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This is Alan Condon back with the Becker's
ASC podcast,
and I'm delighted to be joined today by
doctor Hugo Ribeau, medical director and CEO of
Georgia Advanced Surgery Center for Women.
Hugo, a pleasure for you making your debut
appearance on the Becker's podcast with us today.
For those of our listeners who may not
be as familiar with you or the work
that you you and your your practice does,
do you mind taking a moment to give
us a little bit more information about your
role and your background?
Sure.
We are
actually a very small ambulatory surgery center, but
we think we're
fairly
pioneering and unique, at least in our state.
We are a GYN only, you know, gynecology
only ambulatory surgery center,
but we
have managed to pretty much convert
every single surgical procedure that is commonly done
in gynecology
other than
oncology
to a completely nonhospital setting. And we're talking
about everything, hysterectomies,
prolapse surgery, urogynecology,
you name it. We we pretty much do
all of ours. And,
we were able to show
as far back as
02/2006
that major procedures that had
previously been confined to hospitals only, usually with
at least one one anywhere from one to
three nights overnight stay in the hospital,
could be done and done very well and
and very, tolerably in an outpatient setting where
the patient goes straight home.
So
we,
you know, did a proof of concept
and ended up presenting our findings at our
annual minimally invasive surgical society meetings
back then. And in 02/2010,
'1 of my two partners and I decided
to develop we had an opportunity,
to acquire
a property, which happened to be in our
own medical office clinic building, which is adjacent
to our hospital. And, we converted it to
we built it out into a, you know,
fully
outfitted ambulatory surgery center.
And it's been
going great ever since, and now we're we're
up we're in our fifteenth year.
Fantastic. So I'd love to just kinda pick
up on something you mentioned there. It's super
impressive in terms of
to your point, converting every surgical procedure that
is commonly done in gynecology, I believe you
said outside of oncology
to the ASC or outpatient setting.
I'd like to just kinda get one bit
deeper there in terms of transitioning some of
those more complex procedures at the gynecology
space to the ASC setting. Kind of, any
tips that you would have for other
physicians,
surgeons in your specialty area who are looking
to do the same at their ASC?
Well,
yeah. I mean, you know, the first inclination
we have is we don't wanna give away
all our ancient Chinese secrets. But, no. I'm
just kidding. We
don't really have it.
The landscape
in our state, like in many other states,
is
somewhat restricted
because of,
these certificate of need laws. Are you familiar
with those?
Yeah. Absolutely.
Yeah. So c o n laws unfortunately, Georgia
is a c o n state,
but Georgia happens to have an exception where
if you're a single specialty
facility
and only the doctors who own that facility
are allowed to operate there, then you get
an exemption
where you don't have to get approval, you
know, from the state or apply for a
formal CLN.
But so there's really and we researched it.
In our state, there's literally only,
like,
one, two, three like, three or four ASCs,
the Duke gynecology in our state, and ours
is the only one that does major procedures
like hysterectomy.
So to convert
major procedures like a hysterectomy to an outpatient
setting,
you have to do sort of a multimodal
approach, which people are just now cluing into.
They they just they call it and sometimes
they goes under the name of ERAS protocols,
e r a s, which stands for enhanced
recovery after surgery.
But,
basically,
there's a way to there are various different
ways to preemptively
address
the things that used to keep patients
needing a hospital after the surgery, which is
pain control and and control of nausea and
vomiting.
And so
there are very specific and targeted ways to
do that in gynecology,
and
we borrowed some techniques from certain pioneering surgeons
in our specialty
and in also orthopedics
where you can there there are ways to
put very targeted regional blocks
inside the pelvis in certain locations
so that the patients
just simply don't wake up with all the
all the usual pain. And it's all very
manageable. And if you know what you're doing,
these folks go home with,
you know,
a a few,
a limited number of pain meds that they
can take at home, and and most of
them don't even use those pain meds for
more than a few days.
So, you know, regional targeted pain blocks,
preemptive
prevention
of nausea with, you know, scopolamine patches,
Zofran,
IV hydrocortisone.
There there's various different things that we all
package together, and and it really works well.
So you can do that for both gynecologic
and laparoscopic surgery.
Fantastic. And the only ASC in Georgia, I
believe, that performs hysterectomies on an outpatient basis.
What a what a feather in your cap.
Hugo, moving to there's a lot that's going
on in health care at any one time.
But as it specifically relates
to ambulatory surgery centers and your practice, can
you share what are two or three trends
that you're paying close attention to now, and
why?
So one of the things that's really gathering
a lot of momentum
is, you know, as the cost of health
care keeps skyrocketing,
you probably know that
most
businesses in The United States that have 50
or more employees are effectively self insured.
You know, they they actually pay for all
the claims and the surgeries and the hospitalizations
of their employees. They just use, you know,
Blue Cross or United or Cigna or these
folks most of the time as a third
party administrator just to give them a network
to send patients to. But the actual payment
comes out of those companies themselves, and a
lot of these companies are
really trying to find where the low hanging
fruit is to trim some of their bigger
costs. And, of course, surgical
expenditures are, you know, high dollar expenses for
a lot of businesses. So there's a whole
industry that's
mushrooming of I don't even know how to
describe them. I don't know if I'd call
them brokers or they're sort of a hybrid
type of
administrator.
They don't give businesses
necessarily access to a network like a traditional
insurance company has, but they seek out
facilities
and doctors
who can
do things
for, I guess, reduced cost,
but yet maintain high quality. And that usually
means ASCs as opposed to hospitals.
And we have been able to develop what
they call bundled rates where, you know, the
entire episode for, say, hysterectomy
is just one price and they know it
upfront.
And it's not your usual, you know, 25
to $35,000.
It's it's way less than that, and it
includes the surgeon, the facility, the anesthesiologist,
and the pathology.
Everything. It includes everything. And so we've been
getting we've developed relationships with multiple
outfits that
send us patients. I mean, at first, I
thought the only folks who are gonna go
for traveling far away from home to get
a surgery were people who are spending, you
know,
$50,000
or more for a joint replacement in orthopedics
or something like that. But, oh, no. There's
lots of gynecology
business out there. I mean, we've we've had
people from,
I mean,
out of state, Texas,
Virginia, I mean, Alaska,
Canada. You wouldn't believe it. These folks will
fly in. And so a lot of these
folks are are marketing
these, I guess, you'd call them surgical benefits,
providers that that
helps steer patients
in in self employed, companies
to
potentially lower cost of care settings. So
the scenario, you know, forgive me if I'm
going on, is that the patient will typically
have a relationship with their own hometown gynecologist,
and they'll find something that needs a surgery
like a hysterectomy or something. Then they
either the patient has been given this information
when they get their health plan enrollment upfront
or a navigator,
you know, benefits navigator contacts them when they
when they start to schedule a surgery and
they'll say, hey. Listen. You know, you can
go to your own doctor here, to your
own hospital here where you had your baby
and have your hysterectomy there, but you'll have,
you know,
through x thousand dollar deductible and 20% co
pay. Or
we've got these crackerjack surgeons who will we'll
pay for you and a companion to fly
out there or or your transportation, your hotel,
your food, and we'll, you know, no deductible,
no co pay, nothing out of pocket. And
so the patients are like, well, sounds good
to me. Is he a good surgeon? And
they're like, yeah. We've vetted him thoroughly. And
so these folks just come on in. I
I did two of these today. As a
matter of fact. One lady
came from seven hour drive away in Alabama
somewhere, and another one came from South Georgia
near Savannah, which is about four four and
a half hours from us.
Wow. Okay. So so this is obviously, I
presume,
what's gonna be a huge area of growth
for for your ASC in terms of these
bundle based rates, bundle based programs.
What is the key to meeting your quality
goals through those bundle bundle based programs, but
also also meeting those financial goals, which are
closely tied together. Right?
Right. Well, so quality goals
one of the things that we've been obsessive
about even before we built our ASC was
tracking our all our surgical outcomes.
So we've made it a point to you
know, we keep a spreadsheet of every single
surgery we've ever done
and whether any complications occurred, when any hospital
readmissions,
any any infections, all of that. And so
we
have a huge amount of data that we
can share with any any broker or provider
that's looking to use our facility. And we've
just got a a
just a really I I have to brag
on it. We have an amazing record of,
I mean, virtually nil in terms of complications
or readmissions or need for reoperation.
So the folks that we've developed a relationship
with know that they're getting a a very
reproducible product and, you know, if anybody has
an issue, they can always come back and
we'll take care of it. I can't even
remember the last time we had to do
that. So our quality data is unassailable. Our
infection rate is zero. I mean, it's always
gonna be way lower in the hospital,
in an ASC.
But overall, complications,
transfusions, all of that is just vanishingly low.
So that that's that's well established.
That data that you've got in on hand
for every single procedure that you performed,
zero complications, zero emissions, I imagine now more
more than ever, that data, having that on
hand is so so crucial to ASCs, owners,
CEOs like yourselves.
And while you're like you said, I guess,
going into these conversations with some of these
maybe health plans or maybe establishing some of
these bundle by bundle based payment relationships.
Yeah. They the each new relationship we develop
typically has some sort of credentialing,
but you'd be kind of amazed.
A lot of them, they don't even ask
that much about surgical outcomes or complication rates
or anything. They just wanna make sure people
are licensed, that there's no liability issues, that
we've been up in operation for a certain
amount of time, and that we have, you
know, fully credentialed
Medicare
certified,
you know, state, joint commission accredited, everything.
It's it's almost a tiny bit of a
wild west out there. They're they're mainly,
if their patients are happy and nobody complains
and they're getting a a great huge deal
on their surgeries, they don't even
I'm almost
taken aback by how they don't really ask
for that much in terms of
data and quality outcome numbers. We have it
all. And I I strongly feel that every
person who's a surgeon should keep track of
every single procedure they do and whether there
were or weren't any complications, so, you know,
for self improvement if nothing else.
You know?
Yeah. No. Fascinating to hear that. Hugo,
kind of following on from that, I wanted
to get your perspective.
When you look ahead the next twelve months,
twenty four months at your ASC,
how are you thinking about growth? Is it
adding new procedures, adding new physicians, providers?
What what's our kind of next step as
you plan for the future?
Well, our primary
directive, so to speak, is just
continuing to develop relationships with,
people who do
direct to employer contracting, like, you know, cutting
up the middleman, so to speak. That's we
we're we're not quite maxed out as far
as,
you know, all our all our time is
filled.
As far as recruiting new surgeons,
that's a that's a unfortunate and sad,
difficult thing that that is is
yeah. That's one of the things I guess
we wanted to bring up.
For private private practice independently
owned ASCs,
it is it's tough going just like it
is for just our regular medical practice.
Trying to recruit has become
probably the number one difficult issue for us
because,
as you know, hospitals are buying up practices
right and left, and they're buying up ASCs
because they're trying to, you know, protect their
referral streams and keep all everything being referred
to the hospital.
And what the hospitals are offering a lot
of these doctors, it's just it's very tough
for us to match as a private practice
group.
And so getting a doctor to
come join our group
and they'd have to be part of the
group to be able to operate there because
of these CON laws. But getting a doctor
to come join our group has been has
been very challenging,
not because I mean, we have a fantastic
opportunity for somebody who's
good at minimally invasive surgery. It's just, you
know, our location we're close enough to Atlanta.
We're only 40 from Atlanta, but the town
is called Cartersville. And when people say Cartersville,
Georgia, where the hell is that? They think
it's out in the middle of nowhere. And,
you know, it seems like all these docs,
especially coming out of residency,
they all wanna go, you know, practice in
a big city or a big metro area.
And then, you know, a lot of them
don't
really wanna work and develop a a a
private practice, but it's it's real our area
is growing so fast. We we really could
use another doc.
That's just a challenge. Try to we need
a doc who has a long term outlook
where they wanna settle in the community, build
a practice, and establish their reputation here, and
and, that's just been a a big challenge.
Well, if there's any physicians listening to this
podcast,
maybe they'll reach out to you.
Yeah.
Yeah. If if anybody wants a very very
high volume successful g wine practice
and and and it's a good town. It's
close enough to Atlanta. We, I mean, litter
we literally go to Atlanta pretty frequently, go
out to dinner, go to shows, go to
sports events. It's really just a suburb.
I mean, there are people in our county
who commute daily to Atlanta for jobs, so
it's really not that far.
Mhmm. Fantastic.
Hugo, last question for you before I let
you go. Some fascinating conversation so far. I
learned a lot more about you, your ASC.
There's a lot of challenges in health care.
We're kinda ending on a little bit more
of an upbeat question.
What are you most excited about when you
think about your ASC, health care more broadly?
Kinda what what what really gets you going?
Well,
one of the things we,
often say to each other, us three docs
who who are partners in this ASC is,
if you enjoy doing surgery as a physician,
having your own ambulatory surgery center is is
like
the best dream possible for a surgeon. Not
having to deal with hospitals, trying to, you
know, begging for OR time at a hospital,
not getting the OR time when you want
it, just being able to schedule your own
cases whenever you want it. That's that is
an incredible luxury for us, and we just
are we it just puts a huge smile
on our face every day to go to
our own surgery center. I literally just walked
down the hall from my office, and I'm
in in our own surgery center. So it's
great.
There's a lot to be said to that,
and all respect for you physician owners and
ASC owners out there. Hugo, really, really appreciate
you taking the time out of your busy
schedule.
Certainly learned a lot, and no doubt our
our audience will have as well. Look forward
to connecting with you again down the line.
Yes. I I appreciate your call. And if,
if anybody out there
has ever thought of, as a gynecologist or
a minimally invasive g y n surgeon, has
thought of
trying to develop their own ASC,
I would love to talk to them and
and tell them how to do contracting, how
to get good rates for your surgeries, and
how to how to market it to employers.
Fantastic. Thank you. Hugo.
Alright.