At the 11th Annual Orthopedic, Spine & Pain Management-Driven ASC Conference in Chicago on June 14, a roundtable of ambulatory surgery center industry experts discussed evolving business, clinical and competitive issues in spine and pain. The roundtable included President and Medical Director of Illinois Pain Institute John Prunskis, MD; CEO and Medical Director of Deuk Spine Institute Ara Deukmedjian, MD; Vice President of Acquisitions and Development for Symbion Healthcare Danny Bundren. The panel was moderated by Holly Carnell, JD, an associate at McGuireWoods. 
One of the biggest issues is hospital employment of physicians, particularly of spine and pain management specialists. Some hospitals now seek to retain facility fees from pain physicians by hiring them as employees, and these fees are reimbursed higher in the hospital setting than in the ASC.
"Hospital relationships with physicians vary," said Mr. Bundren. "There will always be inherent conflict when you have physicians that want to control the continuum of care versus the hospital who wants to see control from the revenue side. Hospitals can provide security for physicians, and within that context we are seeing some statistics that say 2/3 of orthopedic residents are going into hospital employment."
As another option, some surgeons and surgery centers are seeking joint venture ownership to further align with hospitals, and more are opting for the 100 percent hospital-owned strategy, said Mr. Bundren.
"This is escalating the entire cost of healthcare," said Mr. Bundren. "The success of the physician/hospital relationships is dependent on how the hospital views their market relationships. In terms of outpatient opportunities and fueling inpatient volume, they may be viewed as a consolidation mechanism."
Another big topic discussed for physicians was reimbursement trends. More surgeons and pain physicians are reporting lower reimbursements than in the past, and continued downward pressure on Medicare and other payers could mean the situation will get worse before it gets better.
"Physicians have seen a decline in professional reimbursement, which forces them to look for alternative funding sources," said Dr. Deukmedjian. "Traditionally hospitals are referring to patients with their services, but now physicians have learned they have to adapt and get into ancillary revenue. Now the goals of the hospital and physicians aren't aligned, but the government payers are trying to align all providers with accountable care organizations. It looks like hospitals will be controlling most of them, and one of the concerns I have is the antagonistic relationship developing between hospitals and physicians."
Alternative payments as well as billing and collection strategies were discussed among the panelists. Bundled payments, out-of-network and ACO models are becoming more common in orthopedics and spine across the country. While bundled payments haven't hit ASCs in full force, they could become a valuable asset to these types of agreements in the future.
"We would be the lower cost provider in this paradigm of care," said Mr. Bundren. "We are in fact reaching out and trying to establish relationships with payers to provide a higher professional fee as a key component to a physician who brings cases into our center in the in-network model."
Practice billers and coders must be empowered to question physicians and educate them on best documentation to capture the most reimbursement. "The changes are continuous in billing and coding," said Dr. Prunskis. "For those of you who don't have a dynamic relationship with whoever is doing patient accounts, this would be one of the things I would urge you to do. Make sure the biller is well trained and courses are up-to-date."
For Dr. Deukmedjian, bundling codes in spine surgery has had a clear impact on his practice. What was once billable at two separate codes is now bundled into one and reimbursed at a lower rate. However, at the end of the day quality is the most important aspect of success in the physician practice.
"Provide the best quality of care; that's a key strategy," said Dr. Deukmedjian. "If you stay focused on really being state-of-the-art and provide patients with successful treatments that are affordable, you'll be able to stay competitive."
In order for Symbion to remain competitive, Mr. Bundren said the company has invested resources into research and development of new product lines and surgical services to migrate from the hospital into the ASC setting. "We made significant investment in technology from integrating our patient accounting system for business intelligence," said Mr. Bundren. "We can capture best practices and marketing to get feedback on what makes us efficient. We have invested a lot in social media and the internet. From the ASC side, we are also spending a lot of time on physician recruitment."
In his practice, Dr. Prunskis focuses on performance excellence from the medical partners as well as practice personnel. Every candidate for a position with the practice undergoes an intelligence test, background check and drug test, and all references are checked.
"There is a strong foundation of ethics and abilities," said Dr. Prunskis. "It's also important for us to get our message out there, whether it's the simple marketing of calling referring physicians or having a staff member dedicated to print and online media. We have a good culture in our practice, which is one of the things that gives us the competitive edge."
More Articles on Spine:
3 Spine Surgeons on How EMRs Have Altered Patient Interactions
Reoperation for Spinal Fusion vs. Disc Replacement: 5 Things to Know
8 Defining Issues for Spine & Orthopedics Surgeons Today
One of the biggest issues is hospital employment of physicians, particularly of spine and pain management specialists. Some hospitals now seek to retain facility fees from pain physicians by hiring them as employees, and these fees are reimbursed higher in the hospital setting than in the ASC."Hospital relationships with physicians vary," said Mr. Bundren. "There will always be inherent conflict when you have physicians that want to control the continuum of care versus the hospital who wants to see control from the revenue side. Hospitals can provide security for physicians, and within that context we are seeing some statistics that say 2/3 of orthopedic residents are going into hospital employment."
As another option, some surgeons and surgery centers are seeking joint venture ownership to further align with hospitals, and more are opting for the 100 percent hospital-owned strategy, said Mr. Bundren.
"This is escalating the entire cost of healthcare," said Mr. Bundren. "The success of the physician/hospital relationships is dependent on how the hospital views their market relationships. In terms of outpatient opportunities and fueling inpatient volume, they may be viewed as a consolidation mechanism."
Another big topic discussed for physicians was reimbursement trends. More surgeons and pain physicians are reporting lower reimbursements than in the past, and continued downward pressure on Medicare and other payers could mean the situation will get worse before it gets better.
"Physicians have seen a decline in professional reimbursement, which forces them to look for alternative funding sources," said Dr. Deukmedjian. "Traditionally hospitals are referring to patients with their services, but now physicians have learned they have to adapt and get into ancillary revenue. Now the goals of the hospital and physicians aren't aligned, but the government payers are trying to align all providers with accountable care organizations. It looks like hospitals will be controlling most of them, and one of the concerns I have is the antagonistic relationship developing between hospitals and physicians."
Alternative payments as well as billing and collection strategies were discussed among the panelists. Bundled payments, out-of-network and ACO models are becoming more common in orthopedics and spine across the country. While bundled payments haven't hit ASCs in full force, they could become a valuable asset to these types of agreements in the future.
"We would be the lower cost provider in this paradigm of care," said Mr. Bundren. "We are in fact reaching out and trying to establish relationships with payers to provide a higher professional fee as a key component to a physician who brings cases into our center in the in-network model."
Practice billers and coders must be empowered to question physicians and educate them on best documentation to capture the most reimbursement. "The changes are continuous in billing and coding," said Dr. Prunskis. "For those of you who don't have a dynamic relationship with whoever is doing patient accounts, this would be one of the things I would urge you to do. Make sure the biller is well trained and courses are up-to-date."
For Dr. Deukmedjian, bundling codes in spine surgery has had a clear impact on his practice. What was once billable at two separate codes is now bundled into one and reimbursed at a lower rate. However, at the end of the day quality is the most important aspect of success in the physician practice.
"Provide the best quality of care; that's a key strategy," said Dr. Deukmedjian. "If you stay focused on really being state-of-the-art and provide patients with successful treatments that are affordable, you'll be able to stay competitive."
In order for Symbion to remain competitive, Mr. Bundren said the company has invested resources into research and development of new product lines and surgical services to migrate from the hospital into the ASC setting. "We made significant investment in technology from integrating our patient accounting system for business intelligence," said Mr. Bundren. "We can capture best practices and marketing to get feedback on what makes us efficient. We have invested a lot in social media and the internet. From the ASC side, we are also spending a lot of time on physician recruitment."
In his practice, Dr. Prunskis focuses on performance excellence from the medical partners as well as practice personnel. Every candidate for a position with the practice undergoes an intelligence test, background check and drug test, and all references are checked.
"There is a strong foundation of ethics and abilities," said Dr. Prunskis. "It's also important for us to get our message out there, whether it's the simple marketing of calling referring physicians or having a staff member dedicated to print and online media. We have a good culture in our practice, which is one of the things that gives us the competitive edge."
More Articles on Spine:
3 Spine Surgeons on How EMRs Have Altered Patient Interactions
Reoperation for Spinal Fusion vs. Disc Replacement: 5 Things to Know
8 Defining Issues for Spine & Orthopedics Surgeons Today