Mark Gallardo, MD, was inspired to open his own ASC by fellow surgeons who observed him operating in a local multispecialty ASC in El Paso. His El Paso Eye Surgeons is a “center of excellence” for minimally invasive glaucoma surgery (MIGS) procedures, demonstrating devices and procedures from Glaukos and other companies to surgeons from all over the world. “Doctors would come in who had their own ASCs, and would see the volume of surgery I had, and would whisper in my ear that I really needed to get my own ASC,” says Dr. Gallardo. “That started the little fire for thinking about it.” A belief that he could provide greater patient satisfaction in his own facility than he could in the ASC where he was operating, which is owned by a large hospital corporation, was another factor, he says.
Before making a decision, Dr. Gallardo visited several ophthalmic practices that had their own ASCs to learn more about how they operated. “I was specifically looking at practices that were similar in size to mine, to see whether it was possible for me to emulate what they had,” he says. “I didn’t know much about the business side of the ASC, nor did I understand the importance of all the different physical property requirements that are involved in getting a facility state certified as well as certified by CMS. There’s a lot that surgeons like me kind of take for granted when we walk into an ASC and operate—there’s a lot that goes on behind the scenes.”
As he completed his research, Dr. Gallardo developed a rough idea of the caseload he could expect to bring to a new ASC. Recognizing that he understood more about surgery than he did about business, he hired a consultant, the Medical Consulting Group of Springfield, Missouri, to develop the pro forma financial statement and business plan. “The Medical Consulting Group is highly respected,” says Dr. Gallardo. “They’re able to look at your caseload and determine whether you’ll be profitable or not profitable. When they said that we would cover overhead and be profitable with the caseload that we anticipated, that was the nudge I needed to move forward.”
With the pro forma financial statement in hand, Dr. Gallardo was able to arrange financing for the new ASC through a local bank, using his clinical practice as a guarantor for the loan. He planned a building that would house both the El Paso Eye Surgeons clinic and the new ASC, with administrative offices on the second floor.
The Medical Consulting Group also advised Dr. Gallardo during the building design and construction process, helped with the paperwork to get the building certified by the state and the Centers for Medicare and Medicaid Services (CMS), and will remain on board for a few months after the ASC opens to ensure that it is running properly.
The design and construction process did not go as smoothly as anticipated, Dr. Gallardo admits. “Early in the process, my consultant recommended an architectural firm that has extensive experience in building ASCs, but I decided to use a local firm for a design/build approach,” he says. “Despite affirmation that my firm had built ASCs in the past, we had a number of issues with both the design and construction that led to significant delays and cost escalations. The design process could have flowed better had my architectural team worked closer with my consulting team.”
An example of the sort of problems Dr. Gallardo ran into involved the layout of HVAC registers in the operating room. On reviewing the plans, his consultant said that the layout would not pass inspection because regulating agencies want a blanket of “clean” air to flow over the patient, then out through returns on the lower wall. The architectural team pushed back, indicating that they had been assured by their engineers that the plan provided all the proper flow and return of air as required by the state. The plans were sent to the state for review; after several months, the state required changes to the HVAC system, just as the consultant had warned. “Aside from the incorrect HVAC design, the med-gas system was not in the original design or budget, underground plumbing for steam sterilizers was the wrong material, and we had to change out most of the electrical conduit and water supply plumbing after failing our 80% state inspection,” Dr. Gallardo says. Consequently, his ASC project is eight months over the original estimated completion date and substantially over budget.
“My experience was very different from a colleague in the Dallas-Fort Worth area,” Dr. Gallardo notes. “He had an architectural team that listened to and implemented the changes recommended by his consultant, which resulted in a seamless construction project. We broke ground at the same time, but he has been using his ASC for over a year—I am just getting my final state inspection later this month. So, I highly recommend that one interviews their architect to ensure they and their engineering teams have extensive experience in designing ASCs and ask for a list of all previous projects with respective contact information. Hindsight being 20/20, I should have used the firm my consultant had recommended for the ASC design and maintained my current firm for the clinic and project management.”
Now that the facility has been built, Dr. Gallardo is completing the process of getting the ASC licensed, certified, and accredited. That work began during construction, as the state inspected all the mechanical systems (electrical, plumbing, heating/cooling, and ventilation) before they were closed in with drywall. With help from his consultant, Dr. Gallardo has begun the process for getting certified by CMS and accredited by the Joint Commission, and has applied for a pharmacy license.
To help complete the paperwork and ensure compliance with regulators, he hired an administrator for the ASC. “There are a number of required administrative steps prior to and during the accreditation process at the state and federal level that were well beyond my knowledge depth,” he says. “The consulting firm was invaluable in helping us pass each milestone through diligent work, along with my ASC administrator. I was fortunate to have found a registered nurse with previous ASC leadership experience to lead my team. This has virtually eliminated the burdens associated with ASC development.”
Dr. Gallardo doesn’t expect to hire other full-time staff for the ASC until the facility actually opens. “It’s going to take time to get on all the insurance panels,” he says. “As soon as we’re certified by the state, we can start doing cash-pay patients and study patients, but the ASC won’t be open every day. We might only work in the ASC for a half-day a week until we start getting on other insurance plans. What we decided to do is open the ASC on Fridays because the other ASCs where I work typically don’t do eye cases on Fridays. That way we can use those staff as needed, so that we don’t have to hire any full-time nurses or technicians until we’re ready.
— James D. Gallagher, managing editor
