On the Spot: Practice Patterns - Where Are We Headed? Part 2 of 2

Thanks to an off-the-cuff discussion over dinner with surgeons Rami Lutfi, MD, and Jaime Ponce, MD, I became more aware of the growing concerns surrounding the occupational surgery settings of private versus employed versus academic practice. In Part 1 of this two-part column, I shared the perspectives of a group of participants who provided good representation for each model (May 2017, page 14). In a letter I received in response to Part 1 of this installment, Richard Ricca, MD, FACS, wrote to me about the current plight of the private practice surgeon (from experience), stating:

“The government and institutional medicine has destroyed private practice. As a general and vascular surgeon, I cannot accept all the insurance plans, since they do not pay enough to make ends meet. I would like to electively care for all patients, but the unrealistic reimbursements are prohibitive. It is unfair that hospital-employed surgeons are paid nearly double by Medicare for the same services as a private practitioner. As judged by space exploration and defense contracting, private enterprise is still the more efficient and higher-quality system.”

Shared opinions such as those of Dr. Ricca’s and this column’s participants are not just opportunities to elicit debate. Your voices are critical to continuing a dialogue that can hopefully, alongside medical advancements, advance the business end of health care services to a degree that makes all three employment paths sustainable, manageable and realistic options for all surgeons.

In Part 2, we tackle the following issues: bariatric endoscopy being its own independent stand-alone practice versus a bridge or adjunct to bariatric surgery; the role and effect of bariatric practice ancillary service offerings on income and compliance; and practice elements, such as work hour restrictions, electronic medical records (EMRs) and quality measure costs, and insurance requirements becoming deterrents to private practice startups and creating a shift toward the hospital-employed model.

Thank you to all of this month’s contributors for sharing their thoughts on these employment models and the changing face of each. Please feel free to email me at colleen@cmhadvisors.com with any ideas or comments!

—Colleen Hutchinson

Colleen Hutchinson is a medical communications consultant at CMH Media, based in Philadelphia. She can be reached at colleen@cmhadvisors.com.

Panelists
Helmuth T. Billy, MD A private practice surgeon, Director of Bariatric Surgery at St. John’s Regional Medical Center in Oxnard, Calif., and Community Memorial Hospital in Ventura, Calif.	Robin P. Blackstone, MD Professor of Surgery, University of Arizona School of Medicine-Phoenix; Center for Diabetes and Obesity at Banner University Medical Center, in Phoenix.
Jooyeun Chung, MD Director of Capital Health Metabolic and Weight Loss Center, in Pennington, N.J.	Shanu N. Kothari, MD, FACS, FASMBS Fellowship Director of Advanced GI and Minimally Invasive Bariatric Surgery at Gundersen Health System, in La Crosse, Wis.
Rami Lutfi, MD A surgeon in private practice in Chicago, in two community hospitals with surgical residency programs; Chairman of Surgery at Mercy Hospital; and Director of Minimally Invasive and Bariatric Surgery at Saint Joseph Hospital.	Jaime Ponce, MD A bariatric surgeon in private practice at Chattanooga Bariatrics, PLLC; Medical Director of Bariatric Surgery at CHI Memorial Hospital, in Chattanooga, Tenn.
Francis E. Rosato, MD A surgeon with Capital Health Surgical Group, in Pennington, N.J.	Dana Telem, MD, MPH Associate Professor of Surgery, University of Michigan, in Ann Arbor.
Guy Voeller, MD Professor of Surgery, University of Tennessee Health Science Center, in Memphis.	Virginia (Jenny) M. Weaver, MD, FACS A hospital-employed bariatric surgeon at Saint Francis Hospital, in Memphis, Tenn., and President of the Tennessee chapter of the ASMBS.

Statement: Present resident training, work hour restrictions, fear of insurance requirements, compliance, cost of EMRs and other quality measures, as well as overall business aspects of running a private practice, are creating a shift in the workforce toward the employed model.

Dr. Blackstone: On the fence. It seems to me that lifestyle preferences/choices are more important to the younger people graduating from surgery residency. The challenges listed above are often mitigated by joining a thriving private practice with an intact business structure.

Dr. Kothari: Agree. All of the aforementioned factors are making the employed model more attractive for graduating residents and fellows. In addition, the millennial surgeon is more interested in a stable paycheck and a more controllable schedule, as work–life balance is far more of a priority than with previous generations. The trade-off is that one gives up some “professional civil liberties” that those in private practice are afforded. But this mindset and the economic forces previously mentioned are contributing factors to the more than 65% of graduates accepting employment as hospital employees (Charles AG, et al. JAMA Surg 2013;148:323-328).

Dr. Billy: Agree. The resident training model today prepares physicians to be employed. Even when I trained, there was no education regarding how to start or be in private practice; we learned as we matriculated into the workforce. Additional administrative regulation has created barriers to entry that are largely financial and were not in place when I finished my training. Shifts in reimbursement away from out of network and toward inclusion in physician networks makes working in some communities financially undesirable, unless the physician is in an employed model.

The business aspects of running a private practice represent the biggest challenge to success as a private practice physician. Employed models offer better retirement packages that are free from the physician having to manage that aspect as well. Increased costs, increased wages, EMRs and state regulations all drain the resources of the old-fashioned solo practitioner. The private practice of the future will be groups of physicians who are motivated to create large single or multispecialty groups and can excel at insurance contract negotiations and provide critical services that are needed in the community.

Dr. Ponce: Agree. New residents coming out of training are very afraid or skeptical about their ability to handle all these issues and requirements. It makes more sense for them to have a “secure” job, paycheck and support from the hospital.

Dr. Lutfi: Strongly agree. Regardless of the drive someone may have starting surgical residency, five years “on the clock” with a day off after a hard day on call would become a habit and a culture.

Maintaining a sustainable private practice outside the support of an institution requires around-the-clock attention. Like any business, owners always must be present and knowledgeable of all details, monitoring quality and delivering the service at any given time.

In a generation trained on working shifts and told that rest is critical, this mentality is often lost. In addition, our failure to add mentoring on career choices and survival tools to clinical training in this confusing health care system is making the choice and the ability to start a surgical career without academic or institutional support nearly impossible. Graduating residents are taking “the easy way out” by choosing employment instead of the “good old” entrepreneurial practice that used to be the standard.

I believe all the elements of the question above (training, work hours restriction, insurance requirements, EMRs and compliance) are indeed placed to shift the entire medical workforce to an employment model, which would be much easier to control.

Dr. Voeller: Agree. All of those issues that you mentioned, in addition to what I said previously [see Part 1, May 2017, page 14], make it very difficult to be a private practitioner. In addition, in the mindset of the people now training, lifestyle is much more important than when I was training. This pushes them toward the employed model.

Dr. Telem: Agree. Secure paychecks and minimization of administrative burdens make this an attractive option for those entering practice.

Dr. Weaver: Agree. All of these things and many other complexities are driving the shift toward the hospital employment model. Whether this is a good thing or not remains to be seen. I anticipate hospital-employed physicians to enjoy a “honeymoon period” for a number of years, but I suspect this will end with respect to autonomy in practice and compensation, among other things.

Statement: Bariatric endoscopy’s role will always be a bridge to bariatric surgery rather than a stand-alone practice.

Dr. Lutfi: On the fence. More time is needed to give an informed guess! I would have agreed a few months ago, when I was starting my bariatric endoscopy practice, thinking balloon patients will go on to have bariatric surgery eventually. Now, after more than 50 balloons placed and many removed, I have not had any patient ask for or come back for bariatric surgery.

Despite our marketing efforts and educating patients about the risks for obesity (body mass index, 30-40 kg/m²) and the value of endoscopic therapy from a health care standpoint, this particular population—in my practice, at least—comes for cosmetic reasons! And despite the one-year program, it is seldom I see patients after removing their balloons.

Having said that, I believe that endoscopic therapy is driving patients to us who otherwise would not seek help due to fear from surgery. I still hope this would establish contact with the bariatric surgeon and lower the threshold for them to come forward in the future when the weight loss is regained—and it will be!

Dr. Ponce: On the fence. I would never say “always.” As of now, it looks like most of the bariatric endoscopic procedures are not permanent and less effective, and the great majority will need escalation of therapy, including surgery, but who knows what the horizon will bring us. Technology will improve, and we may be able to perform procedures that are more durable and efficient in the future.

Dr. Telem: Disagree. For certain patients, particularly with a lower BMI, these new technologies may provide a stand-alone response and play a role as a primary procedure.

Dr. Billy: On the fence. Bariatric endoscopy needs to be as common in the bariatric surgery practice as the stethoscope is in the internal medicine practice. Each bariatric surgeon should be skilled in endoscopy and have access to the gastroenterology lab, the [operating room] and even transnasal endoscopy in the office. Those who don’t will be left behind as the future unfolds.

In the future, bariatric surgeons may prioritize their ability to excel in bariatric endoscopy much the same way some surgeons have emphasized excellence with robot-based procedures. It’s an exciting future either way. I think the ability of physicians to innovate and develop new procedures might just end up producing a specialty that can treat some patients with good enduring endoscopic procedures. We are just not there yet.

Dr. Weaver: Disagree. While I think that it is still some time away, I do believe that we will reach a point when endoscopic interventions alone will demonstrate comparable results in successful and durable weight loss in obese patients.

Dr. Blackstone: Disagree. The nationally accredited centers through the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program are incentivized to work with their gastroenterology colleagues because all interventions or procedures done for obesity must be reported through the data registry. There is a very real disruptive effect of some of the new devices, and specifically the balloons, which are a portion control device, to stop obesity in smaller patients (BMI, 27-35 kg/m²) from having to come to a surgical procedure solution.

Drs. Rosato and Chung: On the fence. This will depend on which patient population (those who fall outside of the current BMI criteria for bariatric surgery vs. those who qualify for bariatric surgery but are unsure about proceeding) is targeted by manufacturers of the devices. Also, [we] believe the lack of insurance coverage for bariatric endoscopic procedures plays a big part in their usage.

Dr. Kothari: Disagree. I believe endoscopy is still in its infancy when it comes to the future of bariatric and metabolic procedures. There are many innovative techniques and devices in development, any one of which has the potential to be a “disruptive technology” and a true game changer in the field of metabolic and bariatric interventions. I envision a day when we can match the level of invasiveness to the severity of the obesity and comorbid conditions we are treating.

Dr. Voeller: Disagree. While true at present, endoscopic technology will continue to advance.

Statement: Offering ancillary services in bariatric practice optimizes income but is tricky because of compliance.

Dr. Blackstone: On the fence. Offering ancillary services is often not well reimbursed, and like many medical clinics, it makes little profit. It is funded mainly through the surgeon professional fees.

Dr. Lutfi: Agree. Time spent outside the operating room used to be a financial loss for surgeons. Surgeries were well reimbursed compared with patient care and follow-up. The current decrease in surgical reimbursement, however, forces surgeons now to find ways to optimize income outside the operating room in order to maintain their practices.

One way is to offer perioperative testing, such as lab and stress tests and x-rays. Bariatric surgery is a great example, as morbidly obese patients tend to have many risk factors that require investigation to obtain the preoperative clearance—ranging from lab tests and EKG to stress tests and sleep studies—and provide postoperative care (fluoroscopy and cosmetic surgery). Compliance should not be an issue at that level.

Endoscopy is another revenue-generating service that is best performed by surgeons without any issues with compliance.

Dr. Kothari: On the fence. I think it depends on which ancillary services one provides. Offering nutritional counseling by registered dietitians can be a mixed bag because unfortunately, as critical as these services are, many are not reimbursed by insurance companies and result in self-pay by the patient. This can result in a clinical outcome that benefits the patient but is a financial disincentive for the practice. On the other hand, groups that offer their own endoscopic services can often bill for these services, which can optimize income.

Dr. Ponce: Agree. Ancillary services can offer additional revenue, and it requires compliance with the facility requirements, patient referral for use of those services, appropriate billing and indication, etc. It can be tricky but not impossible.

Dr. Billy: Disagree. Compliance issues are easy to manage. They are all published and printed and easy to access. Ancillary services have to be managed as a business, and most physicians do not have a business degree or any experience prior to going into private practice. Introducing ancillary services and doing a proper business plan and analysis as to what things cost, and how reimbursement is going to be obtained, are essential in order to manage a profitable ancillary service. Each service line we introduced—bone density, sleep lab, gastrointestinal endoscopy, cardiac lab, pulmonary lab—was evaluated as a potential profit center and how each new ancillary service affects the other. Most importantly, an accurate assessment of the patient volume, the insurance payments and the costs of doing business have to be properly and accurately assessed. If you simply stumble ahead because you believe it’s a good idea and that you will make money, it can backfire. In addition, the service line needs to be constantly monitored as to its profitability as well as how the service line affects the overall flow of patients. It might make financial sense to maintain a service line with minimal or negative profitability if it helps drive volume to your operating room or improves patient outcomes.

Dr. Telem: On the fence. I am not sure offering ancillary services optimizes income, but I do believe in offering comprehensive care to patients. By placing as much care in one locale, that would likely optimize compliance.

Dr. Voeller: Agree. You have to be careful how you do it.

Dr. Chung: Agree. Offering ancillary services optimizes the income for the program and outcome for the patient. However, this is heavily dependent on the patient’s compliance with their follow-up visits during the postoperative period.

Gut Reaction: Where Do You See These Bariatric Procedures 5 Years From Now?

Contributor	Question 1: Prediction for Roux-en-Y Gastric Bypass	Question 2: Prediction for Laparoscopic Sleeve Gastrectomy	Question 3: Prediction for Mini-Gastric Bypass	Question 4: Prediction for Loop Duodenal Switch	Question 5: Prediction for Bariatric Endoscopy	Question 6: Prediction for Bariatric Revision Surgery
Virginia Weaver, MD	‘Done more frequently and on patients with a lower body mass index’	‘Done less frequently with more conversions necessary’	‘Not sure’	‘Not sure’	‘Increasing exponentially but still not comparable to surgery in weight loss results’	‘Performed with greatly increasing numbers’
Helmuth Billy, MD	‘Will still be the go-to gold standard’	‘Will be the most common procedure undergoing revision’	‘Will be the fastest-growing operation in the United States’	‘Will be the most common procedure for failed sleeves’	‘A critical skill for all new surgeons to master’	‘Stabilizes at about 20% of overall bariatric volume’
Rami Lutfi, MD	‘Slightly down to plateau at 20% of bariatric procedures’	‘Slower growth to plateau at 60%’	‘Slow but definite start, then exponential growth: <5% at five years ’	‘Will take over from conventional duodenal switch, but still overall <5%’	‘Unfortunately, growth mostly by gastroenterologists!’	‘Growth to 20% ’
Robin Blackstone, MD	‘The bulk of the procedures that will be done for morbid obesity ’	‘50% of them will require revision’	‘It will prove to be associated with gastric cancer like the B2 for young gastric cancer patients in Japan’	‘It will prove to be similar to the mini-gastric bypass’	‘A booming business model with good outcomes for overweight and obesity’	‘A requirement for about 40%-50% of patients’
Jaime Ponce, MD	‘Same as today, with a slight trend upward’	‘Same as today, with a slight trend downward’	‘No change’	‘More adoption, more evidence’	‘More acceptance, better tools’	‘Increased numbers’
Dana Telem, MD	‘Still the gold standard’	‘Increased conversions to other procedures’	‘Remain the same’	‘May be conversion procedure of choice for sleeve’	‘Increasing demand’	‘Increasing demand’
Jooyeun Chung, MD/?Francis Rosato, MD	‘As strong as ever’	‘Even more popular than now’	‘Will be fading’	‘Increase in growth as more patients seek it’	‘Unsure how the trend will be’	‘No response’
Guy Voeller, MD	‘Still around, less common, long-term complications bad’	‘Will level off but still going strong’	‘Will be even more mini’	‘Used infrequently due to potential complications’	‘Even larger role than today’	‘Will always be there due to noncompliance’