Starting an ambulatory surgery center takes a great deal of hard-nosed planning, attention to detail and, in particular, unity among the founding physicians, say people who have set them up.
"It's very hard to get (doctors) together on anything," says Lawrence Pinkner, M.D., founder and CEO of SurgiCenter of Baltimore. "There's a natural competitiveness and a natural secrecy."
Depending on specialty, as few as four core doctors are necessary to set up an ASC and ensure enough patient volume.
But volume won't be sufficient if they don't all use it, experts say.
Often, "you get a commitment from 12 guys but only five show up with cases," says Scott Becker, an attorney with the Chicago law firm of Ross & Hardies who has been involved in 150 start-ups. The no-shows, he says, might have been pressured by the local hospital to keep patients away, find the location inconvenient or only want a return on investment.
Multiple specialties can create high overall volume, but if volume in one specialty is too thin, the extra equipment, staff and space will become a liability, Becker says.
Also, certain specialties have better chances of success because of greater volume or better reimbursements. ASCs for ophthalmology, gastroenterology and orthopedic surgery are more likely to make money than those for general surgery, cosmetic surgery and urology, Becker says.
Early in the setup process, Pinkner says, hire a seasoned consultant to conduct a feasibility study pinpointing the size of the center, expected volume, one-time expenses and projected budget. The study will be key to getting a bank loan, certificate of need (if required) and Medicare certification, and it will form the basis of a budget, consultants say.
Pinkner, who started his ASC in 1989, advises would-be ASC partners to split up equal shares of ownership, as the 11 group practices in his ASC do. "People don't want to put money into another doctor's pockets," he says.
Ambulatory surgery corporations can offer expertise as well as capital in exchange for some control. AmSurg in Nashville, Tenn., for example, offers sophisticated outcomes data that can improve contracts and can get discounts for medical supplies, says President and CEO Ken McDonald.
A good architectural plan should facilitate optimum patient flow and conserve space. Some centers open with 15,000 to 20,000 square feet when 5,000 to 10,000 would do, Becker says. But some centers cut too much space. When centers combine pre-op and post-op areas, a glut of post-op patients can choke off the area, McDonald says.
Since centers generally get lower reimbursements than hospitals, staying on schedule is crucial. "Doctors don't show up on time and the center gets two hours behind," McDonald says. Someone has to say "this is having an impact on everyone," he says.