EndoEconomics Fall 2016

A Journal Dedicated to Economic Issues Impacting GI ASCs and Practices

FALL 2016

A Four-Way Partnership Transformed Northern New Jersey Center for Advanced Endoscopy

Page 5

Cyber Security Risks Page 11

New Technologies in GI Page 13

The GI Journal of:

“Improving the landscape of healthcare one surgery center at a time.”

FALL 2016 ISSUE EndoEconomics

by Physicians Endoscopy

Editorial Staff Carol Stopa Editor in Chief cstopa@endocenters.com

11

Lori Trzcinski Managing Editor ltrzcinski@endocenters.com EndoEconomics™, a free quarterly publication, is published by Physicians Endoscopy, 2500 York Road, Suite 300, Jamison, PA 18929.

The views expressed in this publication are not necessarily those of Physicians Endoscopy, EndoEconomics™ or the editorial staff.

POSTMASTER: Send address changes to: Physicians Endoscopy, Attn: EndoEconomics, 2500 York Road, Suite 300, Jamison, PA 18929. Periodical postage paid at Merrill, WI. While every effort has been made to ensure the accuracy of EndoEconomics contents, neither the editor nor staff can be held responsible for the accuracy of information herein, or any consequences arising from it.

Advertisers assume liability and responsibility for all content (including text, illustrations, and representations) of their advertisements published.

Printed in the U.S.A. Copyright © 2016 by Physicians Endoscopy.

5

13

Content 4 Message from the President 5 A Four-Way Partnership Transformed into a Three-Way Joint Venture 11 How Hospitals and ASCs Can Stay Ahead of the Curve to Beat Cybercriminals

All rights reserved.

13 The Incorporation of New Technologies into Gastroenterology

All copyright for material appearing in EndoEconomics belongs to Physicians Endoscopy, and/or the individual contributor/clients and may not be reproduced without the written consent of the Physicians Endoscopy. Reproduction in whole or in part of the contents without expressed permission is prohibitied.

16 An Ounce of Prevention is Worth a Pound of Cure

To request reprints or the rights to reprintsuch as copying for general distribution, advertising, promotional purposes-- should be submitted in writing by mail or sent via email to info@endocenters.com.

18 The Benefits of GI Practices Doing Strategic Planning 20 Working with the Media: 10 Steps for a Better Partnership 23 Business Briefs 24 Front & Center 26 Current GI Opportunities

Find out more at endocenters.com or find us on FAL L 20 1 6 EndoEconomics

| 3

Message from

the President On October 14, 2016, CMS announced the finalization of the MACRA Quality Payment Program. While many gastroenterologists are BARRY TANNER probably already President and CEO, MACRA’d to Physicians Endoscopy death, it is important to note that after listening to all the buzz for the past two years, the program will now take effect on January 1, 2017.

In a manner consistent with nearly any change, MACRA has generated an incredible amount of fear, loathing, speculation and misunderstanding.

By way of background, MACRA repeals the Medicare Sustainable Growth Rate (SGR) update to the Medicare Physician Fee Schedule (MPFS) and replaces SGR with a two-pronged quality payment program comprised of a Merit-based Incentive Payment System (MIPS) and an Advanced Alternative Payment Models (APMs). MIPS does NOT apply to hospital reimbursements nor does it impact ASC facility reimbursement. Although I understand and certainly empathize with gastroenterologists concerning the fears that accompany this change, I can also see a different side of MACRA, specifically, one that is less frightening and assuredly more positive.

I do not believe that MACRA spells the end of healthcare as we know it, as I have so often heard. I believe that MACRA (as finalized) provides for more flexibility and compliance pathways than gastroenterologists have had to put up with as a result of the three predecessor programs (meaningful use, PQRS and value modi4 |

EndoEconomics FALL 2016

fiers). These programs have been consolidated into a single program (MIPS) that now includes a fourth category called Clinical Practice Improvement Activities (CPIA). I suggest that all are both less burdensome and less penal for failure to comply and offer substantial rewards for full compliance in stark contrast to the prior programs.

Before MACRA, small physician groups (2 to 7) faced a maximum combined penalty of minus 8% reimbursement for failure to comply with PQRS and meaningful use.

And there were no positive upward adjustments available for those who did comply.

Under the MIPS program, providers who start reporting data on January 1, 2017, and submit a full year of quality data will be eligible for a 4% increase in reimbursement in 2019. Providers who elect NOT to participate in 2017 or beyond will receive a negative adjustment to their CMS reimbursement of 4% beginning in 2019.

Starting in 2018, full participation, or nonparticipation, will carry either additional positive or negative adjustments two years later of +/- 5% in 2020; +/- 7% in 2021 and +/- 9% in 2022. The final MACRA rule has provided a methodology for 2017 to be a transitional year for providers who want to comply but who need more time to prepare. I won’t try to review the interim rules here, but please note that so far 2017 is the only transitional year anticipated.

For providers who do choose to participate in MIPS (no matter when in 2017 you begin to collect and submit data to CMS), the minimum amount of required data collected for 90 consecutive days during this year must be submitted to CMS no later than March 31, 2018, in order to avoid reimbursement penalties in 2019.

Data must be submitted for four performance categories – Quality, Cost, Clinical Practice Improvement Activities (CPIA) and Advancing Care Information (ACI).

Under the MIPS program, 60% of a provider’s score is made up of quality measure data (the PQRS replacement), and Advancing Care Information (the meaningful use replacement) accounts for 25% of a provider’s score. The last 15% of the score is also quality improvement focused, entitled Clinical Practice Improvement Activities (CPIA). Quality measures are expected to be published by CMS on or about November 1st of each year.

I anticipate that much, if not all, of the quality data and some of the CPIA data will be able to be submitted through third-party intermediaries such as Qualified Clinical Data Registries (QCDRs).

QCDRs are required to apply annually to become a qualified registry. For example, GIQuIC has applied and successfully become a QCDR every year since 2014. For 2016, the registration process opens on November 15th, and we have every reason to expect that GIQuIC will continue to be both a QCDR and at least a partial solution to the MIPS data submission requirements for participating gastroenterologists.

While there is still much more information yet to be disseminated, such as the specific quality measures, I do believe that the MACRA will lead to streamlined data collection and submission. It holds the potential for gastroenterologists to earn meaningful, increased reimbursement from CMS — a significant improvement from the dark cloud of SGR that providers have lived under for so many years.

I hope that you will enjoy this edition of EndoEconomics!

A Four-Way Partnership Transformed into a Three-Way Joint Venture Northern New Jersey Center for Advanced Endoscopy

By Robert Kurtz Joint ventures are challenging, and many attempts at them fail. Bringing multiple parties together and getting them to agree on the parameters necessary for a project to move forward is far from easy. And as the number of parties involved in a potential joint venture grows, the difficulty magnifies.

But when all participants share a similar vision for a project, amazing things can happen. In the case of Northern New Jersey Center for Advanced Endoscopy (NNJC) in Englewood Cliffs, NJ, that vision was to provide high-quality, lowcost care using the latest equipment and technology to the Englewood area community.

NNJC is a three-way joint venture between Gastroenterology Group of Northern New Jersey (GGNNJ), Englewood Hospital and Medical Center (EHMC) and Physicians Endoscopy (PE).

This approximately 8,700 square foot endoscopic ambulatory surgery center (ASC) features four procedure rooms

and is expected to perform more than 9,000 procedures annually. It is state licensed, certified by Medicare and accredited by the Joint Commission.

center, but neither surgery center was state licensed which required meeting a higher regulatory standard as per New Jersey law.

The official opening of the ASC, which took place in early October 2016, represented the culmination of several years of collaboration between the three parties. Why and how was this project accomplished? Representatives of each of the partners have a story to tell that sheds light on what is required for a project of this size and scope to reach the finish line.

“That presented a difficult situation,” says GGNNJ’s Kenneth Rubin, MD, formerly of Englewood Endoscopic Associates and a co-medical director of NNJC. “We were a one-room center recognized by most insurance providers. Even though we had the same people reviewing our center’s compliance and followed the same safety protocols of multi-room centers, we were not considered a licensed center.”

The Practice Experience While NNJC is considered a three-way joint venture, in actuality it is a four-way partnership. When discussions about building the new ASC began, GGNNJ did not formerly exist. Rather, there were two GI surgical practices running independently: Advanced Gastroenterology of Bergen County and Englewood Endoscopic Associates. Each had a oneroom, Medicare-approved endoscopy

“The lack of license created some challenges with commercial payers,” says GGNNJ’s Barry Zingler, MD, formerly of Advanced Gastroenterology of Bergen County and the other NNJC comedical director. “We were unable to secure contracts with some managed care companies, so we needed to perform certain procedures in the hospital unit at a much higher overall cost. They

FAL L 20 1 6 EndoEconomics

| 5

port quality-based metrics, as well as to increase overall efficiency becomes paramount to on-going success and to maintaining a thriving independent practice. Being able to partner with a major health system such as EHMC only enhances the collaborative nature of this effort.

Rubin says the practices’ experience in working with EHMC made it a perfect partner for a new ASC. “EHMC has become recognized as one of the major hospitals in our region. The fact that the majority of our work, as our practices have grown, has always been at EHMC. The match between the hospital and us was perfect. The hospital had always wanted to do a joint venture with us. The missing piece was how it was going to be managed, and managed successfully.” could have been performed in our practice’s center had we been able to secure reimbursement.”

Formation of a Supergroup Despite the challenges, both practices ran successful, independent businesses.

The subsequent merger of those practices into one large group only made them stronger, says Bob Estes, MSPT, CASC, vice president of center development and implementation for PE, who worked closely with the physicians on the joint venture.

“What I learned from working with the physicians is that these were two practices going in the same direction,” he says. “While they had their differences, including culture, the approach to running the business, and some services, these differences were strengths, not weaknesses. They saw a great opportunity to take the best parts of each practice and combine them.”

But one thing was still lacking, Dr. Zingler says. “While our practice was running well, we wanted to become a state-licensed facility. That gives you a lot more options and the ability to ne6 |

EndoEconomics FALL 2016

gotiate managed care contracts.”

Dr. Rubin adds, “We realized with the growth of our practices, we really needed to look beyond our existing operations.”

A Shared Vision United as practices, the physicians united behind the idea of opening a multiroom licensed ASC — an opportunity that presented itself when the practices were approached by PE about the prospect of a joint venture with EHMC. “We viewed this as a way for our groups to move further forward into the new environment of medicine,” Dr. Rubin says. “We determined that a multi-room center was the way to go as this would ensure success for our younger associates and us as the years move forward.”

Estes says that the dynamics of the healthcare marketplace made the practices’ decision to form a supergroup and then pursue a multi-room ASC a wise one. As healthcare moves toward value-based care and reimbursement, the need to access information technology and to measure and re-

That missing piece was Physicians Endoscopy, Zingler says. “We really were looking for a company to help us not only open a licensed facility, but handle administrative responsibilities, provide us with expertise, and ultimately streamline the process. Working with a company like PE that manages so many ASCs throughout the country really lets you learn from them and take advantage of their experience.”

Fitting the Pieces Together While all of the parties were on board with the idea for the project, it didn’t come together overnight. Rather, it required a great deal of work from everyone, Rubin says. “As the negotiations moved forward, there were three moving parts: 11 gastroenterologists from the two practices, EHMC and also PE, which was putting the management team together. While we all had the same goal, at various times we felt these three pieces were going in different directions. PE helped everyone keep their eye on the ball to get this deal to closure.”

The differences between the practices were evident during negotiations and planning, Estes says, but a focus on the bigger picture helped keep the project moving forward. “Each understood that compromises and buy-in were necessary for this new construct. They knew they needed to collaborate, compromise, and make decisions together in order for the new entity to be cohesive and successful.”

That ability to work together was tested regularly as the project progressed, he says. In some instances, it was easy to give both practices what they wanted.

Other instances, such as staffing, benefits, and clinical decisions required the practices to be flexible.

Estes points to the creation of the surgery block schedule as such an example. “We have two very different groups with different anesthesia providers, practice patterns and wants for their staff. The question then is how do we put them all in one center? We have five days of open time and need to figure out who is working what days and taking which blocks. Some physicians had worked the same days and blocks for many years.”

Estes says he worked to mimic the physicians’ existing schedules as best he could, but then left it to the physicians to fill in the blanks. “Something as basic as working together on this weekly schedule was a good test of their ability to collaborate with one another.”

The physicians’ — and their staffs’ — willingness to be flexible was critical even once NNJC began accepting patients. After receiving its state license and Medicare approval, physicians started performing procedures at the ASC, but initially only on Medicare patients as managed care contract negotiations took place.

During this period, the practices kept their single endoscopy rooms open for

procedures on non-Medicare patients, with physicians and staff members working between both facilities. “This transition period was tough,” Zingler says, “but it worked out very well in the end. Once we secured our managed care contracts, the practices essentially closed their endoscopy rooms on a Friday, and we fully opened the new ASC on a Monday. It was seamless.”

Throughout the entire experience, Estes says what made the practices successful was their openness to change.

“We took two different groups of individuals and pulled them together to become one body, with one governing board of the new ASC. PE helped them navigate through the process, and now they share a great new facility with one another.”

The Hospital Experience For several years, EHMC worked to determine how to most effectively improve the quality of GI care provided to its patient community, says Michael Pietrowicz, chief strategy officer and senior vice president of planning and program development for the hospital.

“We have been firmly committed to our overall GI service line. We wanted to find the best path, the best opportunity, to create something very important and meaningful for our community as it relates to advances in GI care,” he says.

That vision jumpstarted what would eventually become the NNJC project, says Carol Stopa, senior vice president of business development for PE. “The hospital decided it wanted to build a digestive center of excellence in partnership with their GI physicians.

But creating a partnership between a hospital and physicians can be difficult given the dynamics of their business relationship.”

She continues, “EHMC recognized this challenge, and therefore the value that a third-party mediator could bring to forming such a partnership. That’s where PE came in. There was a lot of trust built between our organizations over many years.”

EHMC and PE agreed to partner on the project and approach the physicians together. “We have had a long,

FAL L 20 1 6 EndoEconomics

| 7

deep-rooted and successful relationship with all of the doctors in our GI division,” Pietrowicz says. “That was particularly true of the physicians within these two groups that merged into a single group (GGNNJ).”

The hospital’s desire to align with its physicians is commendable, Stopa says. “I give a lot of credit to the hospital; they really wanted to do this project for their community and their physicians.”

On paper, the plan was just what EHMC wanted, Pietrowicz says. “The opportunity to partner with our physicians and with PE, a leading, very successful management firm that focuses on GI — that marriage of three parties met our needs and wishes.”

He says the hospital had a few other expectations of what would make the project a success. “The center had to be built on a foundation of trust between all of the parties — a common commitment to providing the highest quality of care possible. It also needed to make business sense.”

That was true for the doctors as well, Stopa says. “The physicians wanted this project to happen, but they had been successful in their practices for many years. To give up their autonomy, it needed to be significantly worthwhile.”

Making a Deal Negotiations between the parties didn’t always go smoothly, Pietrowicz says. “We had some starts and stops, and hit some dead ends along the way.

But we always worked to plow forward and find new common ground.”

As with most deals that are eventually made, patience during the process was critical, Stopa says. “Everyone can get caught up in deal fatigue. All parties involved need to have the patience to work through the complexities and

8 |

EndoEconomics FALL 2016

never give up. If one pathway doesn’t work, you have to try another. And keep trying.”

A significant challenge to overcome was bridging the natural divide that exists between hospitals and their physicians, she says. “Joint ventures between hospitals and physicians can be very rewarding but take a significant amount of trust building. It can be difficult to earn physicians’ trust, especially in an arrangement like this where PE had initially partnered with the hospital. It took a long time to maneuver through that relationship so the physicians felt like they could appreciate PE as an impartial mediator. We needed to prove that we wanted to help them achieve this win as much as we did for the hospital.”

After lengthy discussions, a major breakthrough occurred: the physicians committed in their mind to a joint venture in some form with EHMC and PE. “Recognizing the direction where healthcare was headed, it economically made more sense to consolidate their business in a new ASC,” Stopa says. “While their surgical practices did have a value associated with them, the ASC would create even greater economic reward in terms of true equity, especially at the time when a doctor retired and sold their equity. They did not have that in their practices per se.”

The physicians brought in an advisor (The Bloom Organization) to represent their interests in the joint venture negotiations, which was a driver in moving the deal forward, Stopa says. “The challenge for PE was to determine how to structure the deal so everyone would be happy going forward. There were a significant number of meetings and discussions, but we were able to come up with a satisfactory agreement. PE and the hospital formed a holding company to own 51% of the

ASC, with the physicians owning the remaining 49%.”

PE’s transparency was vital to securing an agreement that satisfied all of the parties, Pietrowicz says. “They are forthright, fair and honest partners.

Those are very important qualities.”

He says the many years of hard work and perseverance paid off when the ASC finally opened its doors. “The experience strengthened and brought to the next level our relationship with the GI physicians. It helped us create one of the most modern facilities in our service area for our patients, and continued us on the path of allowing us to make the program advancements we want in our entire spectrum of GI care.

We’ve been able to bring the best and brightest talent together in a very exciting, cutting-edge facility.”

The PE Experience PE leaders had several objectives in mind when they approached the physicians regarding the prospect of a three-way joint venture, says Ann Sariego, PE’s vice president of operations.

“We take pride in ensuring all of our centers provide low-cost, quality care for their communities,” she says.

“That’s what we do, and that’s what we wanted to do for this project. We also wanted to keep the physicians independent. We have seen firsthand that physicians can partner with a hospital and management company while remaining independent in their practice.

When that happens, the strength each party brings can make a facility that is truly amazing.”

Once PE was able to get EHMC and GGNNJ to agree on the parameters for the joint venture, it was time to move forward with turning the vision into reality. First step: finding a suitable location.

That was easier said than done, says Mary Ann Gellenbeck, vice president

of implementation services for PE. “We encountered a few challenges, but I like to think all things happen for a reason. After an extensive search, the site we eventually found and selected was superb. It had easy access for patients, and the entrance was right next to a beautiful, newly renovated front lobby.”

Before construction could begin, the necessary approvals were secured from the state. Then came the matter of designing the space. Since the new ASC was going into an existing medical building, there were a few obstacles to overcome.

“We had to design the space so it was adequate enough to accommodate the physicians and their expected volume, and we wanted to have some room for future growth,” says Gellenbeck.

Few hurdles were encountered during construction, which took roughly 20 weeks. A new set of challenges surfaced when staff were able to occupy the space in mid-February 2016.

“We wanted to transition from occupancy to state licensure as quick as possible as the state needs to come out and survey the facility in order for you to be able to see patients.” Gellenbeck says. “You enter a building that has no supplies and equipment, and have essentially a brand new staff of individuals you are hiring and training. In three weeks, we were totally trained and all of the competencies were completed.”

This was made possible thanks, in part, to significant contributions from members of the PE team, she says. “In addition to assisting with competencies for the staff, they also stepped up to help with receiving and coordinating all of the equipment to be delivered to the site, making sure it was installed correctly and then training the individual staff members on its use, which was

necessary to pass state inspection successfully.”

Inspection took place the first week in March. Ten days later, the first patient came to NNJC. Three weeks later, the ASC went through and successfully passed an unannounced Joint Commission Medicare-deemed status survey. “The timeline was very compressed, but we collaborated so well that it wasn’t a problem,” Gellenbeck says.

An Unusual Arrangement Once NNJC was licensed by the Centers for Medicare & Medicaid Services, the physicians shifted all their Medicare volume over to the ASC from their practices. As noted earlier, the physicians continued performing nonMedicare procedures in their practices’ individual endoscopy suites.

“This was the truly unique piece of this whole project,” Gellenbeck says. “We are used to dropping all case volume into a new center regardless of payer contracting status. In addition, if you’re only operating a few days a week, the revenue coming in is minimal but there are certain expenses that are pretty fixed.”

This placed an impetus on obtaining managed care contracts, she says. “A lot of the payers won’t even play in the sandbox with you until you have undergone your Medicare and accreditation survey. Then they’ll start working with you.”

The hospital’s relationships with insurance companies helped move negotiations along quickly. Gellenbeck says Anthony Orlando, EHMC’s senior vice president of finance and chief financial officer, deserves a great deal of thanks in this regard. “He was instrumental in fostering the relationships and opening some of the doors quicker.”

Once managed care contracts were secured, the physicians stop perform-

ing procedures at their practices and shifted all of their volume to NNJC in October 2016. “There were a few hiccups, but we always worked through them,” Gellenbeck says.

Sariego says the overall experience shows the importance of partners sharing an aligned vision. “With the changing landscape of healthcare, it is important to recognize the value of preparing yourself for the future so you can remain profitable and continue to serve the community by delivering quality care. With this venue, the physicians can practice and deliver their quality care while PE and the hospital works to ensure we are continuing to drive that quality and provide all of the services necessary to help the center run in an efficient, profitable manner.”

The Future of NNJC While the physicians may have had some initial doubt about whether the joint venture ASC was the right direction for their practices, they have no regrets about their decision to partner on the new facility.

“Both the older and younger physicians in the practice are all excited about the facility,” Rubin says. “NNJC offers a growth opportunity for the practice and an ability for us to have a stronghold in our region. We are performing world-class medicine in an environment that is nurturing and caring.

We can more effectively monitor the quality of our care. With this joint venture, we believe we are in a perfect position for a future of medicine that is no longer going to necessarily be based on total volume but on the quality of care.”

So far, patients are singing the praises of the new center, Zingler says. “The reviews thus far have been great. Patients love coming to the ASC. It’s a beautiful, physical plant with great parking. The patients really appreciate the efficiency

FAL L 20 1 6 EndoEconomics

| 9

of coming to our facility and receiving care in a very professional, safe environment.”

All of NNJC’s partners believe there is a tremendous opportunity for growth of the ASC, which is one of the reasons why it was purposely overbuilt. Only three of the procedure rooms were operational when the center opened. “There are ongoing discussions about growing the center through adding physicians,” Estes says. “We have assertive efforts to attract additional providers and grow, and we have a facility that can accommodate it.”

The ASC gives the practice and hospital a valuable recruitment tool, Stopa says. “It’s a way to attract other GI physicians to the community by having a state of the art center with the best equipment, experienced staff and potentially center ownership in the future.”

Emulating the Model NNJC’s co-medical directors are both pleasantly surprised about how well the new ASC has worked out thus far.

“When you’re running an endoscopy unit for more than 20 years, you think you’re doing a great job, and we were,” Zingler says. “But until you experience the expertise and efficiency of working with a company like PE and a hospital partner, you get to a different level.

This type of partnership allows physicians to concentrate more on taking care of patients and performing endoscopic procedures rather than running the ASC. You are still involved in making decisions, but there is much less administrative work on your plate.”

Rubin also speaks highly of the three-way joint venture model. “I think it makes perfect sense to align yourself, at least in part, with a hospital. In this point in time, free-floating practices without any connection to a major medical center may struggle in terms of insurance contracts and various new statutes that will be presented in the coming years.”

He continues, “However, in partnering with a major hospital in a center, it’s very important to bring in the expertise for managing an outpatient endoscopy unit. While hospitals are very good at many things, they do not have the business expertise in outpatient endoscopy care that a company like PE brings to the table.

We now have the expertise of PE to make sure our center, in conjunction with the hospital, delivers on its potential now and in the future.”

Zingler advises other physicians who are weighing whether to pursue a joint venture to strongly consider doing so. “If you are performing procedures in your office and think you are doing a good job, there may be a better way. Once you work with a group like PE and EHMC, which have such experience, expertise and are so easy to work with, it makes you realize that you should have made the change years earlier.”

Questions or comments, please contact Carol Stopa, SrVP business development at cstopa@endocenters.com.

10 |

EndoEconomics FALL 2016

The Risk is Real: How Hospitals and ASCs Can Stay Ahead of the Curve to Beat Cybercriminals

By Lt. Col. Jim Emerson, iThreat Inc. and Rajiv Sharma, MD With the progressive electronization of medical records, hospitals and ambulatory surgical centers have become gold mines of patient information that when improperly secured can cost centers hundreds of thousands if not millions of dollars.

RAJIV SHARMA, MD

Cybercriminals are targeting healthcare organizations because of the wealth of knowledge that is stored and transmitted. Hospitals have names, addresses, Social Security Numbers, billing information, and much more stored away at the click of a button and logically connected to every other technology sharing the network.

In many of the victim systems and networks which Mr. Emerson has investigated, one common causative factor was apparent: cybersecurity was delegated by senior management and not managed with the same granular awareness, measurement, priority, and constant urgency as the corporate business logic and operations demand. To establish meaningful advantage, organizations must understand their cyber risk and respond with continuous diligent cybersecurity, just as they run the core business and not as a necessary but ancillary requirement.

When a company sets out to enhance their cybersecurity, they must begin with an honest and cyber threat-informed risk assessment inclusive of information, technology, and human stakeholders. What is real risk, what does it expose, does it map to a viable threat, and what alternatives exist to mitigate these risks. This includes consideration and testing to determine if there are active or latent treats already in place. This provides the continuously updated foundation for companywide information and technology security policies, safeguards, continuous reevaluation and update; minimizing the risk of successful or serious attacks.

Information security is not just about data and technology, it must reduce and attempt to eliminate the human element at risk. A significant number of attacks are starting with low technology schemes via an interaction or communication with a human. Some security reports have estimated more than 70% of attacks in recent years began with an email. Email attacks can contain malicious software as attachments; however, just as likely, infection or compromise of credentials occurs via a link in the email or interaction with a malicious website as a result of a link sent.

Mitigating unwitting human support for these type cyberattacks would result in a substantial gain in cybersecurity safeguarding the effectiveness of the average organization with relatively simple and low cost measures; user training!

Hospital administrators, physicians, and other healthcare personnel are so focused on patient care that cyber security is not the first thing on their mind.

A small unaddressed hole in a network or a misconfigured link could become the dreaded point of intrusion and ultimately jeopardize patient information. These types of events can take a large chunk out of the center’s bottom line, but a cybersecurity attack also erodes the patient’s and the public’s trust which could have dooming, longer term effects.

Another measure for increased mitigation of cyber risks requires an increased understanding of how an organization’s enterprise works, the measured risk derived from connecting various and disparate technologies and data together, and the ability to effectively segment high-value data from highrisk technology.

COO/Managing Director of New Jersey-based iThreat Cyber Group, Inc., Jim Emerson shared some observations regarding cyber threats based upon common problems he sees among the clients they have helped. He offers some fairly basic solutions to help mitigate a substantial amount of cyber risk exposure.

Most organizations have relatively limited up to the minute understanding of how their networks function regarding cyber risk; where critical data is in use, in transit, and even stored. Mr. Emerson indicates this must be mapped for non-technologist decision makers just as the hospital staff regularly reviews patients’ medical information to visualize problems or improvement in key areas.

FAL L 20 1 6 EndoEconomics

| 11

These are simple and relatively modest costing mitigation strategies that every organization can afford, master, and become diligent in practicing; training users, granular understanding of risk, and segmenting high-value data from higher risk environments.

Mr. Emerson says, “I think that executives can greatly enhance their cyber safeguarding posture for very little expense. Even if it’s something as simple as putting a reminder to employees in every email.”

Understanding the risk technology poses to your data is a crucial step needed to eliminate that risk.

But you cannot just assess and relax, you must do it constantly; monitor, assess, and adjust continuously.

Addressing cybersecurity can be prioritized and done in descending risk-based segments. By tackling the biggest risks the healthcare facilities has in their network first, an organization’s security situation can gradually improve over time, until it eliminates most of the risk posed to an organization.

Although daunting at first glance, securing healthcare facilities is not an insurmountable or an extravagant task, and it’s generally less expensive to tackle before an attack happens then after an attack happens.

There is a strong push on Capitol Hill regarding cybersecurity in the health care industry, as is evident by the Social Security Number Removal Initiative.

MACRA requires us to remove Social Security Numbers (SSNs) from all Medicare cards. When we replace the SSN on all Medicare cards, we can better protect private health care and financial information, and federal health care benefits and service payments.

Cyber awareness is the KEY for us to protect ourselves in future.

Lt. Colonel James J. Emerson USMC (Ret) is the COO/ Managing Director at ICG, Inc. He provides management of cybercrime investigation and mitigation services for private sector victims in cooperation with public sector agencies.

Mr. Emerson’s law enforcement and security background encompasses a wide spectrum of national security and public safety disciplines over 37 years with a focus on cybercrime investigation, computer forensics, and related criminal intelligence over the past 12 years.

Rajiv Sharma, MD, is a board-certified gastroenterologist and wellness physician in private practice. He is the founder of RAAMS Consulting, clinical advisor at EGM Health and author of the book “Pursuit of Gut Happiness: A Guide for Using Probiotics to Achieve Optimal Health,” which was published in 2014. For more information, visit http:// rajivksharmamd.com.

Stop an Attack Security Awareness Training Physicians Endoscopy provides the IT systems and security for their 42 partnered centers across the county. Gene Goroschko, Senior Vice President of Information Systems, heads up a team of system and network administrators, program developers, and help desk support who monitor each ASC on GENE GOROSCHKO a daily basis, 24/7.

“A security breach is always just one click away,” says Mr. Goroschko.

“Hackers and other threat actors pay close attention to their audiences and environments. They are nimble, and they never rest.”

Potential intruders always look for the easiest way in and, in most cases, that path leads through your employees and not your IT security. Each day your staff is getting bombarded with spam emails, some of those emails are phishing attacks. Spam filters and antivirus systems can’t stop them all. Some of those emails are getting through to your users today. All it takes is one user to click on one link in a phishing email and your network is compromised.

Firewalls and antivirus systems won’t help you when the attack starts with a user action from INSIDE your security perimeter.

Security Awareness Training is key to stopping this threat. Every healthcare facility, from the smallest practice to the largest hospital network, needs to constantly test and train their staff to prepare them for an email based attack. Larger networks and facilities that are members of management groups should have full-time IT staff conducting these tests. It’s the small practices and unaffiliated surgery centers that are at the greatest risk. They are a prime target for this type of attack.

If your center or practice doesn’t have adequate IT support (and don’t assume that it does), then you need to act now and get ahead of this threat. If you do have IT support and they have not talked to you about Security Awareness Training, you should approach them about training. If you don’t have support or you are looking for more information, you should contact one of the many companies that offer Security Awareness Training programs.

Security Awareness Training needs to be a long-term commitment.

It’s not something you can do once and forget about it. The time to train is now, before the breach happens, not after your systems have already been compromised. There are costs to Security Awareness Training, but they are minimal compared to the costs of recovering from a data breach.

For questions, contact ggoroschko@endocenters.com.

12 |

EndoEconomics FALL 2016

A Gastroenterologist’s View of the Incorporation of New Technologies into Gastroenterology

By Michael L. Kochman, MD, AGAF, FASGE Innovation is the lifeblood that fuels advancements in the delivery of patient care. All disciplines and specialties within medicine are impacted by innovation. Innovations may impact on and be impacted by insurance coverage, care delivery models, MICHAEL L. KOCHMAN, techniques, and technologies. The MD, AGAF, FASGE overarching goal is to continuously improve patient health.

Some of the most important movers and external forces that enable innovations or require innovations are patient expectations and the changes that are occurring to our traditional service lines including gastroenterology. We all recognize the desire of patients to have painless and scarless procedures; ergo the drive and ready acceptance of laparoscopic surgery and other minimally invasive procedures. These desires have been especially pertinent to gastroenterology given the advent of EMR, ERCP, and EUS-based procedures.

Concurrently with the patient expectations are issues that affect gastroenterology and may impact the financial basis for many practices. Multiple changes to colon cancer screening, the traditional backbone of many practices (academic and private practice alike), will result in many

changes in care delivery. The advent of multiple alternatives to traditional colonoscopy take aim at its weaknesses as a population-based screening modality. Those include the cost and the inconvenience of the prep and procedure.

Changes to reimbursement in a fee for service model (FFS) and the advent of quality and value-based provision of care will be impactful. If we don’t embrace these changes and additionally help guide their development, then we and our patients may lose the opportunity to shape the future.

If we do not avail ourselves of the opportunity to innovate and change the way we provide health care, the tools that we use, and develop the metrics to measure our successes (and failures), then others will. Some of the competition may be obvious: family practitioners and referring internists may utilize the non-invasive colorectal cancer screening tests, and we may never see those patients. Other implementations of the innovations may result in gate-keeping and patient-steering from the payors and ICNs. It is important that we embrace and recognize innovation and its potential for impacts on the practice of gastroenterology–both direct and indirect.

A basic understanding of the types of innovation is needed in order to frame the difficulties surrounding innovation and its eventual adoption into practice. Christensen (Innovator’s Dilemma, 1997) helped clarify the types into disruptive and

FAL L 20 1 6 EndoEconomics

| 13

sustaining innovations. Disruptive innovations create new markets and value and will displace or sundown an earlier technology or technique. Sustaining innovation does not truly create a new market or value network, but it does mature or evolve existing markets by increasing the improvements and allowing for better value in the existing market. To further subgroup the sustaining innovations, they may be discontinuous (which are transformational), or they may be continuous (which are inevitable changes). For example, in the automotive space, one may consider the electric car to be disruptive (eliminates the internal combustion engine), while the bridge steps of hybrids are an inevitable sustaining innovation (augments and improves the internal combustion engine).

In the gastroenterology space, there are obvious innovations which are illustrative. The development of video capsule endoscopy is a disruptive innovation; it does not require the capital, the infrastructure of an endoscopy suite, the skillset of a trained endoscopist, and in some instances may be performed and potentially interpreted by a non-endoscopist. In contrast, the introduction of high-definition video endoscopes with the accompanying 4K screens is an iterative innovation, one that sustains the underlying technology and paradigm of use. Some potentially disruptive technologies, such as polymer injections at the GE junction to treat gastroesophageal reflux disease, sounded attractive until the complications and concerns became apparent. In contrast, the transoral antireflux and metabolic procedures that are currently approved appear to have safety and efficacy profiles that are needed for ultimate success. Unfortunately, safety and efficacy are not the only necessary hurdles to overcome

14 |

EndoEconomics FALL 2016

prior to widespread adoption and ultimately success in the marketplace.

So what are the drivers that will ultimately result in the adoptions of innovation? They are multiple and complex, yet seemingly are easy to identify.

For patients, the drivers are apparent: the desires for less invasive procedures that are less painful to undergo, less interruption to the daily routine with a faster return to the pre-procedure activities, and with fewer reminders (scars) of the procedure. For physicians, the interest in innovation is based upon whether it is deemed useful to the patient population that one treats, is easy to use, not cost-intensive, and there is a clear reimbursement pathway for not only the device associated costs but for the physician’s time and effort. For patients and physicians, the decisions usually can be distilled to two questions: does the innovation make the procedure easier and/or is it obviously better and/or safer.

Pasricha (CGH, 2004) postulated that the success of an innovative device or procedure has certain prerequisites: unmet need, simplicity, and efficacy. His construct is interesting and simple as success may be determined by achieving two of the three prerequisites. For example, in gastroesophageal reflux there is arguably a low unmet need such that success of any new therapy or intervention will require the other two characteristics; it must be simple and efficacious. On the other hand, obesity has clearly defined unmet needs and therefore only one of the other characteristics of either simplicity or efficacy is needed for success.

This model held well until the current era of ACA and MACRA. The largest issue now confronting adoption of innovation is the value proposition that the innovation brings forth.

The role of the payors, be it the Federal governments, private insurers or a patient self-pay model is at times the seemingly unsurmountable hurdle that must be overcome. Payors are still, for the most part, based in the FFS model which relies on a CPT code and ICD10 match to ensure the possibility of reimbursement. Of course, when new devices are approved by the FDA on the basis of safety and efficacy, there infrequently exist the studies that are asked for by payors to support reimbursement. Usually, the first step to obtaining reimbursements is a CPT code, which due to the initial low volume of procedures and a low number of practitioners, are difficult to support with published literature, making this objective difficult, at best, to obtain. If the hurdle of obtaining a CPT code is overcome, then the payor requests for literature are the next issue to overcome.

Initially, there are few published trials; so payors will consider a non-coverage determination as the first step.

To overcome this, time is needed but for a nascent, innovation that can be a body blow as the cycle of adoption is slowed. If there is not reimbursement, physicians (along with their health systems) and patients are often financially unwilling to take on the financial risk associated with a novel technology. It takes time to develop studies that are large enough to be publishable and to demonstrate clinically meaningful impact; something that few start-up companies have the financial wherewithal to undertake.

Other complexities that may impede the adoption of innovation are the guidelines and commentaries that are published by our societies. It is important that clinical researchers produce data and accurately report it. Guidelines cannot be written without data whether supporting or refuting the

use of a device, drug, or technique in the treatment of a medical condition.

When studies, both investigator and industry initiated, are developed, it is incumbent upon the investigators to design the trial to appropriately answer the clinical question being asked and to do so in a definitive manner.

Whether the trial design is a prospective registry, a pragmatic trial, a prospective randomized controlled trial, or a retrospective case-control study, it is important to accurately power the study and design end-points that are meaningful in clinical practice. Too often the initial FDA pivotal trials have been performed to answer one question to obtain FDA approval, which may not be the relevant question for clinicians and the payors.

When guidelines are being formulated, it is critical that the authors and society leadership be aware that the readership and use of the guideline will be much broader than the society membership. Payors and industry will scru-

tinize them and utilize the publications in ways and manners that were often not anticipated and often not intended. The choice of individual words and meaning within the guidelines and implications that an innovation is ‘limited in application,’ or that ‘further study is needed,’ or ‘not ready for prime time’ can have an unintentional chilling effect when the real issue is simply that the data has yet to be developed.

As gastroenterologists, what can we do to either participate in the process of innovation or in the adoption of innovation? It may at times seem that we are bystanders. Indeed, in some instances, we may not have the ability to directly impact on the development or approval of a device, but we all ultimately have the ability to determine the eventual success or failure of an innovation. It is incumbent upon us to look objectively at new technological and technical innovation and to see if we believe that it may be useful to our patients: the ultimate consumer of

health care. To help viable innovations reach our patients, become involved and engaged with payors, societies, and provide objective advice to companies that may approach you.

Michael L. Kochman, MD, AGAF, FASGE is the Wilmott Family Professor of Medicine and Professor of Medicine in Surgery in the Gastroenterology Division at the Perelman School of Medicine at the University of Pennsylvania and Hospital of the University of Pennsylvania. He completed his fellowship in Gastroenterology at the University of Michigan.

Locally he has served on multiple committees and directs regular and advanced endoscopy training. He has received teaching awards for the education of fellows and residents and nationally he was named “Master Endoscopist.”

He is frequently a speaker at national and international meetings well as being faculty for hands-on training courses. Dr. Kochman has published over 225 articles and chapters and a number of videos.

He is Editor for Techniques in Gastrointestinal Endoscopy and has edited 19 published books: including the Clinicians Guide to Gastrointestinal Oncology, Advanced Gastrointestinal Endoscopy, and Endoscopic Oncology: Gastrointestinal Endoscopy and Cancer Management.

FAL L 20 1 6 EndoEconomics

| 15

Benjamin Franklin Was Right!

An Ounce of Prevention is Worth a Pound of Cure

By Andrew D. Feld, MD, JD, and Klaus Mergener, MD, PhD, MBA Gastroenterologists are strong advocates of prevention. We counsel our patients regarding the benefits of colorectal cancer screening. We help them take appropriate action, rather than the proverbial head-in-the-sand approach. We encourage a variety of other preventive measures, such as vaccinations for our patients with inflammatory bowel disease. Sometimes we even give travel guidance to help prevent illness.

eration of State Medical Boards (FSMB) model guidelines1 as well as the American Medical Association (AMA) policy regarding social media use and networking.

ANDREW D. FELD, MD, JD

But how much attention do we pay to prevent legal problems in our own practices? Do we have a good understanding of the common legal risks KLAUS MERGENER, MD, PHD, MBA and practice management pitfalls we face? And are we doing everything possible to avoid or minimize them?

Here are just a few of these everyday legal issues and pitfalls: Do we know how to handle digital age questions? How do we harness the power of the internet while safely handling our online presence? We certainly can’t violate HIPAA regulations. But we need to also be aware of evolving ethical guidance from our own state medical boards and the Fed16 |

EndoEconomics FALL 2016

For instance, “friending” your patients on Facebook may now be considered a boundary violation and should, therefore, be avoided. You could otherwise be sanctioned and publically listed on the state medical board website!2 In fact, state medical boards have been surveyed with examples of behavior that they would pursue should a complaint be brought.3 What if a patient posts what we believe is defamatory material on a doctor rating site? Do we understand the potentially severe consequences of attempts at retaliation? In general, the use of the courts to sue a patient for posting defamatory materials will backfire, giving the complaint even more exposure and making the doctor appear vindictive.

Experts advise to create a modern looking, user-friendly practice website with helpful patient information and to engage IT professionals to improve the SEO (“search engine optimization”) ranking of your website and other positive materials in order for them to appear first on internet searches.2 What happens if a patient complaint goes to a state medical board? Do we know how to respond? Do we know how we may be required to respond, and what the potential consequences might be? Busy physicians faced with a letter from their board outlining a patient complaint may tell themselves, “Well, it’s not a lawsuit, and this won’t go anywhere.” How-

ever, the state medical board may require written explanations, may schedule hearings, and it has the power to demand remediation (such as taking targeted CME courses). The board may even restrict a physician’s license, or in extreme cases revoke that license to practice medicine in that state.4 And regulatory pitfalls abound for all clinical gastroenterologists. For example, professional activities such as medical directorships may pay well. But if they pay too well, beyond fair market valuation or are based on volume of referral, they could be considered unlawful “kickbacks” and trigger regulatory scrutiny and sanctions.5 Most of us have a general sense regarding a lawsuit that alleges negligence, and we know that informed consent and standard of care are important concepts. But a more detailed understanding of the structure of a lawsuit may help us review our practices and habits in a helpful preventive manner, and may provide a “survival guide” with a roadmap and legal “pearls” to help in the unfortunate event we are suddenly confronted with a lawsuit.

One such pearl, regarding the handling of depositions, explains the difference between medical thought (“I need to fully explain myself, and of course I will be vindicated”) and legal thought: the purpose of a deposition from the plaintiff attorney perspective is not to understand what happened, but to ‘find enough rope to hang you.’ You should, therefore, be truthful, but give the minimum information asked. Don’t volunteer long-winded answers. You are not there to teach!6 In our everyday clinical practice, we know where to find expertise related to clinical practice guidelines, quality measures, and controlled clinical trials. But where do we find comprehensive risk management information about how clinical guidelines or quality measures can be used in a legal setting?

Guidelines often state they are not intended to represent the standard of care. But when brought to trial by an expert witness, courts may find them very persuasive.7 And there are specific risks to be considered with specific diseases.

Most of us have struggled with decisions about “top down” versus “bottom up” therapy for our patients with inflammatory bowel disease (IBD). Of course, if that patient refuses a recommendation for top down therapy out of concern for the risks associated with those medications, we have no legal exposure, correct? The patient gets to choose, right?

–Yes, but only as long as we have made the risks of disease progression very clear, so the concept of “Informed Refusal” can’t be applied against us.8 Other diseases and procedures such as colonoscopy and ERCP have their own sets of risks,9,10 and a more detailed discussion of how to minimize legal exposure in the event of missed cancers or post-ERCP pancreatitis is beyond the scope of this article.

Preventing legal problems and minimizing the liability exposure of our practices is indeed critically important. If anything, in this time and age of rapid change and increasing production pressure, these issues are becoming more important than ever! We may attend the occasional seminar, but we don’t have easy access to comprehensive information tailored to gastroenterologists.

Next year’s GI Roundtable (GIRT) conference, which takes place on March 17-18, 2017, at the Worthington Renaissance Hotel in Fort Worth, TX, sets out to change this situation. GIRT 2017 will go beyond the above examples and provide a comprehensive collection of indepth materials organized by practicing gastroenterologist with legal insight, and particularly suited to the practicing gastroenterologist and administrative leaders. Plenty of time will be set aside for Q&A with attorneys and physician experts about specific problems, and there will be lots of oppor-

tunity for general networking and an exchange of ideas in a relaxed and ollegial atmosphere.

Let’s not avoid the sometimes unpleasant topic of legal aspects of GI practice and pursue the head-in-the-sand approach, but let us instead get together to review this topic in a comprehensive fashion at GI Roundtable 2017. An ounce of prevention is indeed worth a pound of cure!

For more information about GI Roundtable 2017, to review the entire program, and to register, go to www.giroundtable.com References 1. Federation of State Medical Boards Model guidelines for the appropriate use of social media and social networking in medical practice. https://www.fsmb.org/Media/Default/PDF/FSMB/ Advocacy/pub-social-media-guidelines.pdf ; accessed Oct 27, 2016.

2. Belle JM, Feld KA, Feld AD. Internet liability for gastroenterologists: select issues from social networking to doctor rating sites.

Clin Gastroenterol Hepatol 2013;11:883-886.

3. Farnan JM et al. Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards.

Ann Intern Med 2013;158:620-627.

4. Feld KA, Feld AD. Understanding legal and regulatory adverse actions: how trouble could come at you. Clin Transl Gastroenterol 2016;7:e158.

5. Bartian JC Jordan WH “ Treacherous terrain: how to avoid getting caught in the Government’s crosshairs” Am J Gastroenterol 2016; 111:1376-1377 6. Feld AD Moses RM. Most doctors win: what to do if sued for medical malpractice. Am J Gastroenterol 2009; 104:1346-1351.

7. Moses RE and Feld AD. Legal risks of clinical practice guidelines. Am J Gastroenterol 2008;103:7-11.

8. Feld AD. Informed consent: not just for procedures anymore.

Am J Gastroenterol 2004;99:977-980.

9. Rex DK. Avoiding and defending malpractice suits for postcolonoscopy cancer: advice from an expert witness. Clin Gastroenterol Hepatol 2013;11:768-773.

10. Cotton PB. Analysis of 59 ERCP lawsuits; mainly about indications. Gastrointest Endosc 2006;63:378-382

Andrew D. Feld, MD, JD is the Program Chief of Gastroenterology at Group Health Cooperative in Seattle, WA, and a Clinical Professor of Medicine at the University of Washington. He is a past president and a current board member of the Pacific Northwest Gastroenterology Society, and he serves as the current Governor, WA State, for the American College of Gastroenterology (ACG). Dr. Feld will be co-directing GIRT 2017.

Klaus Mergener, MD, PhD, MBA, is a partner with Digestive Health Specialists and the Director of Interventional Endoscopy at MultiCare Health System in Tacoma, WA. He serves as an Affiliate Professor of Medicine at the University of Washington and is Vice-Chair of the American Society for Gastrointestinal Endoscopy (ASGE) Foundation Board of Trustees. Dr. Mergener is the co-founder of the GI Roundtable and will serve as a co-director for GIRT 2017.

FAL L 20 1 6 EndoEconomics

| 17

The Benefits of GI Practices Doing Strategic Planning and How the Various Ancillaries Come Into Play

By David K. Batulis, MHA

You are a busy practice with an affiliated endoscopy center facing the consolidation of health insurers and hospital employment of physicians.

Practices like yours may be facing a myriad of challenges related to Medicare payment rule changes, DAVID K. BATULIS, MHA flat insurance reimbursement, rising overhead, aging facilities, difficulty recruiting new physicians, employee turnover, and the whole alphabet soup of government regulations. What are the things you need to do to thrive as an independent practice? The primary challenge being that the Income Statement oversimplifies the operation of today’s private physician practice.

How effective are your marketing expenses?

Many practices think that revenue growth comes from marketing, but what if they are wrong? Our experience is that the things that drive volume growth include: getting patients in when they want to get in, developing a two-way relationship with patients based on their preferred method of communication, and having patient expectations for waiting and service managed by your staff so patients will return and recommend your practice to others. These

18 |

EndoEconomics FALL 2016

‘word of mouth’ referrals are an effective way to grow your patient base without incurring additional marketing costs.

• 60.4% of practices do not have a two-way relationship with patients that prefer to communicate via email (AGA 2015 survey) • 74.8% of practices do not have a two-way relationship with patients that prefer to communicate via text message (AGA 2015 survey) • Many groups lack a central log of patient complaints and compliments from which to identify opportunities for improvement and employee recognition

How well do you generate cash from assets?

Many practices think that revenue production is a business office function, but what if they are wrong? Our experience shows that the largest opportunities for revenue production are in underutilized space and front-end functions such as scheduling, registration, eligibility, and authorizations.

• With rising insurance deductibles practices need to provide an experience that patients are willing to pay for out of their own pocket

• Many practices track physician production, but few are also trending patients seen per hour to quantify throughput • Look for ways to use staff to the top of their license and skills to ensure that you are optimizing valueadded time

How well have you contained overhead costs?

Many practices think that managing overhead is about cutting staff, but what if they are wrong? Our experience is that overhead can be reduced through a marathon of efforts to eliminate work and waste: people development, process improvement, throughput, and forecasting. Over time we need we talk about the challenge of breaking even on your Medicare rates.

• Employee turnover is a source of avoidable costs. Investing time in developing and cross-training staff to meet practice needs is an effective strategy for holding down overhead costs • Harnessing the power of improvement ideas from frontline staff – seek out opportunities to solicit input from staff and engage them

in helping solve problems and reduce costs • Make working towards breaking even on Medicare rates a target the practice is working towards collaboratively by reducing overhead and streamlining workflows • Take the mystery out of staffing to volumes by forecasting your projected patient demand and building schedules based on the projections

How well can you attract new partners?

Many physicians coming out of training shop around for the highest guarantee because they think that alone will secure their financial future; but what if they are wrong? There has never been such a challenging time for private physicians. Medical students are graduating with large loan burdens, delaying full earning potential until completion of training and then entering their profession faced with the pressure to provide care that is sometimes reimbursed below what it costs to deliver.

• Compensation structures that attract today’s recent training graduates do not look the same as they did 10 or 20 years ago

• Developing relationships with training programs and providing opportunities for trainees to learn about what makes the private practice model unique and rewarding can help ensure you are attracting talent that will thrive in the private practice environment • Practices that have senior partners near retirement need to understand their complete cost structure and model transition planning options for phasing in new partners In the evolving healthcare environment, private practices need to stay in front of the changes and capitalize on them to ensure their ability to retain the autonomy of the private practice model. Moving beyond the income statement and digging deeper into the fundamental drivers of practice performance can provide practices with insights that will allow them to anticipate needs, enhance revenue and reduce expenses. What would an assessment of your practice uncover?

David K. Batulis, MHA, is Founder and Managing Partner of Pro Fee LLC a physician services management company. Pro Fee serves only fiercely independent physicians that want to control their own destiny.

FAL L 20 1 6 EndoEconomics

| 19

Marketing

Buzz

Working with the Media:

10 Steps for a Better Partnership

By Lori Trzcinski, Marketing Communications Specialist

For organizations of any size, working with the local media can be an effective way to gain publicity and exposure.

With the increase in competition for patients, physicians and staff members, a little positive press coverage can go a long way toward LORI TRZCINSKI putting your organization on the map for these individuals.

The good news is that getting media coverage may require little to no investment besides time. Also working in your favor: local media are often eager to develop relationships with providers. Healthcare is a year-round issue of interest to your community (i.e., consumers of local media). There are topics that receive recurring coverage, such as flu season, youth sports safety and insurance enrollment, while others can

20 |

EndoEconomics FALL 2016

receive coverage over a limited period of time — think Zika.

Some topics may only receive coverage for a single day, such as the opening of a new facility, addition of a physician or a special event, such as a fundraiser. When the name of your organization and/or staff is included in coverage, it will raise the profile of your organization in ways that you cannot replicate on your own.

To help you work with your local media — and do so effectively — here are 10 steps you can take.

1. Find your local media. Do you know all of the media organizations that cover your market? These can include daily and alternative weekly newspapers, television and radio stations, and magazines. Conduct searches online to identify these organizations. Once you have a list compiled, consider running it by staff to see if you omitted any.

2. Determine how to contact media. Most media organizations include information on their website explaining how to contact them to share news. Look for pages

Marketing

Buzz with titles like “Share News Tip,” “Submit Your News” and “Contact Us.”

Once you find the organization’s instructions for sharing news, which will usually be through an online form or via email, make a note with the name of each organization on your list.

3. Identify healthcare reporters. Some media organizations assign specific “beats” to team members. A beat is an area of focus for a reporter. Take some time to see if the media on your list have reporters assigned to a healthcare beat. Sometimes media will identify which of its team members have a beat.

If you can’t find this information spelled out, look at the byline for recent articles about healthcare, including coverage of other providers in your area, to see if a reporter(s) name is associated with any of them. When that’s the case, it is likely that this individual has at least some form of a healthcare beat, even if it’s not a dedicated beat. Note what you learn with the information you have already assembled about your local media.

When you identify someone who likely has a healthcare beat, see if there is a way to contact that individual directly.

Oftentimes, clicking a writer’s name in the byline will bring up information about the writer that may include an email address, contact form and/or social media handle (usually Twitter, if anything). Note this information in your media documentation as well.

5. Periodically review media list. Just like any company, media organizations undergo turnover and changes to staff responsibilities. It is worthwhile to, at least annually, review the information you have compiled about local media and confirm it is correct based on what you can find online. Update any changes you find, including any new reporters assigned to a healthcare beat. When reporters leave an organization or change responsibilities, they do not always share a comprehensive list of their community contacts, so make sure to introduce yourself to any new reporters.

6. Make it easy for media to contact you. Even with your efforts to educate media organizations about how they can contact you for assistance with a story, it is best to assume that this information will not always reach the right people, let alone “stick” with the people you reached out to.

That’s why it’s important to make sure media can easily determine the best way to contact your organization for assistance with a story. Receptionists should be informed of your organization’s media point person. (Note: It is best to also have a secondary/backup media contact in the event that the primary point person is unavailable.)

Also provide contact information for media on your website. If your “contact” page on your website is a form, include an option for submitters to identify themselves as media. If you provide phone numbers and/or email addresses for specific departments, make sure there is a listing that speaks to the needs of media. If your website has a section dedicated to news about your organization, list this information there as well, or at least provide a link to your contact form with a note that points media in that direction.

The easier you can make it for media to contact your organization and reach the right person, the more likely it is that you will be included in stories. If media representatives find it difficult to contact you, especially on a short deadline, they are more likely to seek other sources.

4. Introduce yourself. The media can’t work with you if they don’t know about you. Contact the media organizations on your list and any healthcare reporters you identified, and express your willingness to help with stories. Also provide background on your organization, including your list of services and areas of expertise for physicians and staff.

This will help media gain an understanding of the different subjects you are in a position to discuss.

Make sure also to explain the best way for media to contact you for assistance with a story. If you are initiating contact with a media organization via email, it is best for the sender to be that individual. If you are submitting a form, share this individual’s contact information.

If you receive replies to your initial contact efforts that provide additional details about how your organization can work with the media, add this to your notes.

FAL L 20 1 6 EndoEconomics

| 21

Marketing

Buzz 7. Submit your news. When you have news to share, share it with the media. This is where the time spent researching your local media pays off as you will know who should receive your announcements.

As mentioned earlier, your news may include the opening of new facility, addition of a physician or a special event (e.g., fundraisers, open houses, educational sessions at your organization). It can also include awards for your organization or members of your staff, milestones, the addition of a new piece of capital equipment (as this is not only a substantial investment in your organization but often in your patients) and partnerships with other organizations.

content on major areas that may not just be about a single organization but are rather topics that affect an entire community. Reporters will be looking for community experts to speak to these issues, and you can potentially provide these sources.

For example, March is National Colorectal Cancer Awareness Month. As March approaches, contact the media organizations on your list to see if they are planning any coverage about the importance of screenings. Ask if they are looking for physicians to comment, and offer members of your staff as sources.

As another example, there have been a number of gastroenterology/endoscopy-related stories that have gained national attention over the past few years, such as new screening test options and treatment regimens for hepatitis C, as well as the infection outbreaks associated with reprocessed duodenoscopes. These are all topics where members of your organization may be in a position to serve as sources who can add a local perspective.

Make sure your submission identifies how media can contact you to learn more about your news. There is a good chance that if media organizations have interest in covering your news, they will want to conduct an interview. It is best to have identified members of your team, including physicians, in the best position to speak to the news. Also, confirm in advance their willingness to be interviewed, whether it be over the phone, on the radio or in front of a camera for television. When you are prepared to handle media requests, the coverage tends to go more smoothly.

When you know or learn of a major issue that may receive coverage, be proactive by bringing sources to reporters rather than hoping they will come to you. When you can get members of your staff quoted on these issues, it will send a message to the community that you have experts working in your facility.

8. Extend invitations. When you share news about an upcoming event involving your organization with media organizations, invite them to attend. As previously noted, you will want to make it easy for media to get the coverage they want, so share the contact information of the event’s media point person. This person should always be near the entrance to the event. If this individual needs to step away, other staff members near the entrance should know how to reach the media point person.

When you submit your news, provide the most critical background information and explain the significance of the news so media can easily understand why you believe the announcement is newsworthy. A quote or two from leadership can help add a little more color to the piece, as can the inclusion of images.

9. Remind media of your expertise. Media organizations strive to provide coverage that matters to as much of their audience as possible. That’s why media produces 22 |

EndoEconomics FALL 2016

10. Promote coverage. When you are fortunate to have news about your organization covered and staff members quoted in stories, maximize the benefits of and show your appreciation for the coverage by helping promote it.

Share links to coverage on your website and social media.

In addition, look for opportunities to share and support (“like”) coverage unrelated to your organization but that might be of interest to your patient community. Media organizations will appreciate your bringing more attention to their coverage, and these efforts will help keep you on their radar for future stories.

Lori Trzcinski is the marketing communications specialist at Physicians Endoscopy and the managing editor of EndoEconomics. With over seven years of marketing experience, Ms. Trzcinski leads the corporate and center marketing initiatives of PE and its affiliated centers. Ms. Trzcinski earned a B.A. in Business & Economics and Media & Communications from Ursinus College.

For more information, she can be reached at ltrzcinski@endocenters.com.

Business

Briefs Physicians Endoscopy’s New Strategic Partner In August 2016, PE took on a new private equity partner, Kelso & Company headquartered in Manhattan, New York, replacing their 2013 private equity partner, Pamlico based in Charlotte, NC. This strategic partnership provides a much larger infusion of capital to continue to build, acquire and further develop company initiatives for the future.

Guidon Partners made a minority investment alongside Kelso & Company. The Company appointed Greg Roth, a founder and partner of Guidon Partners, and former CEO of TeamHealth, to its Board of Directors.

Barry Tanner, PE’s CEO, noted, “We are very grateful to the Pamlico team for all that they have done to help us grow. They have allowed us to stay focused on helping physicians deliver high-quality care in the most patient friendly and cost effective setting. Our partnership with Pamlico has been absolutely wonderful. We look forward to continued growth with our new partners at Kelso.”

Art Roselle, Partner at Pamlico, said, “We enjoyed partnering with Barry Tanner and his team over the last three years as they have significantly enhanced PE’s value proposition to the Company’s partner physicians and driven growth through both organic initiatives and center acquisitions.”

Hank Mannix, Partner at Kelso, stated, “Kelso is thrilled to be partnering with Barry Tanner and his team at PE. PE has an unparalleled reputation as a value-added partner to GI physicians, and we look forward to supporting the Company’s continued growth and success.”

Kelso & Company has been investing in North American private equity for over 35 years. Kelso benefits from a successful investment track record, a long-tenured and stable investing team, a reputation as a preferred partner to management teams and strategics, and a significant alignment of interest with all partners. Since 1980, Kelso has raised a total of nine private equity funds, representing $11.2 billion of capital, and has made over 115 investments, over 90 of which have been exited. For more information, visit www.kelso.com.

Guidon Partners, a hands-on partnership founded by leaders in health care services, derives its name from a small, swallow-tailed flag that serves to rally the troops and signifies leadership. Their investment strategy focuses on helping companies who want expertise and guidance.

They co-invest alongside venture, growth equity and buyout funds helping new investments or existing portfolio companies get to the next level of growth and profitability.

FAL L 20 1 6 EndoEconomics

| 23

Front and

Center Growth & Expansion The physicians of Gastroenterology Group of Northern New Jersey (GGNNJ) are pleased to announce the opening of their new surgery center, Northern New Jersey Center for Advanced Endoscopy (NNJC). NNJC is a joint venture between the physicians of GGNNJ, Englewood Hospital and Medical Center (EHMC), and strategic corporate partner Physicians Endoscopy (PE). NNJC is an 8,500 square foot single-specialty endoscopic ambulatory surgery center with four procedure rooms. The Medicare-certified, state-licensed, and Joint Commission-accredited center is expected to perform more than 9,000 procedures annually. As healthcare reform continues to change, the new center will seek to provide low-cost, highquality outpatient endoscopic services to the Englewood, NJ area community.

Strategic Alliances Physicians Endoscopy hosted a meeting at the corporate office on October 5, 2016, with representatives from AAAHC. The purpose of the meeting related to AAAHC’s surveys and quality initiatives. Center administrators and nurse managers, along with PE operations, implementation, and clinical executives, were also in attendance and discussed center initiatives and challenges.

practice, Digestive Disease Associates, supported the event with a booth at the fair.

East Side Endoscopy and Pain Management Center (Lower Manhattan, NYC) hosted an open house at the Center on September 28, 2016. At the event, referring physicians were provided an introduction to the center’s new pain management service line and received a tour of the State licensed, Medicare certified and AAAHC accredited ambulatory surgery center.

were present on the day of the attacks or who worked, lived, or went to school in the New York City disaster area on September 11th or the months that followed. For more information on the World Trade Center Health Program, visit http://www. cdc.gov/wtc.

Physicians Endoscopy and their partnered centers have joined forces with over 500 local and national organizations to increase colorectal cancer screenings across the country with the “80% by 2018” campaign by the National Colorectal Cancer Roundtable (NCCRT). The organizations have committed to reducing colorectal cancer as a major public health problem substantially and are working toward the shared goal of 80% of adults aged 50 and older being regularly screened by 2018.

Several surgery centers participated in National ASC Week events August 8-12, 2016. The week is meant to raise awareness of the benefits of ASCs. Centers are encouraged to market their facility within their communities by hosting an event or open house to educate key policy and decision makers about the benefits of ASCs and to promote public awareness.

Island Digestive Health Center had Town Councilman John C. Cochrane Jr. and Councilwoman Trish Bergin Weichbrodt, both representatives from Islip, NY, tour the center in celebration of the week.

Community Initiatives Dr. Aperna Mele from Berks Center for Digestive Health has built up the Guts & Glory Health Fair over the last three years starting with just an idea and her passion for GI health. The event took place on Saturday, October 8th at the Fire Energy Stadium in Reading, PA. The Center’s affiliated private 24 |

EndoEconomics FALL 2016

Island Digestive Health Center is officially on PAR with the World Trade Center (WTC) Health Program. The WTC Health Program offers high-quality, compassionate healthcare to those directly affected by the September 11th terrorist attacks. The Program provides medical monitoring and treatment for all responders including emergency personnel, recovery and cleanup workers, and volunteers who helped at the World Trade Center, the Pentagon, and the crash site near Shanksville, PA. Additionally, the Program helps the survivors by providing initial screenings and treatment to those who

Front and

Center high-quality care. They show a strong focus on patients, continuous quality improvement, organizational involvement in the pursuit of quality, and use of data and team knowledge to improve decision making.

Congratulations to Carnegie Hill Endoscopy (Manhattan, NYC) for receiving approval from the New York State Department of Health (NY DOS) and Public Health and Health Planning Council (PHHPC) on their Certificate of Need (CON) Application for indefinite life licensure! The approval, as of October 14, 2016, is WITHOUT contingencies. The Carnegie Hill physicians and staff have made their surgery center and charity care programs a success, as well as a model for other GI programs in the ASC space.

Physicians Endoscopy held a suit drive where professional clothing was donated by employees to low-income job seekers through Robert Half, Dress for Success and other nonprofit organizations. PE has participated for the second year in a row collecting hundreds of men’s and women’s career attire. For more information on the cause, visit www.dressforsuccess.org and www.roberthalf.com.

Awards & Recognition The American Society for Gastrointestinal Endoscopy (ASGE) honored Advanced Endoscopy Center (Bronx, NY) for successfully meeting the requirements to be acknowledged as a unit that promotes quality in endoscopy through the ASGE Endoscopy Unit Recognition Program (EURP).

Participants are part of a growing national network recognized for their dedication to

Drs. Barry Jaffin and Anthony Weiss of Carnegie Hill Endoscopy will be honored with the Rosenthal Humanitarian Award at the 49th Annual Crohn’s & Colitis Awards Dinner. The dinner, in memory of Michael S. Modell and William D. Modell, will be held on December 14, 2016, at the Sheraton NY Times Square in New York City. The Greater New York Chapter hopes to raise more than $900,000 to support CCFA’s mission of finding a cure and improving the quality of life for the more than 1.6 million Americans affected

by Crohn’s disease and ulcerative colitis.

South Broward Endoscopy (SBE) was named one of Modern Healthcare’s Best Places to Work in Healthcare for 2016. SBE received the award for the 4th straight year and overall six times in the past seven years.

The Endoscopy Center at Bainbridge (Chagrin Falls, OH) and University Suburban Endoscopy Center (South Euclid, OH) physicians Drs. Robert B. Cameron, Michael K. Koehler, and Raymond W. Rozman Jr. were named “Top Doctors” in Cleveland Magazine’s annual issue. Cleveland Magazine partnered with the Castle Connolly Medical Ltd. research team to review physicians nominated by their peers for providing the most outstanding health care and clinical excellence. Center hospital partner, University Hospitals Health System (UH) had nearly 300 physicians named as “Top Doctors.”

Physicians Endoscopy (PE) was named one of Becker’s ASC Review’s ‘38 ASC Management & Development Companies to Watch’ for 2017. Founded in 1998, PE specializes in developing and managing single-specialty endoscopic ASCs in both the joint venture and physician-owned formats.

Barry Tanner is CEO and founder of the company. Physicians Endoscopy is in partnership with 42 centers across the nation that include over 300 gastroenterologists.

FAL L 2 0 1 6 EndoEconomics

| 25

Current

GI Opportunities Submit your CV online at www2.endocenters.com/opportunities

Cortlandt Manor, NY

Laredo, TX

An opportunity in Northern Westchester with a two-physician practice.

• • • • • •

Full-time or part-time: perfect for young families State-of-the-art endoscopic equipment Physician efficiency and optimal patient quality of care Light call schedule: 1:6 One hour to New York City Beautiful scenic area

For more information, contact: Annie Sariego, CASC, VP, Operations (215) 589-9008 • asariego@endocenters.com

North Bergen, NJ

An outstanding opportunity for a gastroenterologist!

Advanced Center for Endoscopy (ACE) has an immediate opportunity available for GI physicians looking for an outstanding ASC in which to perform procedures. Our single speciality, nine physician GI center is the perfect environment for you and your patients.

Gastroenterology Consultants of Laredo – Laredo Digestive Health Center The physicians of Gastroenterology Consultants of Laredo, a private gastroenterology group, are seeking a gastroenterologist to expand the practice. This candidate will have ownership opportunity in the affiliated endoscopic ambulatory surgery center.

This two-room facility is located in Laredo, Texas in the Northtown Professional Plaza on McPherson Avenue.

• Physician-owned and controlled center • State-of-the-art endoscopic equipment • Medicare licensed and AAAHC accredited • Anesthesia services for patient comfort • Physician efficiency and optimal patient quality of care • Nursing staff has extensive experience in GI endoscopy • An outstanding benefits package is offered • Professionally operated and managed • Group participates in research • High population to GI Doctor ratio 60,000:1 • 2 Nurse Practitioners with over 11 years of GI experience

For more information, contact: Lara Jordan, VP, Operations • (215) 589-9038 • ljordan@endocenters.com

Our center can help drive additional patient volume to you through the ASC, allowing you to increase your procedure volume in the environment that is more convenient. Our center can provide your patients a better outcome, and you will have satisfied and loyal patients.

ACE is ideally located in North Bergen along the banks of the Hudson River—the “gold coast” of Northern NJ, with a spectacular view of the NYC skyline. This is an excellent opportunity for a motivated physician.

For more information, contact: Annie Sariego, CASC, VP, Operations (215) 589-9008 • asariego@endocenters.com

Bellingham, WA NW Gastroenterology & Endoscopy Exciting opportunity to join a nine person single specialty GI practice in Bellingham, Washington. This progressive coastal community offers ocean and lake recreation, skiing, and miles of hiking and biking trails. Small college town atmosphere with proximity to Seattle and Vancouver, Canada.

Great place to raise a family! This collegial group has a freestanding AEC and pathology lab. EUS optional, ERCP strongly preferred. Outstanding benefit package.

Central New Jersey

Garden State Digestive Disease Specialists, LLC Garden State Digestive Disease Specialists, LLC is seeing a BC/BE Gastroenterologist to join our three physician practice in Central Jersey for a full-time position. The job offers an excellent salary, competitive benefits package, a reasonable call schedule (which includes other gastroenterology colleagues in the rotation), and an opportunity for full partnership track in 2- 3 years. EUS/ERCP training is preferred.

We serve culturally rich and diverse communities; our patients reside primarily in the Union and Middlesex counties of Central Jersey. Our SurgiCenter is a state-of-the art Endo Center presently being expanded into a 3 room facility. We are affiliated with 4 local hospitals, 2 of which are teaching hospitals with residency programs. We are in the NYC metropolitan area, 45 minutes from Manhattan, conveniently located near an international airport, and in close proximity to many cultural centers and the Jersey Shore.

Interested gastroenterologists may submit CV/or inquiries to: Ms Liza Macalincag, Practice Administrator • Lmmac@comcast.net

Rochester Hills, MI

For more information, contact: Lisa Burcroff at LMBurcroff@hinet.org

Mesa, AZ

Central Arizona Medical Associates The physicians of Central Arizona Medical Associates (CAMA) are seeking a full time Gastroenterologist to join their practice. Physician can expect to step into a busy practice while replacing a retiring partner. Anticipate a short track to practice partnership and ASC ownership. Practice operates out a single office and covers one hospital. Outpatient endoscopy is performed at a 2 room ASC with maximum efficiency and quality of care.

Enjoy sunshine and a great lifestyle in the metro Phoenix area.

Candidate should contact: Britannia Blanchard, Office Manager CamaBBlanchard@Virmedice.com • 480-834-0771 • 480-834-1136 (fax)

26 |

EndoEconomics FALL 2016

Troy Gastroenterology

The Center for Digestive Health (Troy Gastroenterology) is a well-established, highly respected private practice looking for two Gastroenterologists to join our growing practice. We have several offices across Metro Detroit with two state-of-the-art AAAHC accredited ambulatory surgery centers. We’re looking for an enthusiastic physician skilled in general endoscopy, ERCP and EUS. • • • • • •

Competitive base salary with productivity incentive Incentive bonus Retirement plan Discretionary allowance Eligibility for member status, after two years Insurance (malpractice, health, dental, vision, life, supplemental & dependent life, short & long-term disability)

Interested candidates please contact: Angela Johnson, Chief Operating Officer • (248) 243-0570 ajohnson@troygastro.com

Current

GI Opportunities Submit your CV online at www2.endocenters.com/opportunities

Lima, OH

Gastro-Intestinal Associates, Inc.

Lumberton, NJ

Gastroenterology Consultants of South Jersey

The physicians of Gastro-Intestinal Associates are seeking a BE/BC gastroenterologist to join our six physician, four CNP single-specialty practice.

Gastroenterology Consultants of South Jersey is a privately owned, seven physician practice located in Lumberton, NJ. We are a well-established practice of 25 years that is located among several growing communities in Southern NJ.

Established in 1977, the practice has an outstanding reputation with the local Lima community. This is an opportunity to join a GI physicianowned 18,000 square foot combined office and three-room endoscopy center. The center, built in 2008, is AAAHC and ASGE certified. In the area are two local hospitals with state-of-the-art facilities.

• Located within 30 minutes of Philadelphia and within 1 hour of New York City

This opportunity offers: • 1:7 call rotation • First year salary guarantee • Outstanding earning potential • Professionally operated and managed

For more information, contact: Robert Neidich, MD, President of Gastro-Intestinal Associates Phone: (419) 227-8209 ext. 100 Fax: (419) 222-6007

• Affiliated with Burlington County Endoscopy Center, a three room ASC which is physician owned and operated • We are seeking to add a full or part time gastroenterologist • We offer a 1:7 call schedule and an opportunity to perform ERCP/EUS (not required) • Partnership will be offered in both the practice and ASC Please contact Monica Awsare, MD at 215-718-6085 or monicaawsare@gmail.com

Williamsville, NY On-Site Endoscopy

Northern CA Central CA

GI physicians: are you looking for flexibility and supplemental income?

Our mobile endoscopy practice is seeking board-certified gastroenterologists in Northern CA (Sacramento/Stockton/Tracy) and Central CA (Fresno/Tulare/San Luis Obispo)!

Flexible schedules allow you to work as many as 1-2 days per week or as few as 1-2 days per month. Position offers competitive pay.

For more information, contact: Amy Fasti • afasti@securemdca.com Toll Free: 1-877-613-3494

Cleveland, OH UHMP Gastroenterology Associates The physicians of UHMP Gastroenterology Associates, a private gastroenterology group affiliated with University Hospitals of Cleveland and CWRU School of Medicine, are seeking a gastroenterologist to expand the practice. This candidate will have ownership opportunity in their two thriving endoscopic ambulatory surgery centers. These freestanding, state-of-the-art ambulatory procedure centers are located in Chagrin Falls and South Euclid, Ohio (suburban Cleveland).

This Opportunity Offers: • • • • • • • •

Physician owned and controlled centers.

State-of-the-art endoscopic equipment.

Medicare licensed and AAAHC approved.

Physician efficiency and optimal patient quality of care.

Nursing staff has extensive experience in GI endoscopy.

All physicians and nurses are advanced cardiac care life support certified.

An outstanding benefit package is offered.

Professionally operated and managed.

For more information, contact: Michael Koehler, MD • UHMP Gastroenterology Associates (216) 691-3602 • michaelkkoehlermd@gmail.com

Gastroenterology Associates, LLP An established practice with a solid referral base, Gastroenterology Associates, LLP, located in western New York, seeks a board-certified/ board-eligible gastroenterologist to join our growing eleven physician practice. ERCP experience is a plus.

With two clinical sites and two physician-owned state-of-the-art endoscopy centers, this opportunity includes: • Partnership track in a premier quality driven group • Competitive compensation and benefits package • Nursing staff in our Centers with extensive GI experience • Fully integrated EMR environment. Meaningful Use attested • Professional management staff • 9 mid-level providers including registered dietitian We are located within easy driving distance of The Finger Lakes Region, The Adirondack Mountains, The Great Lakes and Toronto.

For more information, contact: Peg Centola, Human Resources Manager hr@gastrowny.com • Phone: 716-626-5250 • Fax: 716-565-0665

Gastonia, NC

Carolina Digestive Diseases Four established gastroenterologists located in central North Carolina, are seeking a BE / BC gastroenterologist to join our physicians to expand the coverage in our community of Gastonia, NC. The physician candidate can expect to step into a busy practice while replacing a retiring partner. Anticipate a short track to practice partnership and ASC ownership. Practice currently operates out of a single office and covers one hospital. Outpatient endoscopy is performed at a 2 room ASC with maximum efficiency and quality of care.

Located 2 hours to the Smoky Mountains and 4 hours to the Atlantic beaches.

Enjoy sunshine and a great lifestyle in the metro Charlotte area.

For more information, contact: Dr. Austin Osemeka at ogiaustin@aol.com Phone: 704-648-9003 • Fax: 704-772-4456 FAL L 20 1 6 EndoEconomics

| 27

2500 York Road, Suite 300 Jamison, PA 18929