Dr. Zimmerman, left, with colleague Dr. Justin Hamrick, is in his element at the head of the bed.

Dr. Zimmerman, left, with colleague Dr. Justin Hamrick, is in his element at the head of the bed.

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Thank you for joining me for the spring edition of “Ask the Expert.” This month, we delve into the ever-pertinent topic of practice structure and management. The endless debate regarding which operational and staffing models are optimal in perioperative medicine lately seems to tilt toward leveraged (i.e., 1:3 or 1:4) medical direction models, to say nothing of medical supervision. Our expert this month, Dr. Andrew Zimmerman, has a different perspective, however – being a member of a long-standing, successful solo MD practice in California. Dr. Zimmerman will share with us his experiences and insights, and perhaps challenge entrenched beliefs about how to best provide financially viable and clinically superior anesthetic care.

Andy, thank you for joining us. Can you give readers a capsule biography and describe your current position?

I was born and raised in St. Louis, Missouri, so I am a diehard Cards and Blues fan. I attended college and medical school at UMKC (Kansas City), so definitely a Chiefs fan (NFL champions again!). My residency was at Washington University in St. Louis, and I did a pediatric anesthesia fellowship at St. Louis Children's Hospital. I served four years in the U.S. Navy as an anesthesiologist in San Diego, California, and after completing that obligation, I did a pediatric cardiac anesthesia fellowship at Boston Children's. After that, I joined the Washington University faculty at St. Louis Children's Hospital, and eventually made my way out west to the University of Washington and Seattle Children's Hospital, before finally heading back to San Diego in 1999. I am now a pediatric cardiac anesthesiologist at Rady Children's Hospital in San Diego and a partner in Anesthesia Service Medical Group (ASMG). My hospital is a large tertiary pediatric center with complete services, from trauma to transplants. I am the president of the ASMG Board of Directors and the CEO of Anesthesia Management Professionals.

Please provide a description of how your group functions.

ASMG is a physician-controlled, physician-owned, physician-only single specialty group, in existence since 1946. Physicians typically become partners in about two years. We have a seven-member board of directors that is elected annually by the partners. Anesthesia Management Professionals is our management company (owned by ASMG), with ASMG being its only customer. We are 270 physicians serving 10 hospitals and over 20 outpatient centers. We have committees run by our physicians to direct the practice: scheduling, claims, insurance, chiefs, quality, contracts, investment, and others. We use a productivity model for compensation, and there is no variation related to seniority.

Can you elaborate a little on finances?

We have reasonable commercial contracts, but with our payor mix it's impossible to achieve fair market value from collections alone. We are working to increase hospital stipends to narrow the delta between payor mix and fair market value. Everyone in ASMG is paid basically the same for the same work – we pool our unit value and utilize a pure productivity model. There is an overhead assessment that covers the cost of our management company, billing, and the cost of the physicians who do important administrative work. There are no bonuses because everything that comes in goes out. Any extra from overhead is refunded at the end of the year.

How do you cover PACU emergencies and “run the floor” if everyone is in a room?

This varies by hospital. At my primary hospital, we have a couple of residents each day, and the “floor runner” is paired with a trainee and therefore able to handle emergencies. We are currently negotiating with several hospitals for stipends for this position so floor managers will not be in a room. This would facilitate handling PACU emergencies, stroke alerts, airway emergencies, and assistance in the ORs. One hospital is about to pay $275,000 a year for a floor runner position. This isn't enough to fully fund that position, but it's a good start. Other facilities rely upon “first person available,” and usually someone gets there fairly quickly. As a backup, a code can be called that brings an in-house intensivist.

What is the easiest part of an MD-only practice?

We directly take care of our patients – by far the easiest and best part of our practice. Additionally, we are all partners and have a direct voice in the management and future of the group. We don't work for a separate entity whose direction might not agree with what the physicians want. We are about to start a Master Plan Committee to ensure our group is heading in the right direction. This committee will be composed of all generations of physicians.

What is the hardest part?

As group president, the hardest part is navigating the difficult landscape of anesthesia today. Most of our physicians love our style of practice, but the challenges of staffing and fair compensation in an expensive city like San Diego are daunting. Clearly, the payor mix doesn't support what is fair market value for compensation. With a national shortage of providers, this issue has become more acute, and we are struggling, like most of the country. We are seeking greater stipend support from the hospital systems and are presenting revenue guarantee models, but it has been a challenge to achieve.

Has your group considered transitioning to a medically directed model? Why or why not?

Of course it comes up in conversations, but realistically no. A majority of our physicians joined ASMG specifically because it was NOT a medically directed model. We all want to be the physicians we were trained to be; we want to take direct care of our patients.

Have you received push-back from hospital systems regarding your group structure? How do you respond to assertions that your group's staffing model is too expensive?

We always get push-back, and we respond by showing them the facts. CRNAs are almost as expensive and insist on shift work. It would take a massive paradigm shift to incorporate this model in our practice. Also, we would lose a large percentage of our physicians who joined the group specifically to practice independently, and not be part of an anesthesia care team. Some hospitals are nurse-heavy in their C-suites, so the reflexive response is toward the care team model, thinking a CRNA is cheaper than an anesthesiologist. On an individual basis, this might be so, but it takes many more CRNAs to get the same work done under the limitations of shift work. As indicated above, transforming us to medical direction would require hiring multiple people who would be needed to get to a 3:1 or 4:1 ratio, and many of our physicians would leave.

How (and why) has your group remained truly independent and physician-owned?

We have remained truly independent because we are a physician-only and physician-controlled group and almost everyone becomes a partner. A few senior partners cannot “sell out” at the detriment of our younger partners. We explored partnering with private equity/large national groups years ago but ultimately saw this as undesirable. The goals of ownership and those of the practicing physicians don't always line up; corporate finances may take priority over quality of practice. Observing the landscape recently, we feel we made the right decision.

Solo-MD practices appear to be more prevalent in California. Why is this?

Not sure why – maybe based on tradition and relatively little activity in our state in terms of private equity and strategic health care partnerships.

What advice do you have for groups and physicians contemplating the solo practice model?

It is a challenge, but worth it if you want to have direct control on how you practice. You need to partner with a great management team and constantly work on proving your value. Developing strong, long-lasting relationships with the local medical community is vital. Our success is partly due to 78 years of doing so. It takes decades to develop great relationships and partnerships, but only a few hours to ruin them. I know our model may be a dying breed, but most of us feel it's still the best way to practice.

What do you like to do when not at work?

My wife and I enjoy hiking, biking, fly fishing, and spending time with our dog Ellie. I also love cooking, brewing beer, woodworking (luthier), and playing ice hockey.

Any parting words for our readers?

Anesthesia is a great profession, but don't lose sight of what that means – taking care of patients the way we were trained to do. I see this as one anesthesiologist taking care of one patient at a time.

Zachary Deutch, MD, FASA, Associate Professor of Anesthesiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida.

Zachary Deutch, MD, FASA, Associate Professor of Anesthesiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida.

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Andrew Zimmerman, MD, Staff Pediatric Cardiac Anesthesiologist, Rady Children's Hospital-San Diego, President, Anesthesia Service Medical Group, Inc., and CEO, Anesthesia Management Professionals, San Diego, California.

Andrew Zimmerman, MD, Staff Pediatric Cardiac Anesthesiologist, Rady Children's Hospital-San Diego, President, Anesthesia Service Medical Group, Inc., and CEO, Anesthesia Management Professionals, San Diego, California.

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