Central Line

Episode Number: 136

Episode Title: Inside the Monitor – Practice Management

Recorded: July 2024

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VOICE OVER:

Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. KEYA LOCKE:

Welcome back to Central Line. I'm your guest host, Dr. Keya Locke. Today, Dr. Joseph Staggenborg, guest editor of the August Monitor, is with me to share his thoughts on practice management. Yes, it's an enormous topic, and I'm excited to touch on many aspects of practice management that impact our lives and our work. So welcome to the show, Dr. Staggenborg. Thanks so much for joining us.

DR. JOSEPH STAGGENBORG:

Sure. No problem. Thank you very much, Keya. It's an honor to be on here.

DR. LOCKE:

Like I said, we're very grateful to have you and to, you know, share in your expertise. As always, we'd like to start today with an introduction. So can you tell our listeners a little bit about your journey and your practice?

DR. STAGGENBORG:

Sure. Um, so I started out in the mid 1990s in private practice in Springfield, Illinois. I worked there for 17 years. Then I had relocated to the DC metro area, and at that point I was a hospital employee for five years. The thing that was very, uh, impactful to me about that change was I went from a very high functioning operating room to a very low functioning operating room. The place I went to, our first case on time starts 19%. Our utilization was in the mid 40s, whereas the place I'd been before, everything was starting on time. We had great utilization. So while I was a hospital employee, we had a perioperative transformation firm come in, and I worked with them to go ahead and set up new governance, set up new rules to improve the operating room. And it was a great experience. It really, you know, engendered an interest in OR operations in me.

Also, at the same time, I was fortunate that the Johns Hopkins had a satellite site right around the corner from where I lived, and I was able to get an MBA in medical services management. So that's really how I, you know, got more into the operations part of it. I also started to consult with this company. So, you know, I was gaining all this experience.

An opportunity came up with the National Medical Group in 2015, and they were looking for an internal consultant for anesthesiology, someone who could provide interim leadership and assist in transformation in some, some of their practices. So I worked for them since 2015. Uh, it was a great experience. We had 46 anesthesia groups. I got heavily involved in value-based care and quality and performance metrics. So this is like my little Skinner box to really, you know, figure out what were some of the keys to succeeding with the value based care and quality performance metrics.

After the pandemic slowed down I wanted to shift gears, and I wanted to have more of a clinical role, and I wanted to live in a specific part of the country. So I took a job with another national practice company and now working in South Florida, uh, 100% clinical, still doing leadership stuff. I applied to the Committee on Practice Management in 2022. Um, was accepted. And it just had a great experience. I've written a number of articles for the Monitor. I you know, I've really developed a passion for medical writing I didn't even know was there. So it's been a great experience and here we are today.

DR. LOCKE:

Thank you so much for that. It sounds like you have a wealth of knowledge that I'm hoping we can really kind of delve into as we move forward here. Um, and understanding that practice management is a broad topic, and certainly it reaches far beyond a single podcast. But there are a few aspects of it that we definitely want to highlight today. So to kind of give us a quick overview, would you mind sharing what you feel are some of the most salient topics in practice management today?

DR. STAGGENBORG:

Sure. Thank you. Um, you know, the topics are varied and you never know where people's passions lie. You know, I'm the guest editor of the Monitor for August. And if you look at the topics that we we chose, these are like hot button topics. So these are the things that we're dealing with when we go to our committee meetings. First off, we're dealing with a unionization. There's a, uh, anesthesia group out in California that is going to a unionized model. Uh, we felt it was important that we, you know, explored the nuts and bolts of that. And then also to have them talk about what their experience, uh, has been. Uh, we're also touching on under-compensated care, uh, which, believe it or not, uh, you would think this would be a pretty simple thing to talk to. This probably generated the most heated debate, uh, within our committee. So, again, you just don't know where people's passions. Uh, really why. We're talking about, uh, how to succeed in independent practice. Also talking about, you know, an evolution of a practice. How do they end up partnering with a large organization. In this day of burnout, uh, physician shortages, we've been exploring, you know, what are some of the ways we can incentivize people not only to do extra work, but also to stay in the same place. So we have a nice article on, uh, behavioral economics. Uh, I'm touching upon how you can help, uh, hospitals with their quality performance metrics. You know, we all want to demonstrate value to our hospital partners. But, you know, in this age of top-down anesthesia metrics, there's nothing ready made for us. So, you know, we need to be able to look outside of our usual box for that. So those are some of the issues that that come up. We're also heavily involved in education, um, especially with the residents. Uh, we've done a lot of work with the Toolbox. Uh, that has to do with just the the wide swath of practice management. Uh, we're also looking at what is the best way for the ASA members to access all this information. So we've been doing some work on that. And of course, we also have financial responsibility for the ASA Advance, and that's something that we have to work on. But, you know, these are the things that everyone's having to deal with. Uncompensated care. Unionization has come to the forefront. You know how to succeed in private practice. So those are just a few of what we're dealing with today.

DR. LOCKE:

I can definitely respect that. Those are things that kind of probably touch all of our practices. So thinking on your career for the many years that you've been in practice, what do you feel has really fundamentally changed? Do our practices look different than they did a decade ago, in your opinion? And I certainly noticed that there seems to be a shift towards independent practice models. So if you can touch a little bit on, what do you feel is driving that shift?

DR. STAGGENBORG:

So, you know, what's new today is that the drivers have changed. The 33% problem, the Medicare under compensation that has become more of an issue as the as our population has aged. There are groups that prided themselves on not taking any financial assistance from the hospital and suddenly had to go to them and ask for that. As such, some hospitals that weren’t, you know, used to doing that, they're now starting to shop around and see what the different options are. So that's injected some instability, especially with the private practices. However, you know, that doesn't mean that that model is not viable. It's very much viable. Um, I think the advantages that a private practice can bring to the table is that they can be very responsive to changes within their hospital community. And, you know, they're really more ingrained in what's happening with the hospital staff and what the needs of the hospital are. So I can see how that's an attractive model that people want to continue with. However, there are a number of constraints that are making that difficult.

DR. LOCKE:

Okay, thank you for that. So let's talk about how quality and performance metrics are being used to collaborate with our hospital systems. How are anesthesiologists using metrics when dealing with the C-suite, and what metrics matter most for our administrators? And how can we make these metrics on both sides work for us?

DR. STAGGENBORG:

You know what I said at the outset about quality and performance metrics, um, being topped out, it makes it very difficult for us to quantify our value proposition to the hospital. CEOs, they think in terms of numbers, that's what they want to see. And that's how we need to communicate to them that we're providing value. You get these metrics that are people are at a 97, 98 percentile, it's hard to demonstrate that you're making any impactful change. So you really need to go out and see what other pain points they have. Whenever I would talk to the CEO at least a couple times a year, I'd always ask them, what are your top four projects right now and how are you doing with them, and how can we help out? And you know, sometimes you may not think about it, but you may be able to help them out.

And I'll give you an example, PSI11 that's patient safety initiative 11, that's postoperative respiratory care, we were working with the hospital that they were getting killed with this metric. It was costing them, uh, about a half $1 million a year. And when that came up, you know, at that time we were also expanding our ERAS program. So the thought was, maybe with our eras program, we can have an impact on this metric further out than the typical 48 hours of care for anesthesia. So we went ahead and we got the data, did our due diligence to set up this metric forum. And after the first quarter, when the new cases came in, we looked at the cases and we told them, look, you, you don't have a problem with PSI11. You've been miscoding them the whole time. Once they corrected that, that was a huge savings for the hospital. That was something that an anesthesia group may not think about, but that's demonstrating value to a hospital.

The other thing you've got to ask yourself is, you know, when they're bringing problems to you for help, what what's driving that? And one of the common ones is FCOTS. Someone came up to you and said, we got to fix FCOTS right now. And the typical response is, well, you know, the data is pretty consistent, that up to half of that is driven by surge in tardiness. Well, that's not something, uh, that's palatable to an administrator because for them FCOTS, that may be reported at the board level, that may be a KPI for their, uh, OR efficiency and how they're managing the OR, you know. Telling them, no, you're not going to help them out. That's not really going to be an option. But that doesn't mean you can't navigate that and turn that into a clinical practice improvement project. We wrote an article on that in the August issue that tells you how to go ahead and to navigate that sort of problem.

But, you know, the bottom line is that, um, you need to demonstrate value to your hospital partners. You need to be able to quantify that you provide that value. And you have to look beyond our typical anesthesia metric.

DR. LOCKE:

This has been a great conversation so far. I have a few more questions, so stay with us.

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DR. JONATHAN COHEN:

Hi, this is Doctor Jonathan Cohen with the ASA Patient Safety Editorial Board. Amy Edmondson's best selling book, The Fearless Organization, revealed something surprising about psychological safety in health care settings. Better teams report more errors. Higher functioning teams don't actually make more errors, but they have a climate of openness that allows them to be reported more easily, different from a safe space free of differing opinions. A culture of psychological safety encourages members to ask questions, speak up when things seem amiss, and admit mistakes. As leaders on the perioperative care team, anesthesiologists can help foster this climate by doing things like admitting their own fallibility, asking for team member's opinions, and responding productively when they voice a concern or ask a question or admit an error. People will make errors when team members feel comfortable speaking up, we can prevent those errors from harming our patients.

VOICE OVER:

For more patient safety content, visit asahq/patientsafety.

DR. LOCKE:

Welcome back. So switching gears a little bit, another sort of hot topic, as you mentioned earlier in your introduction, is the topic of unionization. Do you have any insight on what some of the pros or cons of unionization are? And most importantly, I imagine, do you feel that anesthesiologists unionizing will affect patients, and if so, how so?

DR. STAGGENBORG:

So to answer your first question, what are the pros and cons? I think it's important to look at how do we get to where we are today. When you talk about unions I think about blue collar work in the 70s and the 80s. That that that's why this concept is a little puzzling to me. But it's not puzzling to other people. What drove this conversation is that a number of our residents were needing some protection on their clinical load, so they needed some way to regulate what their work life balance is going to be. The other thing that's driving this is that up to 74% of physicians are now employed. They are not independent groups. So in order to be in a union, you have to be employed. You can't own your own company. You can't be, uh, within management. You have to be employed. So a number of physicians are looking for a ways that they can have some control, not only over their, you know, work life balance, but patients access to care. So, you know, as far as the pros, yeah, it allows somebody to, to have a voice, um, when they don't have ownership within a company. It allows us to right size patient care. But, you know, the cons it really comes down to what impact is this going to have on patient care. And that's the question that you need to ask yourself. If you're limiting coverage ratios that may actually, uh, limit the amount of care that people are getting. The other thing, no longer are you just answering to a boss, now you're answering to a boss and you're answering to a union. So what if the union is a multi-specialty union? And what if you know what if their goals aren't necessarily aligned with what you do in your specialty? So that's something you have to think about. You know, as far as where this really is right now, it remains to be seen. I don't think we have enough, uh, experience within anesthesia to talk about this. And that's why, uh, it's going to be interesting to hear from the groups in California and what their experience was.

DR. LOCKE:

Yeah. I'm personally very interested to hear how that went. There's been much talk about, you know, this idea of unionizing at several of the meetings I've been at this year. So it's interesting.

Another interesting topic I'd like to ask you about is behavioral economics. Uh, behavioral economics can help us understand intrinsic and extrinsic motivators of behavior, which can be important when structuring financial and non-financial incentives. Can you talk about how it's being used and what we should know and be aware of?

DR. STAGGENBORG:

Sure. Most commonly behavioral economics, it's financial: I'm going to pay you extra money, you're going to go ahead and do extra work. Well, the thing about physicians is they have a backwards bending price supply curve, meaning that as you raise the price, they will be willing to take on more work until you get a price point where the curve actually goes straight up. They're not going to go ahead and provide any more supply, and it actually starts to go backwards, meaning that they'll start doing less work even though they're getting paid more money. So I don't know how that is for, you know, other, uh, professions. Uh, I've seen that, you know, physicians will be cooked while they make a lot of money. They get tired, They get burned out. You know, they're doing less work than what they were doing before. So the important point is, it's not always financial, you know. What are some of the things that you can affect? Well, money, time. That's an incentive for people. Having some control over their workplace: choice of cases, how long they're going to stay. Uh, and the third thing is risk aversion. People are more risk averse, uh, than they are looking for benefit. So if you can convince your group that, hey, if, you know, if we don't, you know, provide this coverage, the hospital may choose to go shopping around and put out an RFP. You know, working extra takes on a different meaning at that point. You know, then just the amount of money, it's really about the viability of your practice. The thing you have to remember is that the power of incentives diminish over time. So you can't just keep giving the same thing, especially with money, because that price just keeps going up and up. And I've seen astronomical amounts of money, people getting paid for taking at home call on a holiday. So that that's not necessarily a financially viable strategy to help with any staff shortages and our coverage lapses.

DR. LOCKE:

Okay. There are multiple practice models, but we're all under the same tent, so to speak. All models might make sense for some people and not for others or at different stages of our careers. Um, why do you think it is important for people to simply remember that we're all on the same team at the end of the day?

DR. STAGGENBORG:

Well, you know, there's a concern about the divisiveness amongst anesthesiologists, you know, is that really productive? Are we really getting anything out of that? In some way, yes. We have got something out of it. I think that our, you know, independent practice colleagues, they've got a voice and they're being heard. They're at the table. And I think that's important that we have all practice models--large companies, independent practice, hospital employees, academics, practices--we all need to be at the table because we all have the same problems and that we can't let up on, you know. Medicare under compensation, in my opinion, I think that is just driving our business model of anesthesia as a whole to the ground. No matter what practice model you look at. And, you know, I think we can't take our eye off the ball on that. I think we need to keep working on it. If something's not working, I think we need to do something else. But we have enough on our plate. There's so many things, uh, you know, the change, uh, cyber attack, independent dispute resolution. There's so many things that we need to focus on together as a team as opposed to, you know, looking at different practice models and seeing how we're impacting each other.

DR. LOCKE:

As you have written for the Monitor in the past, and you're the guest editor for this August issue, is there something people might not know or focus on that they should about the Monitor and anything that you'd like to share about your experience in general working on this issue?

DR. STAGGENBORG:

Sure. I had a great experience. I had a great experience working with the staff at the monitor with the ASA, working with my own colleagues within the Committee on Practice Management. I had a chance to, uh, meet Zach Deutch, who's one of the editors or the Monitor, uh, at ASA Advance, uh, a couple of years ago. I told him, I said, look, I'm really enjoyed writing for the monitor. If there's any way I can help out, I'm happy to. I really enjoyed it. And he goes, you know, the thing you could help with is you need to put the word out that it's our monitor. Anybody can write an article. You don't need to be asked to write an article. You know, if you come across something that's you go, wow, I never really thought about that. That's an article right there. And I'll give you an example. It's working at a hospital on a Saturday, and our central vacuum went out throughout the hospital. I never experienced that in my life. Well there are anaesthesia machine implications to that. So I went ahead and I partnered with some of the guys in the committee on engineering. Those were the machine guys. They had a field day. They loved it, you know, just just really getting down into the the nitty gritty of having no central vacuum, the impact on a scavenger. So anybody can write an article. If you come across something that's interesting, write it down. If you need help, ping one of the committee members and any any committee, one of the chairs and say, hey, look, I'm writing this article. I need some help. There is a wide swath of expertise that people would love to help you out with.

DR. LOCKE:

I agree, and thank you for reiterating that the Monitor really is your voice, and we always are overjoyed to hear from you. Thank you so much for sharing your expertise with us.

DR. STAGGENBORG:

Hey thank you. I really enjoyed this. Thank you very much.

DR. LOCKE:

Yeah, this was a really great conversation. And for our listeners who want to learn more, please visit asamonitor.org. And join us for more Central Line soon.

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VOICE OVER:

Help your anesthesia business succeed. The business of anesthesiology continues to evolve. Gather fresh perspectives, transformative technologies, and practical tools. At ASA advance each January. Get the latest info at asahq.org/advance.

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