April 18, 2025 • 30 mins
Hospital-based specialists such as radiologists and anesthesiologists are critical to the operations of health systems. However, the current landscape is creating new challenges between these specialists and health systems. Rich Chasinoff, Director, VMG Health, speaks with Angela Hill, Vice President and General Counsel, Vandalia Health, about how the relationship between specialists and health systems is changing and how health systems are responding. They discuss issues related to reimbursement and compensation, structuring and negotiating arrangements, and legal considerations. Sponsored by VMG Health.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Speaker 2 (00:04):
Support for A HLA comes from VMG Health, which is
the leading healthcareconsulting firm for business
performance since 1995. Thefirm has designed its business
to address any strategic,regulatory or operational
challenges that affect quality,profitability, and growth. With
eight offices and over 300dedicated professionals
(00:26):
representing an extensive arrayof credentials nationwide, VMG
Health provides the expertiseits clients can rely on. For
more information, visit vmghealth.com.
Speaker 3 (00:41):
Hello everyone, and thank you for joining this
discussion regarding currentissues in hospital-based
specialties and arrangements.
My name is , uh, rich Chasnoff, and I'm a director with VMG
Health. We're a healthcare ,um, management consulting firm,
and a large part of my work isdevoted to compensation
arrangements, includingsubsidies and support payments
(01:03):
paid to hospital-basedspecialties, which is the
subject of our discussiontoday. Um, over the past two
years, we've seen in ourpractice an an increased need
for health system support andradiology and anesthesia in
particular. And today we wantedto provide some background and
share some things we've learned, um, with you , uh, and talk
(01:23):
about some approaches thathealth systems are using in
this environment , um, and havea general discussion about ,
uh, the legal framework aswell. Um , I'm here today with
Angie Hill , uh, delighted tobe together. Uh, Angie has
faced and dealt with thisproblem firsthand. Uh, Angie,
you wanna say hello andintroduce yourself?
Speaker 4 (01:42):
Sure. Thank you, rich. Hi, everyone. My name is
Angie Hill. I'm the VicePresident and General Counsel
of Vandalia Health, which is a, um, 14 hospital system
located in West Virginia, sortof across West Virginia. And ,
uh, I've been with the healthsystem since 1994, so I've seen
a lot , um, over the years. Butcertainly the challenges we
(02:04):
face now are, are significantones, parti , particularly in
the hospital based , uh, um,provider area. And so , um, a
few months ago, we wereapproached by our radiology
group for some financialsupport. And, and this was new
for us, rich, but you tell meit's becoming the norm. Can
you, can you explain a littlebit,
Speaker 3 (02:23):
? That's
right. It's becoming much more
common, particularly inradiology. Uh, the last 18
months or so , uh, has been a ,a tremendous increase. And I
think there are a few thingsgoing on that, that are
important to to know . Itstarts with a simple supply and
demand discussion. Um, thepopulation is aging. Um, a
couple of numbers , uh, about13% of the population was over
(02:46):
age , 65 in 2010. That grew to17% in 2022, and as expected to
jump to 20% by 2030. So all ofthis is leading, not
surprisingly , to more imagingprocedures and more radiology
at the same time. Um, thenumber of radiologists is not
(03:06):
growing to keep up , um,radiologists or an aging
workforce. There are limitedradi , uh, ra radiology,
resident residency spaces. Um,so we're not seeing radiology
keep up. So that's, that's the,the , the , the start of the
discussion around supply anddemand. But the second part is
the radiologists that arecoming out of training and are,
(03:30):
are in current practice, havesome choices , um, and choices
that they didn't havehistorically. Um, of course,
they could join privatepractice groups as, as many had
done in the past, but they alsohave opportunities for employed
groups. They also haveopportunities for , um, large
roll-ups, like, like , uh,large companies that are, that
(03:52):
are providing radiology, andthen there are teleradiology
providers as well. So there area lot of different practice
environments that radiologistshave and have , uh, have their
choice of. And they may choosethat for, for a number of
different reasons. But as youthink about hospital-based
radiologists and the , and theradiologists who decide to go
(04:13):
into the independent group thatis already in your practice,
perhaps , um, or join the, therollup that's already in your,
in your hospital , um, there'sa much more limited pool. So,
so recruitment becomes thatmuch more challenging. And at
the same time, teleradiologyoffers some, some opportunities
(04:34):
that hospital-based radiologydoesn't offer the flexibility
of work schedule, ability towork wherever you you wanna
work. So all of those thingsare really making recruitment
and retention , um,challenging. And lastly, as ,
as if that, that doesn'texplain enough of it, there,
there have been reimbursementchallenges. And since , um,
(04:56):
2021 , uh, there's been about a10% decline in radiology
reimbursement. And what's that,what that's doing is
challenging groups at a timewhen supply, when supply and
demand forces are sayingcompensation needs to go up ,
uh, reimbursement is comingdown at the same time. And then
lastly, any groups that thatmay have investments in imaging
(05:18):
centers have had the samereimbursement problems. So
their profitability in theimaging centers that they may
own , um, aren't quite as , uh,lucr lucrative or profitable
for them. So all of this iscoming together to create a
tremendous upward cropcompensation pressure,
tremendous recruitment,retention challenges for, for
health systems, for, forhospital-based radiology
(05:40):
groups. And they're turning totheir, to their health systems
and saying, please help. Um,and, and health systems are,
are , um, trying to figure thatout , uh, as they do. And, and
I know Vandalia has, has hadthat happen to them. So, so
Angie, tell us a little bitabout what happened at valia ,
um, and how you ultimatelyresolved the , uh, the
(06:03):
situation there.
Speaker 4 (06:04):
Yeah, you know, initially, and , and I think
because of all the pressuresthat you mentioned, rich , uh,
we were initially approached byour, our long-term radiology
group. They've been here 50years , um, about becoming
employed. You know, they, theyreally wanted to look at the
employment model. I think theywere tired of trying to, you
know, keep, keep the practice,you know, together. And , um,
(06:26):
you know, it's still, when youhave a group that's been a
group for 50 years, it's reallyhard to make that transition
from being your own independentgroup to becoming employed.
And, and so for, for that, forthat group, it was just, it
was, it ended up being a bridgetoo far. So we spent a lot of
time, you know, reallydiscussing the employment
model. Both sides were veryengaged in that process, but
(06:47):
ultimately they preferred tostay, stay in a group and , uh,
ask us to evaluate aprofessional services agreement
model, where essentially thehospital would bill , would
bill and collect for all of theservices, and then would pay
the group a fee for theservices they provided. And we
spent, you know, anotherseveral months negotiating that
particular , um, type oftransaction. And in the end ,
(07:10):
um, we were not able to reachterms with that group and , um,
ultimately had a professionalservices agreement with another
radiology provider.
Speaker 3 (07:21):
So, so as you , as you reflect on that, that
process and that series ofevents, what, what are some of
the, the lessons that youlearned about structuring
deals, negotiating these, thesetypes of negotiating in this
environment , um, where, wherephysicians really do, are
needing some support, but atthe same time , um, you have
(07:43):
obligations to the healthsystem to make sure that, that
you, you are proper financialstewards of, of the health
systems , resources,
Speaker 4 (07:51):
Right? Absolutely.
And you know, in West Virginia,certainly our population is
aging, and our payer mix isnot, you know, is , is, is, is,
is not , uh, very commercial.
So we have a , you know, the,the , the payer mix is a
challenge, which does, and ,and we're a level one trauma
center. We are, you know, asafety net hospital. So, you
know, the groups that practicehere do , uh, take on the
(08:14):
responsibility of providing alot of care to those who don't
necessarily have the ability topay. So subsidies are becoming,
you know, be becoming somethingthat we've, we've had to
consider that we hadn't reallyhad to consider before. I think
the thing that , the thingsthat I learned is, you know,
particularly for these hospitalbased specialties of , know ,
we talked about, we touched onanesthesiology too, but
(08:35):
radiology, you know, it affects, it affects everything you do.
You know, the radiologyradiologists are key to
everything that you do. It's,it affects inpatient, it
affects outpatient or a traumacenter. You know , we need
x-rays, we need MRIs, we needcancer diagnosis and screening.
So those services touch everyaspect. And so you really have
to be sure that you, you'remindful of that and that you
(08:59):
keep others, you know, in the,in the loop. Because the, the
worst thing that could happenis you have a lapse, you know,
you, you have a , a change incontracts, and then all of a
sudden you can't provideservices, necessary services to
your community. So , uh, youknow , certainly , um, that
was, that was key for us. Thesecontracts are often also
exclusive contracts. So, youknow, those who exercise
(09:21):
privilege in a certain spacecan't exercise privileges if
you change contractedproviders. So you have to be
mindful of , um, you have to bemindful of that. So if you
switch groups, likely you'regoing to have to have a whole
new group of providers thathave to be credentialed within
your organization. That takes,that takes time to, to
credential, you know, 25 newradiologists within your
(09:46):
system. They may not havelicenses, you know, in West
Virginia. So how do they , howdo we get them licensed here?
That also takes time. So , um,you know, you also have to look
at what you need from aninpatient standpoint. The , the
teleradiology , um, space isvery attractive to a lot of
people. A lot of people don'twanna be on site anymore. They
(10:07):
wanna, they wanna stay wherethey are and continue to
provide services from thoselocations. So that is , um,
that's difficult. But you dostill need onsite radiologists
for interventional procedures,and those are, those are really
difficult to find, particularlywhen, you know, a lot of these
groups have non-competes andthings like that. So it's , um,
(10:30):
that was, that was a realchallenge.
Speaker 3 (10:34):
How did, how did your medical staff respond and
react? You know , you know, theradiologists are so integrated
with the medical staff and ,and the , the surgeons, the
oncologists all rely on thejudgment of the radiologists
and, and like that, you know ,really appreciate the
relationship that they formwith the radiologists and
radiology groups over, overyears. How did, how did you
(10:57):
work with them to, to addressthis?
Speaker 4 (10:59):
Yeah, it was very, it was a very difficult
transition because you'reright, they do, they do , um,
trust those individuals. Theyhave their, you know, everybody
has their go-to person. So itreally was, was working with
them and making sure that wehad, you know, as we went to a
new service provider, we keptthe same turnaround times, we
kept the same quality metrics,you know, that, that we were
(11:22):
very conscious of what thesedoctors needed to continue to
perform the services that theywere performing and to, to
address the needs of their, oftheir patients in, in real time
.
Speaker 3 (11:33):
Mm-hmm
. Yeah . That's, that's
terrific. And it , it is alarge undertaking. Prior to my
, um, you , you may know this Ithink Angie, but prior to my
role as a consultant , um, I, Iwas a hospital administrator as
well, and we were in theposition to change radiology
groups. And I know that justhow hard it is , um, to, to go
(11:55):
through that with, with yourorganization. And, and, and it
is a big undertaking and, and aheavy lift, so to speak. Um,
you know, as, as organizationssee these challenges with , um,
you know, financial challengesand the , and the need to
provide additional support, youknow, we, we've seen this take
(12:15):
a lot of different forms. Um,and I think what's interesting
is an Angie walked through alot of different options that,
that you explored with, withvandalia . You kind of went
down a lot of different,different avenues. Um, we've
definitely seen , um, a numberof different things. You know,
the first one that, that a lotof health systems are trying
are , um, some of thetraditional, you know, other
(12:39):
types of arrangements we'veseen on-call arrangements.
We've seen medicaldirectorships offer to pay ,
offers to pay for Nighthawkcoverage or, or some, some
other sort of coverage. And ,um, I think that works
sometimes, but, but quitehonestly, in, in our experience
in the last two years or so,those types of payments have
(13:02):
not solved the , the, thefinancial challenge mm-hmm
. That the healthsystems have had. So they've
really moved to PSAs oremployment and explored those
other things. And, and justgenerally, you know, a lot are
, are moving to subsidies.
Health systems are used tosubsidies that they have
subsidies in anesthesia, whichwe'll chat about in a little,
(13:22):
we could chat about in a littlebit. But, you know,
hospitalists are oftensubsidized, sometimes emergency
medicine physicians. So healthsystems see this for their, for
hospital-based groups. And, andit's often a , um, it's, it's
often a , a , an avenue or apath that, that , um,
organizations think about. Uh,it add radiology has a slightly
(13:45):
different challenge than someof those other specialties that
they're, they're much moreproduction based of the other
specialties. They're much moretime and shift based radiology,
because the shifts are sovaried, it , it, it changes
things up a little bit in ourexperience , um, where you've
got teleradiology, you've gotdoctors who may be part of the
group, but working completelyremotely. Um, you've got , um,
(14:09):
sharing across multiplefacilities and , and different
things. So the subsidyarrangements , um, you know,
measuring subsidies and sort ofcalculating and identifying
the, the number of FTEs and thestaffing and the costs that you
need to meet when, when thehealth system start , starts
with, you know, our, our, ourrevenue is no longer meeting
our expenses. Um, it's, it canpose a challenge to, to figure
(14:33):
out what those expenses are.
And it starts often inradiology with a, with a
production model. But, butorganizations like valia are
also thinking about, you know,this question I think that's
relevant is, as you think aboutthe financial picture, there's
also this question that getsraised about which party is
(14:54):
best in a position to, to billand collect for the services
mm-hmm . Uh, whohas the, the resources in place
to do it, and the , the processin place to do it , um, and who
can really maximize revenue.
And that includes who's , who's, um, contracts are better. So
that's another thing that wefrequently see in this space
(15:14):
is, is a black box analysis to,to begin to assess which , um,
which party's reimbursement is,is , um, you know, is stronger
in that. And, and then thisconsideration of , um, as you ,
you mentioned an Angie movingover and, and having, rather
than letting the group continueto bill, having the hospital
(15:37):
billing and collect, and thatoffers two opportunities. You ,
you , you went down both roads, um mm-hmm . But
one with the employment or , ora PSA or both, both options.
And they offer different levelsof control for the , for the
group. But, but, but honestly,the, the economic outcome , um,
tends to be, tends to besimilar in both, in both
situations.
Speaker 4 (15:59):
Yeah. And, and you know, of course for us,
historically, we had not billedfor radiology services. So it's
standing up the whole aspectof, you know, billing for those
services. So, and , and , andthe mechanism building, you
know, building it in the, inthe electronic health record
and the revenue cycle. Sothat's, you know, it's a huge
lift to, to do that, to , toswitch. And it's, you know,
it's a cultural change, youknow, for, for everybody as
(16:21):
well, so. Right .
Speaker 3 (16:22):
And some organizations don't even have ,
uh, contracted rates forradiology. I don't know if you
went through that.
Speaker 4 (16:29):
We did. I sure
Speaker 3 (16:30):
Did. So you , so you actually needed to go to go
negotiate rates for radiology.
Yep .
Speaker 4 (16:37):
Um, so Rich, what do you think as far as the demand
goes? Is it, do you see anychange as far as the , the ,
the data that you're pulling?
Is it,
Speaker 3 (16:48):
I I think in terms of demand for
Speaker 4 (16:50):
Any hope in sight ,
Speaker 3 (16:52):
, ,
you know, I think it's gonna
level off . I , I do think it'sgoing to level off, but there's
definitely an increase in, inradiologist compensation that's
happening right now. And Ithink, I think there is , um,
some hope in sight , but Ithink we've, we've gotta get
through this sort of increaseand, and, you know, I'm hopeful
(17:12):
long term that, that we're, wecan put out and, and train
more, more radiologists, Ithink becomes a , um, becomes
part of the solution here. Um,but, but other parts of the
solution I think are, are justhealth systems are starting to
rethink how radiology isprovided in the health system.
(17:35):
Radiology is one of the last ,um, specialties to take on apps
and, and understanding the roleof apps and apps are starting
to do some, some basicprocedures in radiology, which
is taking some pressure off ofthe radiologists. Um, so that's
an op an an option. We're alsoseeing hospitals think about
(17:58):
the, the requirement thatradiologists be in-house as
well. And by changing some ofthat dynamic and some of the,
the, sometimes it'sinterruptions, sometimes it's
workflow changes that allow theradiologists that are there to
become that much more efficient, um, and assuring that the PAC
system is working well, and allthe structures in place that
(18:20):
help radiologists becomeefficient are , um, are in
place. I think that that alsohelps and take some of the
pressure off of the radiologistto allow them to , um, to, to
do more, to be more productiveand, and, and addresses some of
the recruitment and retention ,um, issues that we're, that
(18:41):
we're seeing mm-hmm
Speaker 4 (18:42):
.
Speaker 3 (18:43):
But I think health systems getting involved early
is , is, and having thatdiscussion with the
radiologists early is alsohelpful. We've seen , um, quite
a lot of fire drills in ourpractice, a lot of sort of
emergency , um, you know, needsthe , the radiologists are
really struggling and we don'thave a plan in place. Um, so,
so addressing it early is also,is also helpful.
Speaker 4 (19:06):
That's key, because again, these things take time.
You know, you can't just standup a whole new group overnight.
So yeah, you do have to be, youdo have to be mindful of , uh,
the time that it takes , uh,to, to do that. Um , and, and
you know, just from a , I thinksome of the other contractual
things that we've found that weneed to really be mindful of
(19:27):
is, again, every arrangementhas to comply with Stark. So
whether you do the employment,personal services arrangement,
whatever has to comply withstark fair market value is
always a key, a very keycomponent to these. And , uh,
these arrangements arecomplicated. So we definitely
have found that we needed someexpert help in, in determining
what the reasonable, you know,whether it's, you know ,
(19:49):
initially the subsidy that weconsidered, the employment that
we considered, the employmentoptions that we considered are
certainly the, the professionalservices arrangement. You know,
certainly looking at fairmarket value and commercial
reasonableness are, are, arekey, are absolutely key to
every analysis. And , uh, youknow, for me, I feel like the
rest of the legal stuff ispretty easy. It's the, it's ,
(20:09):
it's the compensation partthat's, that's always hard.
Although in these, thesearrangements, sometimes the
non-financial terms are whereyou can get, you know, where
you can get hung up as well.
Um, and so, you know, as far asnon-financial terms that we
found that we really have to,you know, that we had to focus
on, were, you know, turnaroundtime requirements to make sure
(20:29):
the needs are met, FTErequirements to, you know, both
onsite hours of operation, whendo we expect somebody to be on
site and at what facilities,what outpatient facilities, you
know, what , what do we need inthe hospital? Um, how many
remote , uh, readers do weneed? Do we offer rights of
first refusal for newlocations? So if we acquire a
(20:51):
facility, a new facility, ahospital facility, or if we
acquire a physician practice,do we give that group the right
of first refusal to providetheir services at those
locations as as well? And dothey, do they have the capacity
to, do they have the capacityto do that? Um, you know,
again, these contracts aregonna be exclusive contracts.
So as you negotiate them, youreally need to consider, do we
(21:12):
have other providers in theenvironment? You know, people
who do nuclear radiology,cardiac CTAs, things like that,
where if you give somebody anexclusive contract, are you,
are you disqualifying one ofthose providers from providing
services that they've, they'veoffered at your hospital for
years? So you have to be reallycareful at looking at the
exclusive services that you'recontracting for in relation to
(21:34):
other services that areprovided by other members of
your medical staff. And then ofcourse, you know, always big
are the non-competition,non-solicitation provisions
where, you know, if you didhave a group that left, can you
hire those doctors? Can thosedoctors work for you? Or , um,
you know, can you solicit them?
And those are all reallyimportant considerations as
(21:56):
you, as you look at how youstructure these arrangements
as, as well.
Speaker 3 (22:02):
Yeah ,
Speaker 4 (22:04):
It's a challenge for sure.
Speaker 3 (22:07):
It , it , it, it sure is. It sure is.
Speaker 4 (22:09):
And we had , uh, as you know, we had a very similar
experience in radiology, Imean, in anesthesiology. So
what are you seeing out therein, in the realm of
anesthesiology? Is it similar?
Speaker 3 (22:19):
Yeah . Um, it , it, it is similar but different as,
as, as o and I I think some ofa anesthesia has been , um, a
specialty for a long timethat's required subsidies. It's
traditionally been a poor payerand an inefficient , uh, you
know, has an inefficientdelivery model. Um, when you
(22:39):
look at anesthesia, there's alot of , um, time that, that
anesthesia is dependent on theway that ORs are scheduled,
the, the uncertainty with ORs,how long they're each going to
run. Uh, obstetrics has uniquechallenges , um, with downtime
and sort of a lot of, a lot ofwaiting in anesthesia. Um, so
(23:03):
there, there are a number ofthings that make anesthesia
inefficient and poor payers,which has always led to the
subsidies there. Mm-hmm . I think what's
what's changing in anesthesiais, and it's also a supply and
demand issue of on, on theanesthesiologist side, but
anesthesia also has a, adifferent staffing model , um,
with , in that CRNAs are veryimportant to the anesthesia
(23:26):
staffing right now. And from asupply and demand perspective,
anesthesi , uh, CRNAs have beenin tremendous demand, and their
salaries have really , um,grown in the last few years.
And as, as organizations havetried to balance their and, and
right size , their staffingmodel and compliment between
(23:49):
anesthesiologists and CRNAs ,that's , uh, increased demand
for CRNAs. Um, DR driven uptheir SAL salaries, and I think
to some extent that's impactedthe anesthesiologist salaries
as well, that they've sort ofgotten, gotten a little bit of
a lift as CRA salaries havecome up. Uh, physician salaries
(24:10):
have come up in this space ,uh, as well. So there, there
are a few different factors at, at play, but, but there are a
lot of similarities andfundamentally revenue, revenue
not meeting, meeting expenses.
And, and that becomes the, the,the challenge , um, in, in that
environment. And what canhealth systems do? They try ,
(24:33):
try to organize ananesthetizing locations in a ,
in a more logical way. Butfundamentally there's a,
there's a, an inherent goal ofassuring that surgery and
surgical care is available ,um, and the anesthesiologists
are, are often at the , um, atthe, the whim of those
decisions made in the OR to, tokeep surgical throughput
(24:55):
coming, coming through. Um,tell us a little bit more about
how , how things played out at,at Vandalia .
Speaker 4 (25:02):
Yeah, so, so in this case , um, the anesthesiologist
did , uh, become employed. Soagain, it was a long, a
longstanding group ofanesthesiologists who had , uh,
provided , uh, anesthesiaservices as independent
contractors for, for a longtime, you know, quite a long
time. And, and they actually ,uh, I , I'm happy to say all,
(25:25):
all of the anesthesiologistswithin the group ended up
accepting employment at thehospital. So that transition
occurred in October. Prior tothat, our CRNAs, to your point,
our CRNAs were employed by thehospital, and the
anesthesiologists were employedby the, by the group. So I
think that now having everybodyaligned as employees of the
group will allow us to be muchmore efficient, you know, in,
(25:45):
in the way we provideanesthesia services. Uh, it's,
it's interesting in our statenow, there's a bill being
introduced to allow CRNAs to,to practice independently more
independently. Um, and so it'llbe interesting to see where
that goes. I think it's becomea real issue, particularly in
rural hospitals. And we have alot of rural hospitals in our
(26:06):
state that, that can't find ananesthesiologist, so they'll
have A-C-R-N-A and then whatcan that CRNA do there?
Oftentimes they're supervisedby a general surgeon who may or
may not know that a generalsurgeon is, is who may or may
not know he's supervising the ,um, the CRNA. So it's, it's
interesting to see that, thatdevelopment within our, within
(26:26):
our state , um, and we'll see,we'll see what happens with
that. But , um, yeah, the , the, um, knock on wood so far
that, that , um, that seems tobe going, that transition seems
to be going very well.
Speaker 3 (26:40):
That's great. You , you talked about the transition
to employment, and that's,that's another, we didn't, we
didn't explore that perhaps ina , at a later date, but , um,
it, it is challenging to bringorgan , um, a group of
physicians in from , um,particularly hospital-based
physicians in from the privatepractice. And, and there, there
(27:01):
are a lot of, in our experiencethere , some of that challenge
relates to, to the healthsystem never having managed
that particular specialtybefore. Um, health systems have
gotten used to, and, and have alot of experience now with
managing office-based practicesor surgical practices, but in,
(27:22):
in anesthesia, there's anentirely different billing
structure and, and, and , um,organizational structure same
in radiology. So it, itpresents some different
challenges as well, and I'msure that you've had some
growing pains there.
Speaker 4 (27:36):
Yeah. Yes, it is very, it is very different. And
I think that, you know, likeone of the key takeaways I
would say from both of thoseexperiences is, is just to have
respect for where each other iscoming from. I mean, it's, it's
logical that a group ofphysicians is, is going to be
somewhat untrusting of thehospital. You , you think you
can get your back and say, youknow, we've been, we've been
(27:57):
doing business together for 50years or 35 years, whatever
that period of time is, butit's really hard to go from
being independent to beingemployed. That's a big, that's
a big shift for a lot of peoplefor, I mean, for I think any,
any group. And so I think that,you know , as you go through
these negotiations, you haveto, you have to keep in mind of
(28:17):
where, where they're comingfrom. And it's, it's
understandable. Um, and, youknow, you just hope that you
can, you can work through it ina, in a rational way. And , um,
yeah, it's been, I think , Ithink that, and recognizing
that you have a lot of, youknow, every specialty in the
hospital, every department inthe hospital is affected by,
(28:39):
you know, this, these servicelines, they're very important
to everyone. So, you know, youjust need to proceed with care,
with what, what , with whatyou're doing, keeping the
hospital's interest in mind aswell .
Speaker 3 (28:50):
Well, terrific.
Yeah, and I think it'simportant, you know, health
systems, when the , when the,when the pro , when the
discussion gets started, it'soften started as, you know, we
need a subsidy or we needsupport. But there, there are
some other options out therethat we've talked about that
employment is always an option.
PSAs are always an option. AndI think it's, it's critical
(29:12):
that, that organizations, youknow, think as , as they're ,
as they're about to make aninvestment, whether it's in
radiology or continuedinvestment in, in
anesthesiology, that, thatorganizations, you know,
continue to think about optionsand explore , uh, ways to, to,
to enter into thesearrangements with, with eyes
(29:33):
open, with a , uh, an eyetoward the financial picture
and outcome. And of course,towards the absolutely
successful operations.
Speaker 4 (29:40):
Yeah, it's getting harder and harder to be in the
healthcare business. You know,things are getting, you know,
the , the tightened all thetime. So it is really, you
know, essential to look atthese other options , um, and,
and not just the subsidies aswe've historically done.
Speaker 3 (29:55):
Yeah. Well, I think this is a good place to
conclude. This has been awonderful discussion, Angie.
Thank you so much for joiningme . Thank
Speaker 4 (30:02):
You, rich. Enjoy it
Speaker 3 (30:03):
And sharing these practical insights. Uh, thank
you to , to all of you who arelistening. Have a great day,
everybody.
Speaker 2 (30:14):
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Speaker 2 (00:04):
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(00:26):
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Speaker 3 (00:41):
Hello everyone, and thank you for joining this
discussion regarding currentissues in hospital-based
specialties and arrangements.
My name is , uh, rich Chasnoff, and I'm a director with VMG
Health. We're a healthcare ,um, management consulting firm,
and a large part of my work isdevoted to compensation
arrangements, includingsubsidies and support payments
(01:03):
paid to hospital-basedspecialties, which is the
subject of our discussiontoday. Um, over the past two
years, we've seen in ourpractice an an increased need
for health system support andradiology and anesthesia in
particular. And today we wantedto provide some background and
share some things we've learned, um, with you , uh, and talk
(01:23):
about some approaches thathealth systems are using in
this environment , um, and havea general discussion about ,
uh, the legal framework aswell. Um , I'm here today with
Angie Hill , uh, delighted tobe together. Uh, Angie has
faced and dealt with thisproblem firsthand. Uh, Angie,
you wanna say hello andintroduce yourself?
Speaker 4 (01:42):
Sure. Thank you, rich. Hi, everyone. My name is
Angie Hill. I'm the VicePresident and General Counsel
of Vandalia Health, which is a, um, 14 hospital system
located in West Virginia, sortof across West Virginia. And ,
uh, I've been with the healthsystem since 1994, so I've seen
a lot , um, over the years. Butcertainly the challenges we
(02:04):
face now are, are significantones, parti , particularly in
the hospital based , uh, um,provider area. And so , um, a
few months ago, we wereapproached by our radiology
group for some financialsupport. And, and this was new
for us, rich, but you tell meit's becoming the norm. Can
you, can you explain a littlebit,
Speaker 3 (02:23):
common, particularly inradiology. Uh, the last 18
months or so , uh, has been a ,a tremendous increase. And I
think there are a few thingsgoing on that, that are
important to to know . Itstarts with a simple supply and
demand discussion. Um, thepopulation is aging. Um, a
couple of numbers , uh, about13% of the population was over
(02:46):
age , 65 in 2010. That grew to17% in 2022, and as expected to
jump to 20% by 2030. So all ofthis is leading, not
surprisingly , to more imagingprocedures and more radiology
at the same time. Um, thenumber of radiologists is not
(03:06):
growing to keep up , um,radiologists or an aging
workforce. There are limitedradi , uh, ra radiology,
resident residency spaces. Um,so we're not seeing radiology
keep up. So that's, that's the,the , the , the start of the
discussion around supply anddemand. But the second part is
the radiologists that arecoming out of training and are,
(03:30):
are in current practice, havesome choices , um, and choices
that they didn't havehistorically. Um, of course,
they could join privatepractice groups as, as many had
done in the past, but they alsohave opportunities for employed
groups. They also haveopportunities for , um, large
roll-ups, like, like , uh,large companies that are, that
(03:52):
are providing radiology, andthen there are teleradiology
providers as well. So there area lot of different practice
environments that radiologistshave and have , uh, have their
choice of. And they may choosethat for, for a number of
different reasons. But as youthink about hospital-based
radiologists and the , and theradiologists who decide to go
(04:13):
into the independent group thatis already in your practice,
perhaps , um, or join the, therollup that's already in your,
in your hospital , um, there'sa much more limited pool. So,
so recruitment becomes thatmuch more challenging. And at
the same time, teleradiologyoffers some, some opportunities
(04:34):
that hospital-based radiologydoesn't offer the flexibility
of work schedule, ability towork wherever you you wanna
work. So all of those thingsare really making recruitment
and retention , um,challenging. And lastly, as ,
as if that, that doesn'texplain enough of it, there,
there have been reimbursementchallenges. And since , um,
(04:56):
2021 , uh, there's been about a10% decline in radiology
reimbursement. And what's that,what that's doing is
challenging groups at a timewhen supply, when supply and
demand forces are sayingcompensation needs to go up ,
uh, reimbursement is comingdown at the same time. And then
lastly, any groups that thatmay have investments in imaging
(05:18):
centers have had the samereimbursement problems. So
their profitability in theimaging centers that they may
own , um, aren't quite as , uh,lucr lucrative or profitable
for them. So all of this iscoming together to create a
tremendous upward cropcompensation pressure,
tremendous recruitment,retention challenges for, for
health systems, for, forhospital-based radiology
(05:40):
groups. And they're turning totheir, to their health systems
and saying, please help. Um,and, and health systems are,
are , um, trying to figure thatout , uh, as they do. And, and
I know Vandalia has, has hadthat happen to them. So, so
Angie, tell us a little bitabout what happened at valia ,
um, and how you ultimatelyresolved the , uh, the
(06:03):
situation there.
Speaker 4 (06:04):
Yeah, you know, initially, and , and I think
because of all the pressuresthat you mentioned, rich , uh,
we were initially approached byour, our long-term radiology
group. They've been here 50years , um, about becoming
employed. You know, they, theyreally wanted to look at the
employment model. I think theywere tired of trying to, you
know, keep, keep the practice,you know, together. And , um,
(06:26):
you know, it's still, when youhave a group that's been a
group for 50 years, it's reallyhard to make that transition
from being your own independentgroup to becoming employed.
And, and so for, for that, forthat group, it was just, it
was, it ended up being a bridgetoo far. So we spent a lot of
time, you know, reallydiscussing the employment
model. Both sides were veryengaged in that process, but
(06:47):
ultimately they preferred tostay, stay in a group and , uh,
ask us to evaluate aprofessional services agreement
model, where essentially thehospital would bill , would
bill and collect for all of theservices, and then would pay
the group a fee for theservices they provided. And we
spent, you know, anotherseveral months negotiating that
particular , um, type oftransaction. And in the end ,
(07:10):
um, we were not able to reachterms with that group and , um,
ultimately had a professionalservices agreement with another
radiology provider.
Speaker 3 (07:21):
So, so as you , as you reflect on that, that
process and that series ofevents, what, what are some of
the, the lessons that youlearned about structuring
deals, negotiating these, thesetypes of negotiating in this
environment , um, where, wherephysicians really do, are
needing some support, but atthe same time , um, you have
(07:43):
obligations to the healthsystem to make sure that, that
you, you are proper financialstewards of, of the health
systems , resources,
Speaker 4 (07:51):
Right? Absolutely.
And you know, in West Virginia,certainly our population is
aging, and our payer mix isnot, you know, is , is, is, is,
is not , uh, very commercial.
So we have a , you know, the,the , the payer mix is a
challenge, which does, and ,and we're a level one trauma
center. We are, you know, asafety net hospital. So, you
know, the groups that practicehere do , uh, take on the
(08:14):
responsibility of providing alot of care to those who don't
necessarily have the ability topay. So subsidies are becoming,
you know, be becoming somethingthat we've, we've had to
consider that we hadn't reallyhad to consider before. I think
the thing that , the thingsthat I learned is, you know,
particularly for these hospitalbased specialties of , know ,
we talked about, we touched onanesthesiology too, but
(08:35):
radiology, you know, it affects, it affects everything you do.
You know, the radiologyradiologists are key to
everything that you do. It's,it affects inpatient, it
affects outpatient or a traumacenter. You know , we need
x-rays, we need MRIs, we needcancer diagnosis and screening.
So those services touch everyaspect. And so you really have
to be sure that you, you'remindful of that and that you
(08:59):
keep others, you know, in the,in the loop. Because the, the
worst thing that could happenis you have a lapse, you know,
you, you have a , a change incontracts, and then all of a
sudden you can't provideservices, necessary services to
your community. So , uh, youknow , certainly , um, that
was, that was key for us. Thesecontracts are often also
exclusive contracts. So, youknow, those who exercise
(09:21):
privilege in a certain spacecan't exercise privileges if
you change contractedproviders. So you have to be
mindful of , um, you have to bemindful of that. So if you
switch groups, likely you'regoing to have to have a whole
new group of providers thathave to be credentialed within
your organization. That takes,that takes time to, to
credential, you know, 25 newradiologists within your
(09:46):
system. They may not havelicenses, you know, in West
Virginia. So how do they , howdo we get them licensed here?
That also takes time. So , um,you know, you also have to look
at what you need from aninpatient standpoint. The , the
teleradiology , um, space isvery attractive to a lot of
people. A lot of people don'twanna be on site anymore. They
(10:07):
wanna, they wanna stay wherethey are and continue to
provide services from thoselocations. So that is , um,
that's difficult. But you dostill need onsite radiologists
for interventional procedures,and those are, those are really
difficult to find, particularlywhen, you know, a lot of these
groups have non-competes andthings like that. So it's , um,
(10:30):
that was, that was a realchallenge.
Speaker 3 (10:34):
How did, how did your medical staff respond and
react? You know , you know, theradiologists are so integrated
with the medical staff and ,and the , the surgeons, the
oncologists all rely on thejudgment of the radiologists
and, and like that, you know ,really appreciate the
relationship that they formwith the radiologists and
radiology groups over, overyears. How did, how did you
(10:57):
work with them to, to addressthis?
Speaker 4 (10:59):
Yeah, it was very, it was a very difficult
transition because you'reright, they do, they do , um,
trust those individuals. Theyhave their, you know, everybody
has their go-to person. So itreally was, was working with
them and making sure that wehad, you know, as we went to a
new service provider, we keptthe same turnaround times, we
kept the same quality metrics,you know, that, that we were
(11:22):
very conscious of what thesedoctors needed to continue to
perform the services that theywere performing and to, to
address the needs of their, oftheir patients in, in real time
.
Speaker 3 (11:33):
Mm-hmm
terrific. And it , it is alarge undertaking. Prior to my
, um, you , you may know this Ithink Angie, but prior to my
role as a consultant , um, I, Iwas a hospital administrator as
well, and we were in theposition to change radiology
groups. And I know that justhow hard it is , um, to, to go
(11:55):
through that with, with yourorganization. And, and, and it
is a big undertaking and, and aheavy lift, so to speak. Um,
you know, as, as organizationssee these challenges with , um,
you know, financial challengesand the , and the need to
provide additional support, youknow, we, we've seen this take
(12:15):
a lot of different forms. Um,and I think what's interesting
is an Angie walked through alot of different options that,
that you explored with, withvandalia . You kind of went
down a lot of different,different avenues. Um, we've
definitely seen , um, a numberof different things. You know,
the first one that, that a lotof health systems are trying
are , um, some of thetraditional, you know, other
(12:39):
types of arrangements we'veseen on-call arrangements.
We've seen medicaldirectorships offer to pay ,
offers to pay for Nighthawkcoverage or, or some, some
other sort of coverage. And ,um, I think that works
sometimes, but, but quitehonestly, in, in our experience
in the last two years or so,those types of payments have
(13:02):
not solved the , the, thefinancial challenge mm-hmm
really moved to PSAs oremployment and explored those
other things. And, and justgenerally, you know, a lot are
, are moving to subsidies.
Health systems are used tosubsidies that they have
subsidies in anesthesia, whichwe'll chat about in a little,
(13:22):
we could chat about in a littlebit. But, you know,
hospitalists are oftensubsidized, sometimes emergency
medicine physicians. So healthsystems see this for their, for
hospital-based groups. And, andit's often a , um, it's, it's
often a , a , an avenue or apath that, that , um,
organizations think about. Uh,it add radiology has a slightly
(13:45):
different challenge than someof those other specialties that
they're, they're much moreproduction based of the other
specialties. They're much moretime and shift based radiology,
because the shifts are sovaried, it , it, it changes
things up a little bit in ourexperience , um, where you've
got teleradiology, you've gotdoctors who may be part of the
group, but working completelyremotely. Um, you've got , um,
(14:09):
sharing across multiplefacilities and , and different
things. So the subsidyarrangements , um, you know,
measuring subsidies and sort ofcalculating and identifying
the, the number of FTEs and thestaffing and the costs that you
need to meet when, when thehealth system start , starts
with, you know, our, our, ourrevenue is no longer meeting
our expenses. Um, it's, it canpose a challenge to, to figure
(14:33):
out what those expenses are.
And it starts often inradiology with a, with a
production model. But, butorganizations like valia are
also thinking about, you know,this question I think that's
relevant is, as you think aboutthe financial picture, there's
also this question that getsraised about which party is
(14:54):
best in a position to, to billand collect for the services
mm-hmm
to do it, and the , the processin place to do it , um, and who
can really maximize revenue.
And that includes who's , who's, um, contracts are better. So
that's another thing that wefrequently see in this space
(15:14):
is, is a black box analysis to,to begin to assess which , um,
which party's reimbursement is,is , um, you know, is stronger
in that. And, and then thisconsideration of , um, as you ,
you mentioned an Angie movingover and, and having, rather
than letting the group continueto bill, having the hospital
(15:37):
billing and collect, and thatoffers two opportunities. You ,
you , you went down both roads, um mm-hmm
one with the employment or , ora PSA or both, both options.
And they offer different levelsof control for the , for the
group. But, but, but honestly,the, the economic outcome , um,
tends to be, tends to besimilar in both, in both
situations.
Speaker 4 (15:59):
Yeah. And, and you know, of course for us,
historically, we had not billedfor radiology services. So it's
standing up the whole aspectof, you know, billing for those
services. So, and , and , andthe mechanism building, you
know, building it in the, inthe electronic health record
and the revenue cycle. Sothat's, you know, it's a huge
lift to, to do that, to , toswitch. And it's, you know,
it's a cultural change, youknow, for, for everybody as
(16:21):
well, so. Right .
Speaker 3 (16:22):
And some organizations don't even have ,
uh, contracted rates forradiology. I don't know if you
went through that.
Speaker 4 (16:29):
We did. I sure
Speaker 3 (16:30):
Did. So you , so you actually needed to go to go
negotiate rates for radiology.
Yep .
Speaker 4 (16:37):
Um, so Rich, what do you think as far as the demand
goes? Is it, do you see anychange as far as the , the ,
the data that you're pulling?
Is it,
Speaker 3 (16:48):
I I think in terms of demand for
Speaker 4 (16:50):
Any hope in sight ,
Speaker 3 (16:52):
level off . I , I do think it'sgoing to level off, but there's
definitely an increase in, inradiologist compensation that's
happening right now. And Ithink, I think there is , um,
some hope in sight , but Ithink we've, we've gotta get
through this sort of increaseand, and, you know, I'm hopeful
(17:12):
long term that, that we're, wecan put out and, and train
more, more radiologists, Ithink becomes a , um, becomes
part of the solution here. Um,but, but other parts of the
solution I think are, are justhealth systems are starting to
rethink how radiology isprovided in the health system.
(17:35):
Radiology is one of the last ,um, specialties to take on apps
and, and understanding the roleof apps and apps are starting
to do some, some basicprocedures in radiology, which
is taking some pressure off ofthe radiologists. Um, so that's
an op an an option. We're alsoseeing hospitals think about
(17:58):
the, the requirement thatradiologists be in-house as
well. And by changing some ofthat dynamic and some of the,
the, sometimes it'sinterruptions, sometimes it's
workflow changes that allow theradiologists that are there to
become that much more efficient, um, and assuring that the PAC
system is working well, and allthe structures in place that
(18:20):
help radiologists becomeefficient are , um, are in
place. I think that that alsohelps and take some of the
pressure off of the radiologistto allow them to , um, to, to
do more, to be more productiveand, and, and addresses some of
the recruitment and retention ,um, issues that we're, that
(18:41):
we're seeing mm-hmm
Speaker 4 (18:42):
Speaker 3 (18:43):
But I think health systems getting involved early
is , is, and having thatdiscussion with the
radiologists early is alsohelpful. We've seen , um, quite
a lot of fire drills in ourpractice, a lot of sort of
emergency , um, you know, needsthe , the radiologists are
really struggling and we don'thave a plan in place. Um, so,
so addressing it early is also,is also helpful.
Speaker 4 (19:06):
That's key, because again, these things take time.
You know, you can't just standup a whole new group overnight.
So yeah, you do have to be, youdo have to be mindful of , uh,
the time that it takes , uh,to, to do that. Um , and, and
you know, just from a , I thinksome of the other contractual
things that we've found that weneed to really be mindful of
(19:27):
is, again, every arrangementhas to comply with Stark. So
whether you do the employment,personal services arrangement,
whatever has to comply withstark fair market value is
always a key, a very keycomponent to these. And , uh,
these arrangements arecomplicated. So we definitely
have found that we needed someexpert help in, in determining
what the reasonable, you know,whether it's, you know ,
(19:49):
initially the subsidy that weconsidered, the employment that
we considered, the employmentoptions that we considered are
certainly the, the professionalservices arrangement. You know,
certainly looking at fairmarket value and commercial
reasonableness are, are, arekey, are absolutely key to
every analysis. And , uh, youknow, for me, I feel like the
rest of the legal stuff ispretty easy. It's the, it's ,
(20:09):
it's the compensation partthat's, that's always hard.
Although in these, thesearrangements, sometimes the
non-financial terms are whereyou can get, you know, where
you can get hung up as well.
Um, and so, you know, as far asnon-financial terms that we
found that we really have to,you know, that we had to focus
on, were, you know, turnaroundtime requirements to make sure
(20:29):
the needs are met, FTErequirements to, you know, both
onsite hours of operation, whendo we expect somebody to be on
site and at what facilities,what outpatient facilities, you
know, what , what do we need inthe hospital? Um, how many
remote , uh, readers do weneed? Do we offer rights of
first refusal for newlocations? So if we acquire a
(20:51):
facility, a new facility, ahospital facility, or if we
acquire a physician practice,do we give that group the right
of first refusal to providetheir services at those
locations as as well? And dothey, do they have the capacity
to, do they have the capacityto do that? Um, you know,
again, these contracts aregonna be exclusive contracts.
So as you negotiate them, youreally need to consider, do we
(21:12):
have other providers in theenvironment? You know, people
who do nuclear radiology,cardiac CTAs, things like that,
where if you give somebody anexclusive contract, are you,
are you disqualifying one ofthose providers from providing
services that they've, they'veoffered at your hospital for
years? So you have to be reallycareful at looking at the
exclusive services that you'recontracting for in relation to
(21:34):
other services that areprovided by other members of
your medical staff. And then ofcourse, you know, always big
are the non-competition,non-solicitation provisions
where, you know, if you didhave a group that left, can you
hire those doctors? Can thosedoctors work for you? Or , um,
you know, can you solicit them?
And those are all reallyimportant considerations as
(21:56):
you, as you look at how youstructure these arrangements
as, as well.
Speaker 3 (22:02):
Yeah ,
Speaker 4 (22:04):
It's a challenge for sure.
Speaker 3 (22:07):
It , it , it, it sure is. It sure is.
Speaker 4 (22:09):
And we had , uh, as you know, we had a very similar
experience in radiology, Imean, in anesthesiology. So
what are you seeing out therein, in the realm of
anesthesiology? Is it similar?
Speaker 3 (22:19):
Yeah . Um, it , it, it is similar but different as,
as, as o and I I think some ofa anesthesia has been , um, a
specialty for a long timethat's required subsidies. It's
traditionally been a poor payerand an inefficient , uh, you
know, has an inefficientdelivery model. Um, when you
(22:39):
look at anesthesia, there's alot of , um, time that, that
anesthesia is dependent on theway that ORs are scheduled,
the, the uncertainty with ORs,how long they're each going to
run. Uh, obstetrics has uniquechallenges , um, with downtime
and sort of a lot of, a lot ofwaiting in anesthesia. Um, so
(23:03):
there, there are a number ofthings that make anesthesia
inefficient and poor payers,which has always led to the
subsidies there. Mm-hmm
what's changing in anesthesiais, and it's also a supply and
demand issue of on, on theanesthesiologist side, but
anesthesia also has a, adifferent staffing model , um,
with , in that CRNAs are veryimportant to the anesthesia
(23:26):
staffing right now. And from asupply and demand perspective,
anesthesi , uh, CRNAs have beenin tremendous demand, and their
salaries have really , um,grown in the last few years.
And as, as organizations havetried to balance their and, and
right size , their staffingmodel and compliment between
(23:49):
anesthesiologists and CRNAs ,that's , uh, increased demand
for CRNAs. Um, DR driven uptheir SAL salaries, and I think
to some extent that's impactedthe anesthesiologist salaries
as well, that they've sort ofgotten, gotten a little bit of
a lift as CRA salaries havecome up. Uh, physician salaries
(24:10):
have come up in this space ,uh, as well. So there, there
are a few different factors at, at play, but, but there are a
lot of similarities andfundamentally revenue, revenue
not meeting, meeting expenses.
And, and that becomes the, the,the challenge , um, in, in that
environment. And what canhealth systems do? They try ,
(24:33):
try to organize ananesthetizing locations in a ,
in a more logical way. Butfundamentally there's a,
there's a, an inherent goal ofassuring that surgery and
surgical care is available ,um, and the anesthesiologists
are, are often at the , um, atthe, the whim of those
decisions made in the OR to, tokeep surgical throughput
(24:55):
coming, coming through. Um,tell us a little bit more about
how , how things played out at,at Vandalia .
Speaker 4 (25:02):
Yeah, so, so in this case , um, the anesthesiologist
did , uh, become employed. Soagain, it was a long, a
longstanding group ofanesthesiologists who had , uh,
provided , uh, anesthesiaservices as independent
contractors for, for a longtime, you know, quite a long
time. And, and they actually ,uh, I , I'm happy to say all,
(25:25):
all of the anesthesiologistswithin the group ended up
accepting employment at thehospital. So that transition
occurred in October. Prior tothat, our CRNAs, to your point,
our CRNAs were employed by thehospital, and the
anesthesiologists were employedby the, by the group. So I
think that now having everybodyaligned as employees of the
group will allow us to be muchmore efficient, you know, in,
(25:45):
in the way we provideanesthesia services. Uh, it's,
it's interesting in our statenow, there's a bill being
introduced to allow CRNAs to,to practice independently more
independently. Um, and so it'llbe interesting to see where
that goes. I think it's becomea real issue, particularly in
rural hospitals. And we have alot of rural hospitals in our
(26:06):
state that, that can't find ananesthesiologist, so they'll
have A-C-R-N-A and then whatcan that CRNA do there?
Oftentimes they're supervisedby a general surgeon who may or
may not know that a generalsurgeon is, is who may or may
not know he's supervising the ,um, the CRNA. So it's, it's
interesting to see that, thatdevelopment within our, within
(26:26):
our state , um, and we'll see,we'll see what happens with
that. But , um, yeah, the , the, um, knock on wood so far
that, that , um, that seems tobe going, that transition seems
to be going very well.
Speaker 3 (26:40):
That's great. You , you talked about the transition
to employment, and that's,that's another, we didn't, we
didn't explore that perhaps ina , at a later date, but , um,
it, it is challenging to bringorgan , um, a group of
physicians in from , um,particularly hospital-based
physicians in from the privatepractice. And, and there, there
(27:01):
are a lot of, in our experiencethere , some of that challenge
relates to, to the healthsystem never having managed
that particular specialtybefore. Um, health systems have
gotten used to, and, and have alot of experience now with
managing office-based practicesor surgical practices, but in,
(27:22):
in anesthesia, there's anentirely different billing
structure and, and, and , um,organizational structure same
in radiology. So it, itpresents some different
challenges as well, and I'msure that you've had some
growing pains there.
Speaker 4 (27:36):
Yeah. Yes, it is very, it is very different. And
I think that, you know, likeone of the key takeaways I
would say from both of thoseexperiences is, is just to have
respect for where each other iscoming from. I mean, it's, it's
logical that a group ofphysicians is, is going to be
somewhat untrusting of thehospital. You , you think you
can get your back and say, youknow, we've been, we've been
(27:57):
doing business together for 50years or 35 years, whatever
that period of time is, butit's really hard to go from
being independent to beingemployed. That's a big, that's
a big shift for a lot of peoplefor, I mean, for I think any,
any group. And so I think that,you know , as you go through
these negotiations, you haveto, you have to keep in mind of
(28:17):
where, where they're comingfrom. And it's, it's
understandable. Um, and, youknow, you just hope that you
can, you can work through it ina, in a rational way. And , um,
yeah, it's been, I think , Ithink that, and recognizing
that you have a lot of, youknow, every specialty in the
hospital, every department inthe hospital is affected by,
(28:39):
you know, this, these servicelines, they're very important
to everyone. So, you know, youjust need to proceed with care,
with what, what , with whatyou're doing, keeping the
hospital's interest in mind aswell .
Speaker 3 (28:50):
Well, terrific.
Yeah, and I think it'simportant, you know, health
systems, when the , when the,when the pro , when the
discussion gets started, it'soften started as, you know, we
need a subsidy or we needsupport. But there, there are
some other options out therethat we've talked about that
employment is always an option.
PSAs are always an option. AndI think it's, it's critical
(29:12):
that, that organizations, youknow, think as , as they're ,
as they're about to make aninvestment, whether it's in
radiology or continuedinvestment in, in
anesthesiology, that, thatorganizations, you know,
continue to think about optionsand explore , uh, ways to, to,
to enter into thesearrangements with, with eyes
(29:33):
open, with a , uh, an eyetoward the financial picture
and outcome. And of course,towards the absolutely
successful operations.
Speaker 4 (29:40):
Yeah, it's getting harder and harder to be in the
healthcare business. You know,things are getting, you know,
the , the tightened all thetime. So it is really, you
know, essential to look atthese other options , um, and,
and not just the subsidies aswe've historically done.
Speaker 3 (29:55):
Yeah. Well, I think this is a good place to
conclude. This has been awonderful discussion, Angie.
Thank you so much for joiningme . Thank
Speaker 4 (30:02):
You, rich. Enjoy it
Speaker 3 (30:03):
And sharing these practical insights. Uh, thank
you to , to all of you who arelistening. Have a great day,
everybody.
Speaker 2 (30:14):
Thank you for listening. If you enjoyed this
episode, be sure to subscribeto ALA's speaking of health
Law, wherever you get yourpodcasts. To learn more about a
HLA and the educationalresources available to the
health law community, visitAmerican health law.org.
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