Characteristics of best gastroenterology practices

Characteristics of best gastroenterology practices

THE AMERICAN JOURNAL OF GASTROENTEROLOGY © 1999 by Am. Coll. of Gastroenterology Published by Elsevier Science Inc. Vol. 94, No. 9, 1999 ISSN 0002-92...

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THE AMERICAN JOURNAL OF GASTROENTEROLOGY © 1999 by Am. Coll. of Gastroenterology Published by Elsevier Science Inc.

Vol. 94, No. 9, 1999 ISSN 0002-9270/99/$20.00 PII S0002-9270(99)00443-8

Characteristics of Best Gastroenterology Practices John F. Johanson, M.D., M.Sc. Epid., F.A.C.G., Bergein F. Overholt, M.D., M.A.C.G., and James T. Frakes, M.D., M.S., F.A.C.G. Rockford Gastroenterology Associates, Ltd, Rockford, Illinois; and Gastrointestinal Associates, P.C., Knoxville, Tennessee

OBJECTIVE: As health care costs continue to rise, competition among providers is increasing. Although this competition is currently based on price, quality of care will become an increasingly important issue. One popular method to assess quality is by comparing physicians’ performance with that of a representative group of physicians, in a process called benchmarking. The purpose of this study was to survey private practice gastroenterologists to identify the practice characteristics, so-called “best practices,” associated with high-quality health care delivery to provide data for use as benchmarks. METHODS: Three hundred randomly selected gastroenterology practices were surveyed regarding practice demographics, administration, financial management, and use of outcomes techniques by mail questionnaire. Analogous questionnaires were completed by representatives of the gastroenterology practices comprising the Gastroenterology Practice Management Group, LLC (GMPG). RESULTS: One hundred and eighty-two (61%) of the 300 eligible practices responded to the questionnaire. Increasing differences between survey and benchmark GPMG practices were observed as the complexity of quality measures increased. Among structure measures, the groups were similar. By contrast, significant differences were observed between survey and benchmark groups with regards to outcomes measures such as the use of practice guidelines, continuous quality improvement, and outcomes assessment. CONCLUSIONS: These results provide a snapshot of gastroenterology practices across the country and can be used as a benchmark for quality assessment purposes to compare with one’s practice, suggesting areas for change or improvement. It seems clear that the defining characteristic of best gastroenterology practices is the demonstration of quality patient care. It also appears that many practices’ efforts in this regard could be increased. (Am J Gastroenterol 1999; 94:2519 –2530. © 1999 by Am. Coll. of Gastroenterology)

INTRODUCTION Since the 1960’s health care expenditures as a percentage of gross national product have risen from 4% to ⬎14%, a level far greater than that of any other developed nation (1).

Despite the significantly higher expenditures, the United States does not rank at the top of any global measures of health (2, 3). As health care costs continue to rise, competition among managed care organizations (MCOs) as well as individual providers is increasing. Until now, this competition has been based predominantly on price: whoever has been able to more effectively reduce costs has prevailed. This trend cannot continue indefinitely. When costs reach a point where they can no longer be reduced, competition will be based on other factors, the most important of which is quality. As health care providers, a greater emphasis on quality should be welcome, as our primary goal is to provide the best possible care for our patients. Before quality can be maximized, however, we must understand what denotes quality health care. In 1990, the Institute of Medicine defined quality to be “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (4). In this regard, there are actually two dimensions of quality: the appropriateness of services provided (high-quality decisionmaking) and the skill with which the appropriate care is performed (high-quality performance). Stated another way, the delivery of high-quality health care consists of “doing the right things right.” On a population basis, quality of care also includes the timeliness, appropriateness, and inappropriateness of diagnostic and management strategies (5). Quality can be maintained or improved in many ways. One widely utilized method is to compare actual patient outcomes with national or regional standards. This process, known as benchmarking or profiling, is simply the comparison of one physician’s performance with that of a representative group of other physicians (6). Comparing endoscopic utilization or complications of endoscopy with national standards, for example, may lead to improved quality of care by identifying individual physicians who might benefit from additional endoscopic training. Using the same process, benchmarking of physician groups may identify practice operations that could be improved, likewise increasing the quality of care. An example of improved practice function might be the implementation of standard operating principles to coordinate the use of antibiotic prophylaxis before endoscopic procedures. Benchmarking

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Table 1. Members of the Gastroenterology Practice Management Group (GPMG) Practice Name

Location

Gastrointestinal Associates Rockford Gastroenterology Associates Gastroenterology Consultants Digestive Health Care Metropolitan Gastroenterology Group Consultants in Gastroenterology Asheville Gastroenterology Associates Gastroenterology Associates of Fort Worth Atlanta Gastroenterology Associates Southern California Gastroenterology Group

Knoxville, TN Rockford, IL Milwaukee, WI Minneapolis, MN Washington, DC Kansas City, MO Asheville, NC Fort Worth, TX Atlanta, GA Santa Monica, CA

is being performed on an increasingly frequent basis by MCOs to identify quality providers to include or maintain in their plans. At the present time, however, the specific physician and practice characteristics that indicate quality have not been validated. The purpose of this study was to survey a random sample of private practice gastroenterologists in an attempt to identify physician or group practice characteristics, or best practices, which are associated with high-quality health care delivery. Elucidation of these attributes would provide meaningful data to be used as a benchmark, facilitating comparison of individual physician groups with a national standard. Clinical gastroenterologists should be the ones identifying and selecting appropriate measures of quality rather than allowing others to perform this important task. The term “best practices” can be confusing because it may be defined on various levels. Best practices may indicate groups of physicians who are recognized as outstanding. Alternatively, the term may represent activities that are performed by physician groups, continuous quality improvement representing one example. For purposes of this study, both of these interpretations were considered, although more significance was afforded the latter because it is difficult, if not impossible, to assess the clinical judgement of individual physicians or their practices based upon their response to a survey.

MATERIALS AND METHODS A 10-page questionnaire was developed to assess a wide range of practice variables (see Appendix). Specific data of interest included practice demographics, physician characteristics such as board certification and teaching activities, the number and duties of support staff, practice management programs, use of consultants, experience with contracting (including capitation), performance of outcomes assessment, and accreditation. Many of these measures are used by MCOs when determining which providers they want in their provider panels. The survey was sent to 300 randomly selected gastroenterology practices. Of the 300 surveys, 100 were sent to small practices (groups of one to three gastroenterologists), 100 were mailed to medium-sized practices (four to six

Physician Representative(s) Bergein Overholt James Frakes, John Johanson Joseph Geenen, Mike Schmalz Robert Ganz Michael Weinstein Gregory Barber James Morgan Thomas Deas Alan Sunshine Richard Corlin

gastroenterologists), and 100 were sent to large groups (seven or more gastroenterologists). Questionnaires were also completed by members of each of the gastroenterology practices that comprise the Gastroenterology Practice Management Group, LLC (GPMG) (Table 1) to provide data for benchmarking purposes. Because the specific characteristics that constitute best practices are unknown, there are no objective standards to use for comparison. Although the selection of these groups for comparison may be open to bias, these groups undeniably include some of the largest and best-known gastroenterology practices around the country, practices that are believed to be on the cutting edge of health care delivery, practice management, and outcomes assessment. Upon completion of the surveys, they were mailed to Rockford, Illinois for data analysis. The data were entered into a Microsoft Excel spreadsheet and 109 distinct variables were analyzed. Prevalence rates for each of the variables were calculated. Comparisons between member groups of the GPMG and all other respondents were performed using t tests and ␹2 analyses for continuous and categorical data, respectively (7).

RESULTS Demographics Of the 300 questionnaires, 182 were returned, providing a response rate of 61%. When stratified by practice size, smaller and medium-sized groups demonstrated significantly higher response rates than did the larger groups, with rates of 87%, 75%, and 17%, respectively. The reason for the large discrepancy in response rates is unknown. The better response rate among smaller groups may have been due to an increased desire for knowledge and assistance with practice management issues. Results of this survey may provide more benefits for small and medium-sized groups than for larger groups. When stratified by geographic region, the highest response rate was from the Southeast, comprising 22.2% of all participants. The Mideast was next, with 18.2%, followed by the Midwest with 13.1% and the Southwest with 11.4%. The remaining regions were similar, each contributing approximately 6%. The 182 surveys represented 673 physicians, the majority

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Table 2. Structure Data: Individual Physician Characteristics Physician Characteristics

General Survey, Number (%)

Benchmark Group, Number (%)

p Value

Board certification (all members) Teaching activities Community service Community education Clinical research Recent publications (within 2 yr)

151/179 (84) 128/178 (72) 110/179 (61) 117/179 (65) 90/179 (50) 48/179 (27)

7/9 (78) 7/9 (78) 7/9 (78) 6/9 (67) 9/9 (100) 5/9 (56)

NS NS NS NS 0.002 0.03

of whom practice in medium-sized groups. Of the total, only 31 (4.6%) were women. The distribution of female gastroenterologists was similar among the three sizes of groups, demonstrating rates of 4.6%, 4.8%, and 3.9% for small, medium, and large groups, respectively. The majority of respondents practiced only gastroenterology (83%) and most groups were single-specialty practices (82%) rather than part of multispecialty groups. More than half of the groups surveyed (58%) added a new physician within the past 3 yr, with most of these being within the last year. Utilization of midlevel providers such as nurse practitioners or physician assistants remains relatively uncommon among gastroenterology practices, as only 12% of practices employ nonphysician providers. Structure Data Structure data refers to characteristics of the individual physicians making up each of the participating groups. Table 2 illustrates a number of specific characteristics surveyed, along with comparisons to responses from the GPMG. In most instances the two groups were similar. Of particular interest is the fact that similar numbers of respondents within each of the two survey populations were involved in teaching. However, more of the gastroenterologists from the GPMG were involved in research and had publications in peer-reviewed journals within the past 2 yr. There are no data to suggest that publications influence clinical judgement. Nevertheless, ongoing scholarly effort indicates a commitment to the science of gastroenterology. The continuous accumulation of knowledge necessary to publish in peer-reviewed journals certainly contributes to maintaining, if not improving, clinical judgement. The two groups were quite similar with respect to the other physician characteristics. When analyzing the scope of endoscopic procedures provided, the two groups were also comparable in most instances (Fig. 1). Notable exceptions included endoscopic ultrasound, laparoscopy, and photodynamic therapy. Only 15% of the practices surveyed, for example, provide endoscopic ultrasound services, in contrast to a significantly greater number of the comparison GPMG practices who offered this service. These differences are not unexpected because endoscopic ultrasound and laparoscopy require significant training and capital expenditures. It is more difficult for small groups to have the financial resources to provide these services.

Process Data In this study we chose to define process data to include components of the routine delivery of medical care. Several key aspects are outlined in Tables 3 and 4, with results for the survey population as well as the comparison GPMG groups. In contrast to results observed among structure data, a more obvious distinction between the two groups was apparent. With respect to financial management, significant differences were observed regarding the use of a budget, negotiations with vendors, and membership in purchasing groups to reduce the cost of supplies. The number of practices that calculated the cost of providing various endoscopic services or the cost of services by individual physician was low in both groups and not significantly different. The differences between the two groups of practices were even greater when issues of practice management were examined. In particular, significant differences were observed with respect to the existence of a mission statement and strategic plan, the use of consultants, and the presence of a physician chief executive officer (CEO). Again, factors such as a physician CEO or use of consultants may be too expensive for a small group. This hypothesis, however, cannot explain the lack of a mission statement, strategic plan, or standard operating procedures among a large number of practices, regardless of size. Outcomes Data Patient-centered outcomes data are the most important data because the information reflects directly upon the quality of patient care. Unlike structure or even process data, which

Figure 1. Comparison of endoscopic services provided among the survey and Gastroenterology Practice Management Group, LLC (GPMG) practices. *p ⬍ 0.05.

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Table 3. Process Data: Financial Management General Survey, Number (%)

Benchmark Group, Number (%)

p Value

80/178 (45) 72/179 (40) 98/178 (55) 71/179 (40) 43/179 (24) 24/179 (13)

8/9 (89) 4/9 (44) 8/9 (89) 7/9 (78) 4/9 (44) 1/9 (11)

0.01 NS 0.05 0.02 NS NS

Budget Cost reduction strategies Negotiates price Purchase group Cost per service Cost per physician

provide an indication of a physician’s credentials or the quality of the practice environment, outcomes assessment examines what actually happens to patients. Analysis of outcomes assessment techniques demonstrates the most dramatic differences among the two groups (Fig. 2). Statistically significant differences were observed for all of the variables surveyed. That is, significantly more GPMG practices performed patient satisfaction surveys, had functioning continuous quality management programs and actually made improvements based on the data collected utilized practice guidelines, and routinely tracked endoscopic outcomes including such measures as indications, complications, and technical success rates. One method to objectively assess whether ongoing quality assessment is occurring is to analyze the number of practices that have been accredited by an independent agency such as the Joint Commission for Accreditation of Health Care Organizations (JCAHO). Of the practices responding to this survey, only 60 were affiliated with an ambulatory endoscopy center (AEC), of which 70% were accredited. However, both the practice and AEC were accredited in the vast majority. As with other measures, accreditation was clearly linked to practice size. Only 25% of small groups achieved accreditation, compared with 32% of medium and 59% of large groups. This is in striking contrast to the GPMG groups, where 90% of practices have received accreditation.

DISCUSSION Traditionally, quality has been measured on the basis of structure, process, and outcomes of medical care (8). These categories can also be applied to physician groups when attempting to identify characteristics that denote quality. In this survey we applied these terms to classify practice char-

acteristics. Structure data were defined to include qualifications of the physicians comprising each of the groups surveyed. Examples included board certification, teaching activities, and recent publications. The scope of endoscopic services provided was also described under structure data. Process data, when applied to physician practices, consisted of components of the delivery of medical care including financial and practice management activities. Outcomes data encompassed a variety of activities, including continuous quality improvement strategies, surveys of patient satisfaction, and routine tracking of endoscopic outcomes. Although there was little difference among groups with regard to structure data, the scope of endoscopic services provided by the various practices was interesting. As might be expected, all groups offered sigmoidoscopy, colonoscopy, and upper endoscopy. Significantly fewer practices offered laparoscopy, photodynamic therapy, and endoscopic ultrasound (EUS). The finding that only 15% of practices offer EUS is disconcerting, as endoscopic ultrasound is increasingly being incorporated into practice guidelines, particularly for tumor staging before curative surgery. Based on the results of this survey, it is unlikely that practice guidelines advocating the use of EUS will be strictly followed because this service is difficult to find among groups in private practice. Patients may be unwilling to travel long distances to the nearest endoscopic ultrasound center. Practicing gastroenterologists may likewise be reluctant to refer their patients to another gastroenterologist for fear of a loss of patients. The limited availability of EUS in routine clinical practice suggests caution should be exercised when including it in practice guidelines. The results of this survey illustrate increasing differences between gastroenterology and the GPMG groups as the complexity of quality assessment increased from structure to process and finally to outcomes data. For nearly all the

Table 4. Process Data: Practice Management Mission statement Standard operating procedures Strategic plan Compare against goals Physician CEO Consultant review Physician Practice Mgmt Corp Administrator with MBA

General Survey, Number (%)

Benchmark Group, Number (%)

p Value

71/178 (40) 131/178 (74) 84/178 (47) 54/178 (30) 95/178 (53) 89/178 (50) 13/178 (7) 28/169 (17)

7/9 (89) 9/9 (100) 8/9 (89) 5/9 (56) 9/9 (100) 9/9 (100) 1/9 (11) 3/9 (33)

0.01 0.06 0.01 NS 0.01 0.003 NS NS

CEO ⫽ chief executive officer; MBA ⫽ Masters of Business Administration.

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Figure 2. Utilization of specific outcomes methods by survey and Gastroenterology Practice Management Group, LLC (GPMG) practices. *p ⬍ 0.05.

variables analyzed, there was also a striking progression in participation rates from small to medium to large groups. It clearly requires time and resources to incorporate many of these functions into routine practice. Groups of two or three gastroenterologists may not have the financial resources to employ a physician CEO or MBA-level administrator. However, many of the practice characteristics that were significantly different between survey and benchmark groups were not associated with substantial costs. It does not require a great deal of money, for example, to develop a mission statement or strategic business goals, yet fewer than half of the practices surveyed had accomplished these fundamental tasks. With regard to financial management, it is remarkable that 55% of the groups surveyed did not utilize a budget. It is less surprising that the majority of practices have not determined their costs for providing various services nor have they broken down utilization and costs by individual physician for specific gastrointestinal disorders. However, these data are extremely valuable when negotiating payment, particularly under capitated contracts (9). It is clear from the results of this survey that most practices are not routinely engaging in outcomes assessment activities. There are three possible explanations for why private practice gastroenterologists are not routinely collecting outcomes data. First, they may not be convinced that collecting these data provides any benefit to them or to their practice. Expending the effort to incorporate outcomes analysis into an already busy practice, however, may provide substantial benefit. Analysis of one’s practice outcomes may provide an important edge when competing for managed care or corporate contracts. Tracking patient outcomes can be used to demonstrate quality, thereby fulfilling some requirements for accreditation. A second possible reason for not routinely assessing practice outcomes may be a lack of resources. But perhaps the most compelling reason why physicians may not be routinely collecting outcomes data is a lack of experience or training in this area. There are few practicing gastroenterologists who are formally trained in outcomes assessment. Without sufficient training or experience, it may be unrealistic to expect busy physicians to routinely track the outcomes of their practices. The key to

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successfully implementing an outcomes assessment program is to identify individuals who can provide the necessary support. Assistance may be found by working with hospital-based resource groups, measuring outcomes as part of endoscopic procedure tracking, networking with other members of endoscopic database groups, or working with MCOs or other payers. Although it is difficult to define quality and even harder to measure it, one goal of health care providers should be to maximize the quality of care. To improve quality, one must be able to measure the impact of the health care delivered (10). Gastroenterologists should take an active role in this process. One easy way to start the process of quality improvement is to use the results of this survey as a benchmark to identify practice characteristics or activities that might be implemented or improved. Another method to enhance quality is to incorporate routine outcomes assessment into one’s practice. Measuring the outcomes of individual patients provides the ability to identify areas for improvement. The incorporation of clinical guidelines into routine practice, when combined with feedback on performance as well as education, has also been shown to increase quality in randomized controlled trials (11). If gastroenterologists are not actively involved in outcomes measurement, analysis, and change to improve the quality and thus value of their own work, someone else will assume this role. In summary, it is not possible to assess the clinical judgement of individual physicians or their practices based on a questionnaire. In the age of outcomes and quality assessment, however, physician practices are increasingly being judged by managed care and accrediting agencies based on many of the practice criteria included in this survey. These results provide a snapshot of current gastroenterology practices across the country. Although only a snapshot, the data can be used as a benchmark to compare with one’s practice to suggest areas for change or improvement. It seems clear, however, that the defining characteristic of best gastroenterology practices is the demonstration of quality patient care. It also appears that many practices’ efforts in this activity could be increased. If we are not actively involved in activities to improve the quality of our own work, someone with interests in mind other than those of the patients’ will undoubtedly assume this role.

ACKNOWLEDGMENT This study was supported in part by an unrestricted grant from Astra Pharmaceuticals.

Reprint requests and correspondence: John F. Johanson, M.D., Rockford Gastroenterology Associates, 401 Roxbury Road, Rockford, IL 61107-5078. Received Oct. 29, 1998; accepted Apr. 2, 1999.

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REFERENCES 1. Fries JF, Koop CE, Beadle CE, et al. Reducing health care costs by reducing the need and demand for medical services. N Engl J Med 1994;329:321. 2. McGinnis M. The state of the nation. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 1989. 3. Scheiber GJ, Pollier JP. International health spending: Issues and trends. Health Affairs 1991:109. 4. Lohr KN, ed. Medicare: A strategy for quality assurance. Washington, DC: National Academy Press, 1990. 5. Starfield B. Quality of care research: Internal elegance and external relevance. JAMA 1998;280:1006 – 8. 6. Frakes JT. Glossary of managed care terms. In: Frakes JT, ed. Managed care issues for the gastroenterologist. Gastroenterol

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Clin N Am 1997;26:923– 43. 7. Kahn HA, Sempos CT. Statistical methods in epidemiology. New York: Oxford University Press, 1989. 8. Brook RH, McGlynn EA, Cleary PD. Measuring quality of care. N Engl J Med 1996;335:966 –70. 9. Weinstein ML. Capitation: Theory, practice and evaluating rates for gastroenterology. In: Frakes JT, ed. Managed care issues for the gastroenterologist. Gastroenterol Clin N Am 1997;26:773– 84. 10. Nelson EC, Splaine ME, Batalden PB, et al. Building measurement and data collection into medical practice. Ann Intern Med 1998;128:460 – 6. 11. Chassin MR. Quality of health care—Part 3: Improving the quality of care. N Engl J Med 1996;335:1060. (See Appendix on following pp. 2525–2530)

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APPENDIX GASTROENTEROLOGY PRACTICE SURVEY We would like a copy of the results of this survey Yes:

Name (Print) Address City, State, Zip PLEASE CHECK/ANSWER ALL THAT ARE APPROPRIATE

I. DEMOGRAPHICS OF YOUR GI GROUP Size of your group: 1–3 Physicians 4–6 7–9 10–20 ⬎20 # Male gastroenterologists # Female gastroenterologists # Pediatric gastroenterologists Single specialty Part of a multispecialty group Practice limited to gastroenterology Region of country (refer to map and insert # please)

We have added a new physician within the last: 1 year 2 years 3 years Time to full partnership for new MD: 1 yr 2 yr 3 yr 4–5 yr ⬎5 yr A physician has left our practice within the last 5 years: No Yes: for retirement other reasons (continued)

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We have a nurse practitioner/physician assistant: No Yes How many? 1 2 We We We We

3 4

provide GI services at satellite sites are part of a GI network have merged with 1 or more GI groups are discussing merger with other GI groups

We cover

(number please) hospitals

Our physicians serve on committees for: hospital(s) serve as medical director of GI lab MCOs/insurance companies national medical societies local medical societies state medical societies Our physicians participate in community services/functions: United Way Chamber of Commerce Arts School Board/School Councils (governance) School parent organizations (PTO/PTA, etc.) City or County governing bodies Church teaching, governance Our practice offers: EGD ERCP endoscopic ultrasound liver biopsy nutrition esophageal motility photodynamic therapy

colonoscopy flexible sigmoidoscopy laparoscopy hepatology flex sig training for PCPs esophageal pH studies

II. GOVERNANCE Our group is governed by: Physician Executive Committee Physician Board Other (please explain) the Board is the entire GI physician group the Board is part of the GI physician group Our group: has a clearly defined mission statement utilizes strategic planning to guide the practice measures its achievements against its established goals has a physician who serves as the leader (day-to-day CEO, managing partner) pays the physician leader salary if so, $ protected time Our group has had a consultant review at least some aspect of the practice: No Yes within the last 1–2 years within the last 2–4 years ⬎4 years Our practice is contractually connected with a Physician Practice Management Company (PPMC): No investigating plan to within 1–2 years Yes (continued)

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III. STAFF The administrator/office manager of our practice is an: MBA BA RN Other (describe) Number (full time equivalents) of practice staff (not endoscopy ASC) Our practice: has a detailed procedure and policy manual has a formal staff evaluation at least annually funds educational meetings for our: RNs LPNs NAs, endoscopic assistants other staff (receptionist, insurance, etc.) bonuses staff based on: annual bonus (e.g., Christmas bonus) performance and achievement of goals patient satisfaction surveys other (describe)

Staff benefits include: health insurance disability insurance life insurance retirement plan incentive bonus free parking uniform allowance sick leave paid vacation lunch other (describe)

IV. PHYSICIANS Our physicians are all board certified in GI (excluding those within 1 year of completing their training): No ( is/are not) Yes The basic method of reimbursement for our physicians is: equal salary salary ⫹ productivity productivity Our practice: has a formal physician performance evaluation at least annually bonuses physicians based on achieving pre-established goals bonuses our physicians based on patient satisfaction surveys bonuses our physicians based on referring physician satisfaction surveys profiles our physicians at least annually (e.g., cost of services per physician or utilization per physician) Our physicians: participate in a teaching program medical students/residents GI fellowship lecture/train PCPs in GI subjects lecture/train GI Physicians provide community education programs conduct clinical research studies has a dedicated research nurse (continued)

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attend on average at least ⬍1 1–2 2–4 ⬎4

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weeks of CME annually

One or more of our physicians has published in a peer reviewed journal within the last: 2 years 4 years Our physicians receive time off for: vacation ( # weeks) education ( # weeks) presentations at meetings professional society activities clinical research (protected time) administrative activities V. MANAGED CARE/CONTRACTING Most contracts are accepted without revision: No Yes Contracts are reviewed: in-house by physicians in-house by staff in-house by both Our practice uses outside advisors for contract evaluations ⬍25% of contracts 25–50% of contracts ⬎50% Our practice has accepted a commercial capitation contract: No Yes If Yes, $

# of covered lives per member per month (PMPM) the endoscopic ASC is included in this fee

The following services have been excluded: screening flexible sigmoidoscopy diagnostic ERCP therapeutic ERCP Pediatric GI transplants out of area services Capitated revenue is distributed to physicians divided according to our regular practice methods divided according to a different method specifically designed for capitation other (please describe)

Our practice has accepted a Medicare risk contract: No Yes If Yes, $

# of covered lives per member per month (PMPM) the endoscopic ASC is included in this fee (continued)

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The following services have been excluded: screening flexible sigmoidoscopy diagnostic ERCP therapeutic ERCP Pediatric GI transplants out of area services VI. PRACTICE COSTS Our practice: has a budget has a clearly defined program to reduce costs (beyond “we want staff to reduce costs”) negotiates prices with vendors are part of a purchasing group has determined a “cost per service” bonuses staff based on cost reductions has determined the cost of providing services by individual physician Our practice funds major practice expenses by: loans monthly practice revenue (cash flow) combination of loans and monthly practice revenue (cash flow) cash set aside in advance for the purpose Electronic Medical Record: Our practice: has implemented an EMR is considering an EMR is waiting for further technological advances before considering an EMR Our office space is

sq. Ft.

Our practice: rents its office space owns its office space VII. MARKETING Our practice: has a clearly defined marketing plan has staff designated part/full time to marketing targets the following for specific marketing: patients hospitals businesss PCPs MCOs/Insurance companies your staff surveys our patients to measure satisfaction quarterly semi-annually annually implements changes based on patient satisfaction survey bonuses our physicians based on patient satisfaction surveys surveys our referring physicians quarterly semi-annually annually implements changes based on referring physician satisfaction surveys bonuses our physicians based on referring physician satisfaction surveys VIII. PRACTICE MANAGEMENT INFORMATION SYSTEM (MIS) Our practice has upgraded (more than minor) our MIS within: the last 2 years the last 2–4 years has not upgraded within the last 4 years (continued)

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Electronic Medical Record: Our practice: has implemented an EMR is considering an EMR is waiting for further technological advances before considering an EMR IX. CONTINUOUS QUALITY IMPROVEMENT (CQI) Practice has a CQI program in place at this time Our EASC has a CQI program in place at this time If Yes, the CQI program is actually operational and has produced results X. GUIDELINES AND OUTCOMES Practice utilizes clinical guidelines Our EASC utilizes clinical guidelines: If Yes, We measure performance based on the guidelines Our

Practice performs outcome measurements EASC performs outcome measurements If Yes, We introduce change based on outcomes

XI. ENDOSCOPIC AMBULATORY SURGERY CENTER (EASC) Our practice does EGDs and colons in the office Our practice utilizes an EASC: No (If No, skip to the end) Yes primarily single specialty multispecialty The EASC is owned by: Our physicians Other physicians Our physicians and an ASC corporate partner (e.g., AmSurg, Columbia HCA; National Surgery Centers) Hospital A PPMC (physician practice management company) An ASC corporation (e.g.) Our group performs what estimated % of its procedures in the EASC: ⬍50% 50–75% ⬎75% Our group performs approximately the following # of procedures annually in the EASC: ⬍1000 1000–2000 2000–3000 3000–4000 4000–5000 5000–6000 ⬎6000 # full time Staff in the EASC JCAHO/AAAHC accreditation: No Yes EASC EASC and office THANK YOU FOR YOUR TIME AND ASSISTANCE!!