC. When establishing their new endoscopy center, leaders at Blaiken Health located the ASC next to densely concentrated, high-volume primary care practices to ensure convenient GI specialist access for newly covered lives. In doing so, the hospital was able to build a new steady stream of referrals and retain cases in their system.

Blaiken Health’s PCP-Centric Endoscopy Center Placement Strategy

A surgery center’s proximity to both primary care physicians and specialists is important, but PCPs impact referrals more directly. While traveling to the ASC should not be inconvenient for proceduralists, it’s more important that primary care physicians are nearby to grow a healthy referral base.

23) Barnett ML, et al., “Reasons for Choice of Referral Physician Among Primary Care and Specialist Physicians,” Journal of General

Internal Medicine, 27, no. 5 (2011): 506-12. 24) Pseudonym.

“Our ASC was not successful because there were no PCPs there to feed surgical specialties. Without primary care physicians, the people just didn’t come.”

Vice Chair, Surgical Operations

Mountain Spring Health

PCP

PCP Hospital-Based

Endoscopy Center

PCP

Competitor’s Endoscopy Center

New Endoscopy Center

50-minute drive

20-minute drive

ASC located next to densely concentrated, high-volume PCP practices to ensure convenient GI specialist access for newly covered lives


Payers Payers are increasingly steering outpatient surgery patients to lower-cost sites of care. As a result, HOPD ASCs, which charge higher prices for surgery, may struggle to maintain volumes. Payers also increasingly discourage ASC patients from going out-of-network by establishing online directories of in-network providers with “cost-of-care” calculators. In fact, 93% of ASC leaders in the VMG Health Survey indicated that heavy reliance on out-of-network payers and volumes poses the greatest reimbursement risk to ASC value, surpassing the risk of declining reimbursement rates.

As such, ASC leaders must understand payer preferences to capitalize on this patient steerage trend.

Tactic #6: Demonstrate Low Costs and High Quality to Payers Hospitals should work with payers to demonstrate the ASC’s value in driving savings and promoting quality.

Cost and Quality Data Bolster Payer Negotiations

Gathering and synthesizing data that demonstrates cost control supports ASC-payer negotiations. Insurers also value quality and patient satisfaction measures. Much like hospitals, ASCs should demonstrate a low number of adverse events and complications to prove safety. Surpassing the competition on quality, efficiency, and patient experience measures can serve as a differentiator as well.

For example, before Medicare approved several spine procedures to take place in ASCs, many ASC leaders brought cost and quality data to payers to persuade them to allow and reimburse spine procedures in their centers, boosting ASC utilization.

Price Transparency an Emerging Trend

Emerging health plans may impact ASC patients’ price-sensitivity. Unlike simple high deductibles, reference-based benefits (RBB) force beneficiaries to pay the difference between the cost and the price limit set for a given surgery. In a recent study, the shift to RBB resulted in increased ASC use in cataract removal surgery patients when they were aware of the costs.25 And, the prevalence of these plans may rise, pressuring ASCs to make their prices clearer. A recent survey of 1,230 employers covering more than 10 million employees indicated 68% of employers plan to adopt reference-based pricing in the next three to five years.26

25) Robinson J, et al., “Reference-Based Benefit Design Changes Consumers’ Choices and Employers’ Payments for Ambulatory

Surgery,” Health Affairs, 34, no. 3 (2015): 415-422. 26) Aon Hewitt’s 2014 Health Care Survey, http://www.aon.com/attachments/human-capital-consulting/2014-Aon-Health-Care-

Survey.pdf.

“Every time you do an ACL repair, every time you do a meniscus repair, you need to understand what it costs. Make a spreadsheet that lists the average cost of every procedure your surgery center performs by physician, then cross-reference those costs with the terms of your payer contracts.”

VP Managed Care Practice Partners in Healthcare

Decrease in payments per procedure for RBB enrollees

19.7%


Consumers Although physician referrals still drive the majority of specialty business, in some specialties, such as OB/GYN, dermatology and ophthalmology, self-referrals can comprise a large portion of office visits.27 Thus, ASC leaders must understand how consumers select their providers. To win patients’ business, ASCs must offer superior patient experience.

Tactic #7: Emphasize Patient Experience According to an Advisory Board consumer survey of nearly 1,300 self-referrers,28 a family or friend’s recommendation is one of the most influential factors in determining specialist selection. A friend or family member’s recommendation is especially important for specialties such as OB/GYN, dermatology, gastroenterology, and orthopedic surgery.

To garner these recommendations, leaders must ensure that their ASCs offer superior patient experience. Components of patient experience include:

• Engaging your physicians in making care personal

• Prioritizing patient-centered care

• Requesting feedback from patients to inform goals

Provider Training Focuses on Communication, Learning Personal Appeal

The communication between patients and their providers is a chief factor in determining a positive or negative patient experience.29 Studies have shown a positive correlation between the quality of physician communication and overall patient satisfaction scores.30 ASC providers should be trained to consider the patient’s mind-set when communicating care plans and to deliver consistent messaging that adds comfort and understanding, rather than confusion and anxiety.

Patient-Centered Care Reduces Anxiety and Improves Satisfaction

Leaders should also evaluate the entire ASC patient experience, from scheduling the appointment, to checking in for surgery, to paying the bill. While clinical safety is paramount, administrative processes can take significant time and impact satisfaction. Managers should ensure their administrative processes are streamlined, avoiding multiple bills, duplicative forms, and technology issues.

Involving the patients’ families and support systems is another way to enhance patient experience. ASC physicians and staff should make the family and support team feel welcome and encourage them to stay involved in the patient’s care.

For example, Harvey Sports & Spine Center31 allows family in the pre-op area, inviting as many family members as possible into private rooms. Administrators find that family members help keep patients relaxed and are an asset when collecting accurate medical histories. Also, these family members will likely become the caregivers once the patient returns home. Staff deliver in-depth information and instruction before surgery—to both the patient and the family—and the information is repeated after the procedure is

27) Oluseyi A, et al., “Specialist Participation in Healthcare Delivery Transformation: Influence of Patient Self-Referral.” 28) MPLC Specialist Consumer Choice Survey, Marketing and Planning Leadership Council, The Advisory Board Company, 2015. 29) “The ‘Influencer in Chief’: Rethinking the Physician Role in Patient Experience,” Physician Executive Council, The Advisory Board

Company, 2013. 30) Clever, et al., “Does Doctor-Patient Communication Affect Patient Satisfaction with Hospital Care? Results of an Analysis with a

Novel Instrumental Variable,” Health Services Research, 43, no. 5 (2008): 1505-19. 31) Pseudonym.


finished. When the patient leaves for surgery, a nurse always walks family members back to the waiting room and makes sure they are comfortable while they wait. This has resulted in less anxiety for both the patient and loved ones at the center.

Harvey Sports & Spine Center’s Family Focus

Long wait times for procedures are one of the most common ASC patient complaints.32 Monitoring waiting patients and updating them consistently may prevent frustration. ASC staff should work to effectively communicate to patients when their procedure will begin, as well as inform them of any variables that may impact scheduled start times. Since some late procedure starts are inevitable, staff should keep patients and their families informed regarding delays. This not only communicates to patients that the center values their time, but also allows them to delay arrival and wait at home.

For instance, Huntersville Surgical Center33 identified, through performance improvement projects, that waiting time—specifically from patient arrival to procedure time—was a significant issue for the center’s patients. After fielding many complaints, administrators analyzed specific physician patterns to more accurately determine and schedule entry times into the facility. The center also eliminated the transportation company it contracted with and instead started driving patients between their homes and the facility.

Patient Surveys Allow ASCs to Track and Improve Experience

Capturing patient feedback through surveys enables ASCs to identify weaknesses in patient experience and plan improvements. According to the Ambulatory Surgery Center Association, 99.5% of ASCs use patient satisfaction surveys.34 Yet patient experience is often hard to evaluate in a meaningful way. ASC administrators should define one or two specific decisions they face and craft survey questions accordingly.

While these specific strategic initiatives may change over time, overall patient satisfaction scores should be tracked and analyzed quarterly.35 ASC administrators may collect patient satisfaction data through surveys distributed through email, print mail, or phone calls. Collecting age and gender data on these surveys allows analysts to break down the data and identify subsets of patients to prioritize for service improvements. Hospitals with standardized data tracking and organization can benchmark the surgery

32) “7 Common Patient Complaints About Surgery Centers—and How to Prevent Them,” Regent Surgical Health, 2011,

http://regentsurgicalhealth.com/eletters/7-common-patient-complaints-about-surgery-centers-and-how-to-prevent-them-3/. 33) Pseudonym. 34) “Outcomes Monitoring Project,” Ambulatory Surgery Center Association (ASCA),

http://www.ascassociation.org/ResourceCenter/ForAdministratorsOperators/Benchmarking/OutcomesMonitoringProject/. 35) Galser T, Seitz J, “Identifying Your ASC as ‘High Performance’ to Generate Results,” Becker’s ASC Review,

http://www.beckersasc.com/asc-turnarounds-ideas-to-improve-performance/identifying-your-asc-as-qhigh-performanceq-to-generate-results.html.

Family Plays Major Role for ASC Patient

Harvey Sports & Spine Embeds Family in Surgery

• Brings patient to center • Comforts and supports

patient before surgery • Cares for patient after surgery

• Allows family in pre-op area • Involves family in collecting patient’s

medical history • Repeats important post-surgery care

plan information


center’s performance against local, state, and national results to evaluate progress and identify focus areas.

Four Components of Successful ASC Patient Surveys

Focus on the negative; address the entire patient experience

Ask Constructive Questions

Streamline the survey process so it is easy to provide feedback

Encourage Participation

Share survey results with ASC staff and physicians to translate patient need into action

Share Results

Create performance improvement projects and hold staff and physicians accountable

Seek Improvement

TOPIC

More in this membership

WHAT’S NEXT?

CREATING A PRIMARY CARE STRATEGY FOR SERVICE LINESTen imperatives for exceeding the service expectations of referring physicians

Read this brief to learn how activated consumers, value-conscious payers, and narrow networks are changing service line growth strategy, and what you’ll need to do to ensure future growth.

RECOMMENDED PREP

Stream or download the Ambulatory Surgery Investment: 2013 Outlook at advisory.com/mic/ambulatoryoutlookwebconference

LEARN HOW TO

Engage the four main stakeholders responsible for ASC referrals to increase utilization

Ambulatory surgery centers

BEST FOR

Business developers

READING TIME

45 min.LEARN MORE AT

advisory.com/slsa or email us at [email protected]

Now that you have learned about engaging four major ASC stakeholders, read Service Line Strategy Advisor’s upstream service line strategy research or commission a custom project.

2445 M Street NW, Washington DC 20037 P 202.266.5600 | F 202.266.5700

advisory.com


31320



Look inside for:

• Proceduralist, primary care physician, payer, and consumer ASC preferences

• Lessons on appealing to each stakeholder to increase referrals and boost utilization

Documents

31320 SLSA Cover - Advisory · impact of each stakeholder can vary. For example, as shown in one study, ophthalmology and dermatology have higher rates of self-referrals.8 Orthopedics