THE PEOPLE
Who’s Who in the Ambulatory Surgery Industry

By Kelly M. Pyrek

In a field populated by so many dedicated professionals, it would be impossible to recognize every individual who has made significant contributions to this industry. But in this first-ever salute to the movers and shakers, we shine a spotlight on those people who have been particularly active on the behalf of their clients, colleagues and constituents, those who continue to set the bar higher in their delivery of the kind of healthcare that is the wave of the future.

Most people consider Becker to be the pivotal cog that helps turn the wheels of the ASC industry. As a partner in the Chicago office of law firm McGuireWoods Ross & Hardies, he practices exclusively in the healthcare regulatory and transactional area and is sought out for his expertise in the ASC arena. He is the author of three books on the outpatient model of healthcare delivery and delivers numerous presentations across the country on legal and regulatory issues pertaining to ASCs.

“I base my success on being very focused on ASCs and enjoying the persons I talk with and interact with,” Becker says. “By being focused on ASCs from a business, legal and legislative side, I really can quickly apply thoughts to issues and connect the intersections in the outpatient business. I cannot overstate how smart and good most of the people in the business are. Most are principled, motivated and not overly bureaucratic. So it’s a pleasure to work with them, whether they are physician leaders, business leaders, administrators or nurse managers.”

Becker devotes his efforts to surgery center, hospital and healthcare provider-related acquisitions, joint ventures, securities, contracting and regulatory matters, and provides counsel to ASCs, surgical hospitals, hospitals, pharmaceutical companies, multi- and single-specialty medical practices and a wide variety of healthcare industry entrepreneurs. While he is continually sought out for his mastery of healthcare transactional and regulatory matters, Becker quickly points to other individuals in the industry he looks up to — without playing favorites.

“As I work extremely closely with many of the leaders in the business, I will avoid singling out any one person I admire most in the business. But I do take off my hat to Kathy Bryant, Craig Jeffries and Alan Pierrot. Each has provided great industry leadership through FASA, AAASC and ASHA at a time when it has been sorely needed. They have been extremely motivated and in many instances, visionary.”

No stranger to the reimbursement and competition challenges the industry faces, Becker chooses to take a positive outlook. “I think we will come to a point in the near future where the nation’s leadership will start to see how physician-owned facilities are hugely important to the improvement of healthcare. If not for physician drive and development, I am afraid that our system would become as second rate as many other systems. Increasingly, I think the government will see this and push past protectionist concepts. It will just take some time.”

Bringing heightened professionalism to the ASC industry has been Bryant’s goal ever since the day she was hired as executive director of the Federated Ambulatory Surgery Association. She points to creation of the CASC credential and the number of administrators taking advantage of this certification, however, as the crowning glory of her tenure at FASA and of her entire career so far.

“We didn’t take shortcuts yet we developed the entire program in two years,” she says, “even though all the consultants we spoke with said it couldn’t be done. The response from the industry — both ASCs and employees of ASCs — has been incredible.” The first exam attracted about 100 participants, and Bryant hopes these numbers will continue to grow for the benefit of everyone in the industry.

Looking after FASA members is something that comes naturally to Bryant, who relishes the fast pace and unrelenting demands of championing the outpatient field. “I’m incredibly excited about the industry. I know that sounds hokey but I enjoy going to work every morning.” Much of her time is spent on the road, fulfilling speaking engagements across the country; in just three months this fall, Bryant will deliver 17 presentations.

“It’s hard for me to say no when our members ask me to speak at their chapter meetings. I am here to help the industry, so if I can, I will. FASA members are trying so hard to deliver a service to their patients while struggling to interpret regulations and what they mean for their very specific healthcare environment.”

Most of her speeches address the developments on Capitol Hill affecting the industry.

“The most critical is MedPAC’s involvement in reimbursement issues; it is based on faulty information. As they got more accurate information, they tailored it to fit the recommendations they wanted to make. They never ask about the good that ASCs contribute to healthcare. They ask, ‘Is the ASC as good as the hospital?’ when maybe they ought to ask, ‘Is the hospital as good as the ASC?’ I haven’t seen anything that looks at how our industry meets the surgical needs of the nation. One of the challenges for the industry going forward is to change the thought process of policymakers. We have demonstrated our commitment to safety and efficiency. Our grassroots campaign is addressing that issue, but we need a whole lot of that to get the public and policymakers on our side.”

Bryant advises ASC owners and operators to “concentrate on what has made us successful for the past 30 years — the focus on the patient.” She adds, “There are challenges we need to address, but the primary reason physicians and patients come to ASCs is because of the service we deliver. People delivering care need to continue to keep their focus there. It’s my job to focus on the other things for them and get them involved as we need them. Bryant encourages members to step up support of FASA’s government relations program. “FASA members wrote 10,000 letters to Congressmembers. I believe that’s an industry record, but there’s a lot more we can do. Members must forge relationships with Congressmembers if we are to be heard. It’s a big effort for FASA going forward, but we will be successful.”

Tenacity is the watchword for a man who has been at the heart of some important organizations that champion surgical hospitals. Lipomi was one of the founders of and the first president of the California Ambulatory Surgery Association, which is now one of the largest state organizations. He also is one of the founders, original board members and president of the upstart American Surgical Hospital Association (ASHA). As CEO and president of Stanislaus Surgical Hospital, Lipomi continues to represent a healthcare delivery model he believes is the wave of the future.

“I’m very proud to be one of the early pioneers in this new aspect of healthcare delivery,” he says. “I believe specialty hospitals are in the best interests of patients and physicians.

Over the years, Lipomi has learned just how reluctant traditional hospitals have been to embrace specialty facilities, and now is taking a strong stand to counter numerous detractors.

“I am still amazed by how non-responsive these traditional hospitals have been to physicians and patients, and resistant to embracing specialty status. We live in an age when healthcare consumers are knowledgeable about surgical procedures and treatment modalities, and they have researched healthcare providers that are going to provide the best care. These sophisticated consumers are flocking toward specialty hospitals.”

Lipomi calls upon personal experience to get his message across that otherwise healthy patients should have the right to be treated in a facility that does not care for chronic patients. Lipomi was in a traditional hospital recovering from a simple surgical procedure when he was forced to share a room with a much more acute patient. He contracted pneumonia from his roommate, who later had expired after Lipomi was discharged.

“It’s gratifying for me to offer an alternative for otherwise healthy patients who have been ignored by traditional hospitals. They have a right to be in a facility where they won’t be exposed to infections — infections, by the way, that traditional hospitals don’t seem to question.”

Lipomi says he has learned a great deal about himself through his work, including that he is extremely passionate about fighting for a good cause.

“I love this profession because it makes a difference,” he says. “I am not a clinical provider but the decisions I make as an administrator affect the health of my patients. If I don’t do my job right it can be a problem, and that is stimulating to me. I’ve also discovered that I am never satisfied with where I’m at; I’m a devotee of continuous quality improvement. I am disappointed by the traditional hospital system. I don’t understand why the infection rate has to be as high as it is, why patients have to wait hours in the ER, why the food is awful, or why there are no extra amenities.”

Lipomi has discovered inner fortitude as he and ASHA lobbyists battle on Capitol Hill against legislation that could attempt to put specialty hospitals out of business. “Our biggest problem is the unbridled attack by the American Hospital Association and the Coalition of Full Service Hospitals that has no foundation. They claim we’re forcing traditional hospitals to close — without a shred of evidence! They are trying to legislate us out of business. In ‘04, I hope for continued growth for us and a greater understanding and acceptance of who we are and what we do. I am hopeful we will be embraced by a White House that has called for innovative healthcare delivery.”

Lipomi continues, “We know we have a great idea. I tell everyone who will listen to make sure you don’t compromise because of the pressures forced upon you. Don’t quit. Every great innovation or great thinker has suffered attacks by naysayers. Only because of desire and dedication did they persevere. The easy thing to do is say, ‘This is too hard; I’ll just sell to the nearest hospital and forget it.’ It’s worth the battle. I’ve been there, done it, and I’m still here.”

Lipomi points to ASC pioneer Dr. Wally Reed as a source of inspiration. “Reed took the bull by the horns and did it in the face of controversy and speculation. There was no method of reimbursement, no Medicare certification, no history, no track record ... but he did it, and that keeps me going.”

There’s very little crossing Serbin’s desk that she hasn’t seen before. As a former nurse and founder of two successful consulting firms — Surgery Consultants of America, Inc. and Surgery Center Billing, LLC — Serbin uses her clinical and business skills to help problem-solve and troubleshoot for her clients. She says her diverse background in nursing, operations, development, finance, marketing, billing and management helps her create a bridge between hospitals and physicians, especially in joint ventures when being able to see everyone’s perspective can keep deals cemented.

“I can balance each side’s needs because I understand where they are both coming from,” she explains. “There are always problems with business and clinical folks butting heads. The beauty of our company is we can understand everyone’s needs and how to work it out. We are able to deal with that delicate balance of what the doctors want, what the hospitals want, and the lack of trust between them. These deals survived and thrived because of our ability to manage them. It’s not easy but it’s an awful lot of fun when it works.”

That balance is what has propelled Serbin’s companies into the upper echelon of firms serving ambulatory healthcare. “I’m proud of having raised the bar in consulting, and that is due in part to excellent communications. I hear from our clients, ‘We can find you anytime, day or night, and you always have an answer.’ I’m proud of our timeliness. We have never not met a deadline on a project.”

If it’s 10 p.m., chances are you’ll find Serbin still working, but she considers it part of the territory. “I guess I could use more balance in my personal life, but there are so many fun things to do in this business and I’m never bored. The reward is happy clients — it doesn’t get any better than that. I pinch myself every day because I get to interact with such interesting people. If you like what you do, you will be successful and you won’t notice the hard work. If you don’t have your heart in it, it won’t happen.”

Serbin has seen tremendous change in the industry and is encouraged about where ambulatory surgery is going. “Years ago, if you mentioned ASCs, people would be standoffish — they thought it wouldn’t be as good or as safe as hospitals. Now we have seen the complete reversal of that. People are more comfortable in freestanding centers.” Still, the industry cannot rest on its laurels.

“We need to continue with the good work FASA and AAASC have done to fight for reimbursements and keep the codes we have in the surgery center environment. There’s a concern that some of the ASC procedures might move to the office setting, but it’s not appropriate for safety reasons. I don’t see hospitals as the threat any longer because they are more open to partnerships. Managed care is not the challenge it used to be. Yes, you have to work very hard to get the contracts you need but we’re working with CMS to get paid.”

Serbin advises clients to be involved. “When the organizations ask for our help, whether it be educating a congressman or letting third-party payors know the value of ASCs, we need to do that.”

In an industry filled with accomplished people, Serbin says she looks up to Scott Becker. “He is probably the most premier ASC healthcare attorney in this country. I can call him anytime and get the answers I need. He is the best communicator. If you ask what Caryl is known for, people say, ‘If you call her you get a call back.’ The same is true for Scott and I admire that. I don’t know too many people who do that, especially in something as complex as surgery center law.”

It’s an interesting time to lead an organization, acknowledges Shapiro, president of the American Association of Ambulatory Surgery Centers (AAASC), who says the group is just “scratching the surface” of the many things that need to be done on behalf of the ambulatory industry, under siege by lawmakers.

“We have infinite potential; the future for the organization and the industry is unlimited,” Shapiro enthuses. “Barring federal intervention, I think there is unparalleled growth ahead. Look at the new construction — facilities are popping up all over. People are building centers and contemplating them even as we speak — it’s exciting to be in the middle of it.”

Shapiro is counting on the industry’s past track record as a failsafe for the future.

“From a medical point of view, what started as a good idea with very limited applications has turned into an even better idea with unlimited applications. Surgery has evolved. When I first started we were doing very noninvasive, short cases and were limited by medical technology. Everything has changed. Back then, none of us could have imagined the kinds of patients we are able to treat and the things we are able to do for them. Procedures done now on an outpatient basis weren’t even done on an inpatient basis then. What’s driving the industry is that everyone prefers it — patients, employees, physicians. When it comes together it’s an amazing thing to see.”

As senior vice president of medical affairs for Surgis, Inc., Shapiro is able to blend his background as an anesthesiologist with his business skills of managing ASCs. “I touch patients indirectly though my business decisions and I’m still able to be a patient advocate. I am very pro medicine and pro physician, but it all comes down to the patient — that’s how I make clinical, administrative and executive decisions. If I were the patient how would I want to be treated? The rest falls into place.”

It may not be so easy in 2004, as the industry will undoubtedly continue to be scrutinized by regulators. “It’s a huge bureaucracy — MedPAC, OIG, CMS, HHS — all these representatives from so many agencies are looking at us and almost none of them are clinicians.

They don’t understand medicine or healthcare delivery. When the industry was in its infancy there were arbitrary definitions in terms of the scope of medical practice carried out in ASCs, so those procedure codes may have been an appropriate way to regulate what things were done in an ASC. But those reimbursement decisions made 20 years ago have no bearing on today. To deny us based on arbitrary rules and regulations and without clinical basis makes no sense. Not only should we, as physicians, be able to do what we think is safe for patients, and patients should expect the same level of proficiency and competence whether in an ASC or a hospital. The corollary to that is reimbursement should be the same, no matter the site of service.”

Shapiro says the fight is on for physician ownership as well. “Our detractors believe that where physicians have ownership, bad things are going on. I think an ownership interest invests them in providing quality care and committed to seeing that good things are done. Ownership should be encouraged, not discouraged. Because hospitals are threatened they are using it as a reason to shut down specialty hospitals. I tell everyone in our industry to keep doing what they are doing — delivering superior patient care. And when dealing with detractors, they have to convince them one detractor at a time.”

Tasset, president and CEO of Nueterra Healthcare, formerly ASC Group, Inc., and a member of the AAASC executive board, credits his success in a challenging industry to a strong personal belief system that guides his business decisions.

“What has driven me personally and has spilled over into the company is trying to do something with a higher purpose, more than just make money. Hopefully that’s what everyone tries to do. I truly believe, despite what the status quo thinks, that what we are doing is good for patients, good for the country, good for the economy, and good for healthcare, period. If it weren’t, why would other countries want us to help them do what we are doing? What we are doing is bringing more complete care to patients and attending to all their needs — physical and emotional. We keep in mind that the most important person in the process is the patient. Exceptional quality of care is a given — it’s expected. But we must take it to a higher meaning.”

Tasset says everything he has worked for in his life thus far has prepared him for success in the ambulatory arena, and confirmed for him what it takes to be a leader — having a vision broader than the nuts and bolts of daily operations.

“I have adhered to basic principles throughout this journey, including following that higher purpose, and sticking to my convictions,” he says. “It’s also critical that when forming an organization, you have a mission statement that is actionable. Otherwise, on a day-to-day basis you will get lost and not have any idea where you are going.”

Tasset believes this roadmap is important in light of the bumpy road ahead. “I believe we have an inevitable crash down the road in terms of healthcare costs. Even those in the Clinton administration who vehemently opposed any kind of nationalized healthcare are saying they don’t know what else to do. We have an imminent crisis, but ambulatory care is the solution. If we can get this to proliferate and deliver lower-cost healthcare, we can help resolve the crisis. What keeps me going is looking back and being able to say I was part of that solution, part of saving the healthcare system — even if we were considered at the time to be the ‘disruptive innovation.’ Healthcare is one-fifth of our GNP, so my sandbox is pretty big.”

Tasset takes a philosophical approach to current struggles in the field. “What everyone is talking about is a blip on the radar screen in a big-picture scenario. We’ll figure ways around any kind of adverse legislation or hospitals threatening our economic viability. We’ll look back on 2003 and say it was a pivotal year; probably next year will be the same thing. It’s just a lot of static — probably the same as what the industry endured 20 years ago. We’ve simply hit another bump in the road.”

Tasset counsels his clients to take an equally calm, pragmatic outlook.

“My job is to drill down into the details for them — what our detractors can do and can’t do, and separate the fact from fiction. We separate the hysteria from reality and once we do that, our physician partners ask, “What am I worrying about then?’ and I say, ‘Exactly.’ I tell them, “Stay the course. You know what your role and your rights are, and what you are doing is the right thing and consistent with principles this country was founded on. We get to the heart of what is happening and they worry less once they understand.”

Tasset takes an equally pragmatic view when it comes to observing his peers and sharing who he thinks are heroes in the field. Companies like ours are the pioneers in this industry, and it’s a collective effort. To single out one of those persons would be like asking, ‘Is Dan Tasset going to make a huge impact?’ No, but all of us collectively, yes. Across the industry, I can’t point to any specific heroes, but I can point to some villains — primarily they are legislators trying to hold back change. But there are dozens of Dan Tassets who actually get it and are starting to promote change. Those are the heroes. The people I try to emulate are those who have resisted the status quo and who try to do the right thing.”

Zasa, one of the founders of respected consulting and management firm Woodrum/ Ambulatory Systems Development, has a very long pedigree that reflects experience in all phases of business development in multi-specialty ASCs, group practices and hospitals. In the 1990s he served as president and CEO of Premier Ambulatory Systems, Inc., and in 1995, he was recognized by Inc. magazine as CEO of one of the top 500 fastest-growing private companies in the U.S. Premier ranked sixth in the nation for its growth in three years, earning more than $35 million in revenues. In the 2000s, he continues to be a widely recognized expert in the ambulatory marketplace, but hasn’t lost touch with the sensibilities he first learned in the 1970s and the infancy of the field.

Zasa points to 1977, when he did his first surgery center, as a year where he discovered the power of benchmarking. He set up a benchmarking system then that has been used by the AAASC and the MGMA in their data collection surveys. “We put together about 15 critical management factors and used them to benchmark ourselves and against other centers, and other companies picked up on it,” he says. “It turned out to be a way the industry has come to manage itself through benchmarking parameters, and it was way ahead of its time. It helped me learn the essential elements of the business and it gave my nurses a tool with which to measure their progress. It gave them concrete goals to achieve and gave them the freedom to know they were achievable.” With the good fortune of having worked with ambulatory surgery pioneer Dr. Wally Reed, Zasa says it was a chance to learn about the fledgling industry — and learn a few things about himself in the process.

“Dr. Reed had a very clear sense of what he was trying to achieve, not just from a business sense, but from a surgeon’s perspective. We didn’t agree on a lot of stuff but we learned from each other. We were often at loggerheads when we took a company public; my job was to make sure we made profit, and his job was to retain the center’s local flavor and quality of service. There was a creative tension but it was very respectful. I learned a great deal about the balance required in those early days, especially because the reimbursements weren’t like they are now. Dr. Reed taught me to make sure we didn’t have ‘economics unbridled’ to the point where it would have killed the goose that laid the golden egg. A lot was at stake — Stark was coming up and Medicare 82 just came to pass, so it was important that the ASCs be run well financially, but properly, at a very high level of quality and ethics. The founding doctors were insistent on doing it well and doing it right, because they were setting the tone for the whole industry to follow.”

Zasa believes that for the most part, ASCs have adhered to Reed’s vision. “I think most centers have stayed true to the original mission — saving the patient money, providing quality, private, convenient outpatient services in an appropriate, safe setting, and providing an appropriate incentive for physicians to take back control of healthcare costs as well as revenues in medicine.”

Zasa says his varied and storied career has taught him to provide stellar leadership but to encourage people to think for themselves

“As a young manager I was very impatient. I felt very strongly about principles I had adopted from good mentors early on. But after a while, I learned there are many ways to accomplish the same goals without spelling it out for people as particularly as I did. Many times it was interpreted as micromanagement when the intent was to make goals very clear,” he says with a laugh. Through the years, Zasa says he has developed a great respect in particular for ambulatory care nurses, who he describes as driven, focused individuals who can make or break a facility.

“Anybody in our field must have a high view of nurses,” Zasa says, adding that he had strong women in his family — including a sister who was an RN — and respect of these individuals stuck with him. “I love working with nurses. They are such self-actualized people, and it’s our duty to provide a good environment so they can do what they do best. They are so good when they get freed up to do their thing, and it’s frustrating for them when they can’t. Most nurses in ASCs want to break away from a traditional hospital role because they are innovative people with a different skill sets than hospital floor nurses. They fight for respect, from the suits, the docs, the vendors ... they are remarkable people, and you never want to abuse their giving, caring attitudes.”

With an eye to the future, Zasa says issues like reimbursement pale in comparison to challenges like a California workers’ comp bill he calls “gutwrenching.” “The bill carries a very strong attempt to outlaw physician-owned ASCs, and had it passed, it would have set a terrible precedent in the U.S. — even though Stark has shown there was never any abuse, and even more utilization because the surgery center was there. It’s not resolved yet, and it’s a real threat. It’s a much bigger issue than whether or not we are going to get the same kind of reimbursement as hospitals, because it attacks the fundamental premise that doctors can be financially accountable and successful in an ASC.”

In this turbulent time, Zasa admonishes industry members to do a better job of growing their centers. “Growth is not just adding doctors here or there. It is proactively addressing how to expand business by knowing your markets better — the demographics in those markets, and the physician mix necessary to be in that competitive market. Hospitals are doing a better job of that, while in our field we tend to grow by accident. Don’t just go after lucrative payers but after specialties that fit your market. Look at morbidity information for your geographic area and go after the appropriate procedures. The bottom line is if you are not moving forward, you are moving backward. Plan your growth by fitting the delivery vehicle to the population. We also must align incentives of the staff to the owners through performance bonuses and profit sharing. Alignment between the ASC’s owners, users, staff and management is critical; when all the oars are in the water at the same time, it’s very powerful.”

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