Welcome to the Advancing Surgical Care Podcast brought to you by ASCA, the Ambulatory Surgery Center Association. ASCA represents the interests of outpatient surgery centers of every specialty and provides advocacy and resources to assist them in delivering safe, high-quality, cost-effective patient care. As with all of ASCA’s communications, please check to make sure you are listening to or viewing our most up-to-date podcasts and announcements.
Bill Prentice: 0:37
Hi, I’m Bill Prentice, the CEO of ASCA and host of this podcast. On this episode, I’m pleased to welcome Nader Samii, the chief executive officer of National Medical Billing Services, a leading revenue cycle management company and ASCA affiliate. Nader is well known to many in the ASC community for his leadership at National Medical, as well as for his thoughtful insights about the ASC industry. Nader began his career as a corporate finance attorney and investment banker, and prior to founding National Medical Billing Services, he was the co-founder and president of Ajuba International, a leading healthcare revenue cycle outsourcing company. Given National Medical’s nationwide role in assisting so many ASCs to navigate a range of administrative and operational issues, I’ve asked Nader to join me for a few minutes to hear his perspective on several topics of interest to the ASC industry. So, with that introduction, Nader, welcome to the Advancing Surgical Care Podcast.
Nader Samii: 1:29
Thank you, Bill. Excited to be here.
Bill Prentice: 1:32
Great. Well, Nader, gratefully, it appears that the worst of the pandemic is behind us, thanks to a combination of vaccines and new drug therapies. While we’re not yet entirely out of the woods, I’m eager to hear your thoughts about some of the lessons that you think ambulatory surgery centers should take from the experience of the last two years. Now putting aside staffing issues, which we’ll get to in a moment, is there a best practice or two that you would recommend to administrators based on what we’ve learned about operating through a pandemic?
Nader Samii: 2:01
Bill, it’s a great question, I think ultimately sort of a timeless question. We never know what is next and around the corner. So, what I would say one of the things that we observed is really take your time, to the extent you can. Things were moving very fast as COVID was hitting, but it felt like there were a lot of very quick reactions to some of the news too. So, take your time within the parameters of what time you have, gather as much information as you can, and then really take thoughtful actions and steps while trying to factor in all your constituents. So, in this scenario, as news was flying and COVID, and there was discussion of do we shut down, do we not shut down, you really saw people take a wide range of approaches—some driven by the local community, some driven by the health system, maybe, if it was a partner of theirs. But really try to factor in the healthcare community at large—your patient population, your employee base, your surgeons—and think about what maybe makes sense. And the groups that were able to sort of manage through and maybe keep their doors open to at least handle urgent and elective cases seemed to be in a better position to, one, really, obviously, help and address their patients that did have an urgent need. And secondly, they were in a better position to rebound because the doors never fully shut; once things bounced back, they were in a little bit better position. So, there wasn’t a right or wrong answer, but I guess I would just counsel on in that sort of scenario, take your time and really assess as best you can, and maybe try not to overreact in a situation where it’s difficult not to. So that’s one big one. I think another one, which also I think is time tested, is just be a little bit more conservative, whether it’s either preserving a bit more cash on your balance sheet, maybe not taking full distributions or maybe another angle at that is while things are good—surgery centers are fortunate to be strong cash flow businesses that you can typically have and will typically have a strong banking relationship—so, while things are good, maybe get a really strong and a larger line of credit than you might necessarily think you would ever need. You don’t have to use it, and in fact, I wouldn’t use it if you don’t need to. But, again, when times are good, really leverage that and make that as large as it can to just put you in a position, then you can continue to operate and make the distributions that you’re used to. And then I guess the final point, which maybe relates to all of it, is I know ASCA was very involved in staying current with the rules, regulations, things that were changing during that timeframe, and other experts in the industry were as well. So, arm yourself with all those resources. Again, ASCA was phenomenal during that timeframe, and like I said, I think others were really trying to dive in and figure out in a moving environment what’s the best way to help surgery centers survive and, ultimately, thrive long-term. So, whether it was learning about initiatives like Hospitals Without Walls, the CMS advances, the CMS grants and different types of initiatives, those were things that were flying every day, every week—hard to keep abreast of all of that. And again, just making sure you’ve got someone who can help guide you through all of that in a situation because those were all extremely beneficial initiatives that were put in place by our federal government at the time, and I think really helped organizations manage through this timeframe.
Bill Prentice: 5:37
Great. I said, I was going to ask you about staffing, but before I do that, what are you seeing in your data now in terms of the pandemic’s impact on patient volumes and operating margins—and hopefully they have grown back since the beginning of the pandemic—but what are you seeing there in the data that you guys collect?
Nader Samii: 5:54
Yes. Now, that’s another great question. This was one, especially when COVID hit, we were running daily and hourly numbers on everything, really trying to get a feel for what was happening at an individual facility level and also kind of on a more macro, national level. And what we found, obviously, you had some variances again on who fully closed doors and who didn’t, but when really the news hit by mid-March on COVID, the centers just started closing left and right. And I would say within about a two-week span, on a national level volumes had dropped about 80 percent, 80 to 85 percent dropped literally, just almost would shut down overnight. And that was obviously pretty significant for any of us who live in this industry. And so that was mid-March, and I would say for that first full month, call it through the end of April, it looked about like that, down, call it 80-plus percent in volumes. By the beginning of May, you started to see, and it was really interesting each week, each day and each week, you started to see an increase, people reopening and getting back to, again, at that point it was really the more urgent, critical nature of cases that were being seen. So, by May, it was starting that if you were down 80 percent, that started to go down kind of to 70 percent, and then a couple of weeks later down 60 percent. Fast forward, I would say mid-July to August, you were starting to get to a pretty solid rebound of where people were open. There were some efficiency issues with the centers, obviously, with all the additional protocols they had to follow, but also people increasing hours a little bit. But you’re getting back to kind of an 85 to 90 percent of normal volumes by the end of summer, so that August to September timeframe. And I would say by year end, you were well into the 90-plus percent normal volumes. A lot of people would ask, “Did you ever get to 120 and 130 percent volumes where all the cases that never happened all came back at once?” We did not ever see that—I think they were spaced out. So that’s probably accessibility and availability of the centers, how much they can handle. But I would say at this point, now we’re coming on two years from that point, I would say volumes and operational capabilities are all pretty much back to normal. But there was one sort of interesting bump I think that did happen in that timeframe. And that was a lot of surgeons that weren’t doing cases in surgery centers when the hospitals were closed for a longer period of time, or at least for elective surgery, more surgeons started to do cases in ASCs with Hospitals Without Walls. You started to be able to bring some other cases over to an ASC that maybe you weren’t performing previously. So, these high-acuity cases—big orthopedic, spine, cardiology, those types of specialties—I think the surgeons, the staff and the patient base have learned that a lot of those are actually quite manageable and doable, for the right population, of course. And so, we do think that that has accelerated a trend that we all saw and believed was coming with those cases, I do think it accelerated that. And so ultimately, what does that do for me? That does drive your top line and your margin profitability up from there as the cash per case increases on these high-acuity cases. So that is one of the things. We sort of would talk during all of this, people were very scared of cruise ships and they were scared of hospitals I think almost equally, and so it really did highlight some of the benefits of being in a surgery center that, again, I think we all know and espouse the virtues of those regularly. I think it did start to hit more of the mainstream masses in understanding that and what a surgery center actually is and where it can play in the healthcare facility space. So, I do think that was, from a pure surgery center standpoint I guess, a hidden benefit.
Bill Prentice: 9:43
Yes, and that’s an interesting little bright side to have identified. And in terms of the volume numbers you were talking about, we saw the same sort of thing in terms of our dues, which for independent facilities is based upon volume, the fact that we were down and then coming back. And actually, this year we’re showing that surgery centers seem to be back where they were, if not a little bit above. And in fact, if anything, I think the drag on that might be the staffing issues that so many facilities have been facing for the last year or so. And I know that’s not your main area of expertise, but staffing/retention/ recruitment is one of the most common concerns that we’re hearing right now from surgery centers. And invariably, what that means, if you don’t have enough staff, is you have to find a way to be more efficient, at least administratively. How are you advising your clients in this regard? What can they do to be more efficient as a way to try and kind of deal with that and all the other financial challenges they’re facing right now?
Nader Samii: 10:44
Yes, Bill, obviously a great question. I think no one has been spared in any aspect of society with the staffing issues, whether it’s healthcare or non-healthcare. I think it’s that issue—go to a restaurant, go anywhere you go—it’s a challenge. And so, certainly utilizing technology to become more efficient in any possible way that you can to minimize the labor and the extra touches that you need, whether it’s the front end, on the interacting with patients and the collection side of things, to the back end, leveraging other organizations that have some of those technologies and have additional resources, is one of the things I think that has helped folks a lot. If you have a big team of people in the back office, obviously you were hit a little bit harder than if that was someone else’s challenge to manage for you. So, leverage technology as much as you can, for sure. And then, as it relates to the staffing issues, again, everyone was faced with those challenges. And we saw things as simple as just people bumping wages to try to keep people or recruit people, and that maybe was a necessary move at some level but a challenging one from a longer-term business standpoint. I think some of the more creative ways we’ve seen had to deal more with managing—potentially providing additional time off, other sort of incentive-based behavior—kind of incentivizing people to focus on the things that matter in utilizing their time, on efficient use of their time and activities. Also, to work from home. Surgery centers are a little bit in a tough spot in a lot of positions to work from home, obviously, a lot of that requires being in the surgery center. But there are certain positions that can, and if you can provide someone some of that flexibility to work from home, maybe a couple of days a week, or some element of that, that helps. And just various initiatives that relate to culture and culture improvements are really an intentional effort to make yourself a great place to work. I think there’s a premium right now on that and we’re all being pushed and challenged to be better employers than we were yesterday so that it isn’t just about a little bit of a pay increase if someone’s going to leave or overpaying someone. So yes, I would say a mix of all those things—process reengineering, technology and then thinking about creative and clever ways to make your employee base happy.
Bill Prentice: 13:09
Great advice. And I think you can’t overemphasize the importance of having the right culture as a way to retain staff and keep them energized and feel good about where they’re working, and I think that’s something that I hope every ASC administrator and governing board takes to heart because it’s really important. We only have a few more minutes and I want to shift gears and talk a little bit about price transparency. Now, Congress has already enacted new requirements for hospitals to make their pricing more accessible to patients, and then more recently, with the No Surprises Act, ASCs are also being asked to provide upfront pricing to patients who request it. So going forward, I think it’s safe to assume there’ll be more pressures, not less, for greater price transparency in all healthcare settings. And I know there’s still a fair amount of resistance to full transparency, but there may also be opportunities there for ASCs, especially since we’re almost always the lower-cost site of care compared to hospital outpatient departments. So, I’d be interested to hear your thoughts about where we are and where we might be headed, and what advice you would give to an ASC administrator about preparing for a more transparent future.
Nader Samii: 14:17
So, this is obviously a very timely and great question, Bill. And so, I guess first and foremost, very big picture, we believe price transparency is here to stay. We believe it’s going to be expanding at the same time. As many things in healthcare, they take a little bit of time to implement, for people to get comfortable with, to roll out, to have the technology, to have the data, to have people who can interpret the data. So, there are a lot of challenges with that and the timing of it, but again, I think that it’s just a matter of time. Overall, while there are, again, some technology challenges to be able to have access to the information and then everyone’s always nervous about what are we sharing and are we sharing too much, especially in a world that’s really never shared any information on this topic. But overall, sitting in the surgery center marketplace that pricing transparency is, again, if handled thoughtfully and proactively, can be an enormous advantage for surgery centers. We’re competing fundamentally with hospitals and hospital outpatient departments for surgeries, it’s much less the case that numerous surgery centers are competing for the same patient, and someone’s making a decision where they’re sitting of, again, are they going to go to the hospital or are they going to go to the ASC? And when they have legitimate, good information, and you can educate them at the surgeon’s office, and they can go on, ideally, a website—we actually have a client that has been proactive on this front and advertising it on a website where you can actually go in and put your procedure, put the CPT code down for what you’re getting, and it’ll tell you right there what your payment is going to be. And so when you get to that place and someone can look at that and realize they may have a 50 percent cost savings to have that done in a surgery center, and if you can add with that maybe some collateral material that highlights some of the wonderful benefits of a surgery center—the convenience, the flexibility, the attention, the personal service, specialization—combine all that with a cost savings, it becomes a pretty easy decision, again, for the right patients, that it should be handled in a surgery center versus in a hospital. And so, again, being thoughtful from a marketing standpoint, from a technology standpoint, from a content standpoint to the patient base, I think will be nothing but an enormous advantage. A lot of times we hear clients talking about how do we increase our case volume, and they’re not even at the core, basic level of the surgeon’s office when you’re talking to the patient and asking them or not asking them. Sometimes people just schedule the patient in a hospital, they don’t even ask the question or provide any information that would give somebody data to be making a decision. So, I always tell our clients that is the simplest and most obvious place. And you’re doing a great service to your patients because most of them do not know the difference unless you tell them and it’s not even about pitching or selling them one thing or the other, it’s just educating so they can make a genuine, informed decision on what they’re going to do and where they’re going to go have their procedure. So, again, big picture overall, I think it’s actually an enormous advantage for surgery centers. I know there’s always resistance to change, even from our industry, but I do think it will help in the end.
Bill Prentice: 17:28
I couldn’t agree more with your perspective there, Nader. And I think that one thing is that I think our ASCs are great at providing healthcare and maybe not as good at promoting themselves and marketing the advantages of what they do, and that’s something hopefully we can help them with in the years ahead. Alright, last question. We’re starting to get back together in person, and I want to thank you and National Medical Billing Services for once again providing great support for ASCA at our annual conference and other events that we’ve held over the years. As you know, our annual meetings and seminars have been virtual the past two years, but we’re really excited to be back in person this April in Dallas. For many in the ASC world, I know this will not only be their first public industry event, but probably the first travel they’ve done for quite a while. And I presume you and your team have been traveling again and attending meetings and seeing customers. What can you share about your experiences the past few months as well as your thoughts about our upcoming Dallas meeting?
Nader Samii: 18:22
Bill, I will say for sure our entire team has sorely missed being out and about and seeing everyone in the industry, from industry leaders at the ASCA shows to just the daily visits to clients, and just being out and about. So that for sure has picked up a lot more, the regular normal visits. There are still certainly some organizations that are still not allowing visitors on site and such, but as it relates to going to shows, that’s starting to again slowly pick up. And from a pure business standpoint and from a relationship standpoint, you have the people that you get to see and you’re used to seeing, and we all miss, I think, that interaction and all of those dynamics. Podcasts and virtual seminars and such are great, but I don’t think they ever replace the in-person. So, and I think it impacted people’s ability to even build and grow their businesses too, so they had to get creative and clever in other ways. But that aside, I know we’re very excited to come to the show, we’ve got some fun things we’re planning to do with all this pent-up energy around being back. And we’re certainly excited to listen to all the amazing speakers. It’s a great show always where, again, industry leaders from all around the country in all different specialties and different perspectives are there, and so it’s a great time to learn and a great time to reconnect with everyone. So, we’re excited about it.
Bill Prentice: 19:43
Well, I’m also as excited as you are, and I think I’ve been starved to get out and see people and meet with our members and the other members of the ASC community. I’ve got some good news that the registrations right now are really strong for the Dallas meeting, so I’m really excited about that. We’ve got great support from National Medical Billing and other vendors in the ASC community, so it looks like it’s going to be a really great meeting. Nader, I want to thank you for taking this time to join me in this discussion. I’m sure many of our ASCA members will find what you’ve said really helpful and insightful, and on behalf of our ASCA members, I’d like to thank you again for your support and participation in our affiliate program and all the ways that you’ve supported ASCA and the ASC community in the past and hopefully into the future.
Nader Samii: 20:31
Thank you, Bill. Truly our pleasure.
Bill Prentice: 20:32
This concludes today’s episode of the ASC podcast. Thank you for listening and sharing your time with us.