Good morning, thank you for having me here this morning. Our talk is Building a Thriving Bronchoscopy and Pleural Service. I have nothing to disclose. We're going to discuss the key components of building a successful bronchoscopy and pleural service and strategies for program expansion. So the first question here is what are we building? Are we starting a new service or are we expanding an established advanced program? The way we're going to do these is going to look a little bit different. I initially started the Navy's West Coast Pulmonary Procedure Service, retired from the Navy, and then Scripps Clinic Medical Group asked me to join their group to start up their Pulmonary Procedure Service. So I figured we'd just walk through how we started up that service for the talk. Scripps Health has five hospitals scattered throughout San Diego. Where we practice is Scripps Green, which is a cancer and transplant center, and Scripps Memorial, which is the cardiovascular trauma center. This is 100% RVU-based practice. We do have GME with an IM residency program and some subspecialties. So when I was asked to do this, the first question I said is, you know, really should I get, should I really get into this project? So in order to kind of put my thoughts together, I formed a mission statement. You know, what service are you going to provide? That's basically, what is your procedural skill set? You know, we're going to do minimally invasive, therapeutic, and diagnostic pulmonary and pleural procedures, okay? What are the benefits of this service? Standard question that most people, you know, response to that question is, you know, it's patient benefit and making a difference. When you think about it, it's a whole patient population that has no access to minimally invasive pulmonary procedures. You can come into that population and make a huge impact. Next most common answer to that question is career satisfaction. Well, I like doing procedures. I want to be the go-to person. Maybe it's, I like building services. You can't talk about what you want to do without some sort of financial discussion. When you look at the 2019 AABIP survey, you can see, you know, the mixed academic, private practice, and the private practice guys didn't do too bad, but you look at how many RVUs that they generated, and that was about 8,000 a year RVUs, which is a lot of work. What are the risks? Financially, if this doesn't go well, you might not be able to feed your family. It is time-consuming. Being a one-on-one service, you're on, you know, you're pretty much the go-to person 24-7. So, being the go-to person is a benefit, but also maybe a liability in this scenario. And then again, if this doesn't go well, your biggest critic is going to be yourself. So looking at all this, looking at the benefits and risks, I figured, yes, this is something. I think the benefits outweigh the risk, and this is something I'm interested in doing. So let's look a little more into this. First thing I did was a gap analysis. Is there a need? You know, what sort of need is there? What services are currently being offered? Right now, before I started, there was no advanced bronchoscopy procedures. There was limited minimally invasive pleural disease management. Who was performing these procedures? All the minimally invasive lung biopsies and pleural drainage procedures were performed by IR. The next question is, can you provide these services better? The answer is, of course. You know, we do this expeditiously, efficiently, safer, better patient satisfaction, and at a lower cost. That is the definition of value-based care, which is really the buzzword nowadays. After we did our gap analysis, looked at the market. So this healthcare system was entering a partnership with a major oncology center at the time, and they wanted a comprehensive lung program. So that was a perfect opportunity. And there was only one IP program in the county at the time. So looking at a favorable gap analysis, looking at a favorable market analysis, I said, yes, this is definitely something, a project I want to do. So now that I'm committed to it, I said, well, let's look at what our support is. You know, what's the referral base? We are part of a large medical group with a pyramid structure, so we have a lot of primary care physicians that funnel into this subspecialist, and it's all internal referrals. So I think we are pretty good as far as our patient population. What's the existing infrastructure? You know, where am I going to see patients? You need clinic space to see patients, but you also need your procedural space. Quite a few options here. We have an outpatient ambulatory surgical center. You can't do inpatients on that, only outpatients. And usually ASCs have some sort of ASA severity cutoff for most of them. So they have to be fairly stable patients. Hospital-based outpatient department, you can do inpatient, outpatient in that, and there's no ASA cutoffs typically on those. And then the OR, same thing, you can do inpatient, outpatient, but it's probably the most expensive, it's definitely the most expensive of the three. What are we going to do for pre-op and recovery areas? You want to have those in fairly close proximity to wherever your procedure room is, just for efficiency of patient flow. So we opted to go with a hospital-based outpatient department endoscopy space, which we share with GI. When we looked at that AABIP survey, about 44 percent of IP docs were sharing space with GI. And it's actually a good fit because you have a lot more resources from a personnel standpoint, as long as you have dedicated block time in there, and plenty of it. Equipment, when you look at equipment, you know, the best strategy would be have everything up front. That may not be possible, so then ask for whatever your high-volume equipment is. So what is going to be your high-volume procedures? Definitely plural procedures. You need an ultrasound. If you're at multiple institutions, you need multiple ultrasounds. Then EBIS, and then some way to do some peripheral lung biopsies, either navigation or robotic assisted. Personnel, you're going to need schedulers, nurses, techs. How are those all accounted for within the organization? And then probably the new personnel that may not have any established relationships is going to be anesthesia and pathology. So you're probably going to have to establish those relationships as well, early on. Going to need some advocates, administrative, you know, you're going to have to have buy-in from the system. There's going to be key stakeholders, administrators, physician leadership, care lines. If you're being hired as the new guy to start up a procedure service, typically that's already been vetted, and you already have administrative support. If you're looking, but you still need to make those connections, know those people yourself, because you're still going to grow your service over time. And then professionally, a lot of times we don't think about this because you're being hired by a division, and you think that that division's all on board with it. Your procedure are also crossing over into different services, CT surgery, ENT, IR, and they all have established practice patterns. This is going to be a huge paradigm shift for them. So what's going to change their practice patterns is outcomes. They're going to want to see good results, good patient care, and that's what's going to change how they refer and how they do business. Looking at a formal business plan, everybody talks about this. This is a nice article in Chess in 2018 by the Chicago Chess Clinic, and they talk about key components of a business plan. In order to formulate a business plan, you need your corporate finance office involved, because they're going to pull numbers. They're the only ones that can pull those numbers. And what your CFO is going to want to see at the end of the day is that this service contains costs while offering high-quality health care. Again, the buzzword for the day is value-added care. And it may be tough to show, because pulmonary procedures don't have a huge contribution margin on it. So we don't make a ton of money like some of the surgical specialties do, and it's very dependent on your payer mix. So it may vary from one hospital to another. It may vary year to year, depending on the contracts that your health care group has plans with. So it's something we need to know, something to understand, but also it's a document that needs a lot of input on your side if a formal business plan is going to be made. So now that we're up and running, how are we going to grow and sustain the program? Marketing. So who are you going to market to? Who is the customer in this scenario? Really you're referring to physicians are the customers. Those are the folks that are going to be sending you to the patients. So if you have an internal structure, then you're going to want to market internally with grand rounds, tumor boards, lectures to various services. If a lot of referrals are coming in externally, then you're going to have to send out brochures to the community, do some community lectures to get your name out there and let people know that you have this service to offer. As far as sustaining and growing the program, you have to take care of the customer. Again, the customer is the referring physician. Good communication. They send you a patient. You make a diagnosis. You have to let them know right away, and then let them know that you've already taken care of all the other steps in their care plan and you're handing them off to the next level of care. And that care has to be expeditious, efficient, safe, and compassionate. That's your product, really. So patient, high quality patient care is your product. The customer is your referring physician. And then you have to say yes. As you're building a service, you can't cherry pick. Somebody asks you to see somebody, yes, I'll see them. And the more yeses you say, the more patients that come in. Don't want to grow too fast, because that's the thing that kills businesses the most, right? Growing too fast, your product suffers. And what's your product? High quality patient care. So if you're too busy, that patient care is going to be noticeable. Stay flexible. Everything changes. That's the only constant in life, is everything's going to change. The administrative may change, the administrators may change, their whole how they do business may change. Again, your payer mix may change. So just stay flexible. If you are, it's easier to deal with those changes. And then you have to have a three to five year plan. Where are you today, and where do you want to be three years from now? If you don't, you're going to get to that point, and you're going to need something, and you're way behind the power curve. It's going to take you a couple years to catch up to that. So always be thinking about where you want to be three years from now. Philanthropy is a great resource, and when you need capital, they're good people to turn to. So make those connections with philanthropy early on. And then be persistent. There's going to be lots of roadblocks, lots of bad days. You know, go back and remember your mission statement, right? You're putting your procedures to use for expeditious, efficient, safe, and compassionate patient care. When you keep that in mind, it's going to help you get through those roadblocks and keep driving forward, okay? A couple of nice resources here, again, from the Chicago CHESS Clinic, a couple of nice articles there. And then AABIP has a nice graduating fellow toolkit that has a lot of information in it. Thank you. Thank you. Okay. Excellent talk, Steve. So our next speaker is Christine Argento. She is an associate professor at Johns Hopkins and did her interventional pulmonary training at Duke. And she is going to talk about how to save money in the Bronx week or spend less. Good morning. Cost containment. Okay. So I don't have any disclosures that are relevant to this talk. The only one that I will say is that I don't contain costs all that well. So here we go. So thinking about this talk, you know, I sort of had to go back and just think, all right, let me get to the baseline. What is cost containment overall? And the best definition I could find was that it's a process of judiciously reducing costs in a business or limiting them to a constant level. But when performed properly, cost containment can ensure or increase profitability without undue difficulty created for those performing the job. And I think that second part is really important to keep in mind as we're thinking about cost containment strategies for our procedural services. So why is this important? At least in the U.S., we definitely spend a lot of healthcare dollars, much more than most other countries in the world. So we outpace others by a significant degree, which I think is great. We say, well, we have the best healthcare system in the world, right? We do a lot of value, a lot of great care, and we take really great care of our patients. But when you break it down, not sure that we're actually doing the best, right? If you look at the report card, we're actually number 11 on here. And we do well in certain things, but overall, we're actually outpaced by most of the European countries, et cetera. And so we do things like patient-centered care, which I think is really great, but we struggle with preventive measures, with screenings, with access to care, and being cost-effective and cost-efficient. And so overall, if you sort of put those things together, we sort of fall in the high-cost and lower-value or low-performance status on a curve. And so we need to think about this and do better, right? And to even just put a little bit more of a pin on it, JAMA published back in 2019 that if you look at annual cost of waste in our healthcare system, it accounts for about 25% of US healthcare spending, which is an enormous amount. So we have to do better. And when I'm looking at this stuff, I'm thinking to myself, I'm not sure that I can make a dent in this kind of problem, right? How do I do that on a personal or individual level? There was this really interesting article that was published in the Harvard Business Review. It was a while ago now, back in 2014. But it's talking about how not to cut healthcare costs. And so it's trying to, again, put things into perspective about increasing value, delivering high-quality care, and then mitigating the costs so that you're trying to get that nice balance of being cost-effective while delivering high-quality care and giving high performance. And what they said not to do, so don't cut back on your support staff. And that's one of the things that comes across first, right? The first thing on the docket is like, okay, get rid of the schedulers, right? They're the lowest on the totem pole. And so they can be gotten rid of, but then what happens? Then it just ends up falling on either your nurse's plate, your APP's plate, or the physician's plate. And then now, instead of a scheduler doing the job, now you have somebody who's being paid more taking their time to get that job done. And if they don't take the time to get that job done, then your access to care severely drops and you end up with delays in care and other issues. So either way, your value, your quality, and ultimately your cost of care will increase rather than decrease. So cutting support staff, probably not the best way to cost-contain. Other things, so under-investing in space and equipment. Our equipment, as we said, is pretty expensive. But we have to think about it in terms of if we don't have that equipment, what's going to happen? I work with Dr. Kopen Wong, who developed the Wong needle, and you can do traditional tBNA with that versus EBIS that most of us use. So could we do lymph node sampling with traditional tBNA? Absolutely. Is it cheaper? Absolutely. Is the case longer? Absolutely, if you use traditional tBNA. Are you going to have a lot more repeat procedures because you don't get a definitive diagnosis? Absolutely. And so then are you causing delays in care and ultimately increasing costs and decreasing effectiveness? Absolutely. The same thing goes with your procedural areas, right? So things to think about. If you have two rooms that you can toggle between, then you're going to most efficiently use your time and space rather than you finishing the case, watching your patient wake up, having them leave the room, turning over the room, bringing in your next patient, and getting them sedated, right? That's a lot of time where you're sitting there. The problem is that those things don't show up on a spreadsheet that your administrators can look at. But these are things to keep in mind. And then other things, so maximizing patient throughput. So instead of getting all these patients in and having only 10 minutes to see them, as Dr. Escobar was talking about earlier, we really want to focus on the value of care and the good quality care that we're providing. So instead of seeing 100 patients at 10 minutes, maybe we see 60 patients at 20 minutes or whatnot. And then really importantly, I think, that this article mentions is failing to benchmark and standardize. I think that's something that we don't do enough, is sort of looking at your own practice, deciding what you do, and just taking a good global overall viewpoint and coming up with algorithms and flows that are going to help make your process easier, more efficient, and ultimately cost effective. So a few truths about IP. So value is a difficult thing to quantify. Again, administration really values things that can be shown on a spreadsheet, and that's not sort of my salary doesn't show up well on a spreadsheet. IP procedures are not well reimbursed, unfortunately. And our technology is pretty expensive. And more and more, we're being asked to combine things. So you don't just need one technology, you need several different things together. And they're all expensive. And that makes procedure times longer, because we're doing more sophisticated things. And then, you know, what we do, it's not well published how effective we are as far as cost and cost containment. So let's take an example of EBIS. We know there are some positive things, right? It attracts new referrals and new revenue. It improves the staging of lung cancer. So it makes things more efficient and effective for our patients. And then it brings a lot of downstream revenue with our radiology colleagues, surgical and oncology colleagues. And so all of these things are really important, right? And you have to balance them and weigh them against the cost of these procedures. So you want to make sure you're staging them appropriately, because if you don't stage them appropriately, the cost is going to significantly raise, the access will decrease, et cetera. And then you think about your capital equipment that you have to purchase. So anywhere from $90,000 to $130,000 of capital investment, but your downstream revenue may increase by $2.4 million, at least according to this article. So you want to sort of just keep these things in mind and this balance at the forefront of your thoughts. So again, delay in diagnosis is going to be associated with a lot of increase in cost. And so we really want to do the right procedure at the right time for the right patient and make sure that everything that we're doing is correct. And so we can start doing that, right? That's what we sort of already do. But then in looking at your procedural service, right? I had a colleague who was just talking about how, like me, he works in a system that has multiple hospitals within the same system. And they just took a survey of all the different hospitals and their EBIS practices and which needles they were using. And found out that every place was using a different needle and it was all based on just physician preference or maybe it was just on what they were used to or what they had available at one point that they just kept ordering. But when you go back and sort of look at the data, which we'll go through in a second, you can see that maybe you should be data-driven in your decision. And although this seems like a little decision, they were able to save about $60,000 a year just in a change in EBIS needles, just by saying, we're gonna use this one needle for the system. Everybody agrees that this one works, it's effective, we can deal with this one. And then we have the other ones available for special circumstances. And it's based on this data, right? If you look at 22 versus 21 gauge needles, no difference in performance. 22 or 21 versus 25 gauge needles, no difference. You look at 22 or 22, here's just more of a summary of 21 or 22 versus 25 gauge needles. Again, no difference. And then even the 19 gauge needle versus a 22 gauge needle, no difference in performance, right? So why are we using these other needles? And it can be, there's individual things, right? Your 19 gauge needle maybe is more flexible. So maybe in certain circumstances, you really need that flexibility to get into the node that you're interested in, but you don't need it for every case, right? So looking at the needles that are on the market, if you have your original VisiShot needles, they cost somewhere, depending on your healthcare system and how much they've purchased them for, it's about 80 bucks. Versus the VisiShot 2, the Boston Scientific and the Cooke needles, those cost north of $200. And then if you're using multiple needles in a procedure, can your procedural suite keep up? Like, is that even worthwhile? Is it worth two needles? Or do you can use two needles that were original in order to sort of contain these costs? But these are, I think, little individual changes that you can make in your own practice that will have a significant impact. And so I think these are the types of things that we need to think about with cost containment. And we can do this for other procedures as well, right? So malignant pleural effusion. This was just a nice study, sort of doing a cost-effective analysis with some decision trees and modeling just to determine what is the best drainage strategy and do we pleurodies these folks? And basically it comes down to if they're gonna live longer than about four months, then you should probably pleurodies them and that will be cost-effective. If they're not gonna live up to four months, then you should drain them according to their symptoms. Daily drainage was not really cost-effective at all, unfortunately, but that's the way it goes. Same with PERC trachs. So this study was done out of Hopkins and just showed that sort of putting a procedural service together where you have an APP running the service that's gonna do the preoperative assessment, go and see the patient, get them scheduled, your operative team comes in. Everybody has agreed to do the similar procedure, whether it's an ENT surgeon, a thoracic surgeon, or an IP person, we do the procedure together, similar fashion, and then the APP follows closely after the trach is performed. You're going to improve efficiency, improve access, decrease complications, and overall that leads to improvement in cost. And so it's a cost-effective thing. So all these things you can actually accomplish in your own practice. And so with that, I'm gonna end and just leave you with a few take-home points. Just think about the cost of our procedures. Really try to analyze your own data. It's really important. And then cost containment doesn't necessarily mean that you need to give anything up. And just keep in mind, there's always someone who will do it cheaper. All right, thanks so much. Thank you. Great talk, esteemed. So our next speaker. Our next speaker is Dr. Scott O, who's a professor of medicine at UCLA and did his interventional pulmonary training at the combined Harvard program and might be the most productive human being I've ever met. I often think he has a twin that he doesn't tell us about, and that's the only way you can get as much done as he does. So, Scott. Thanks, Russ and Chris, for putting together such a great session and the rest of the speakers as well. We're just commenting on how we're enjoying the talks up here as well and find all that we're hearing so relevant. And I'm gonna try to talk about a couple of things and a couple of perspectives here. I'm gonna talk about billing and coding. And I know there's a lot of talks out there about, all right, if you're gonna do this procedure, use these codes and this combination and this will maximize your thing. And it's like a jumble of numbers, right? And so I'm gonna do that a little bit, but I'm gonna try to put it into the context of the bigger picture. So let's go and do this. I'm an associate medical officer with Intuitive, really not relevant to this. I'm gonna talk about things that hopefully will build a basic foundation of coding fundamentals. You're not gonna sit here and become a coding expert, nor do you wanna be, because it's kind of boring. Understanding how you're coding and what you put down in your notes impacts billing, which your billers are really interested in your institution, of course. Try to get a perspective on how much value, financial value, is in the procedures you do compared to non-procedurally based activities you might be involved in, and put that into a relative context. And also, of course, the importance of documentation. So I'm gonna start with this. Let's say you spend two hours consenting, performing and providing post-procedural care on a patient that you're gonna do a media stenoscopy replacing staging bronchoscopy with linear EBUS, right? Something we do all the time. And you end up biopsying five null stations, right? It's a long case. What is your estimated physician reimpayment on this Medicare, based on the Medicare physician fee schedule, which is kind of the standard for insurance companies, right? That's kind of the baseline. So this is not an audience response question, so I just want you to kind of think about those numbers and see which one you think you'll get paid for doing that and spending those two hours. Does that sound about right to you guys, about two hours for a case like that? And then one other question I wanted to ask. This is the, I know, very American-based kind of talks on the US. Are there any non-US physicians or people who work outside the US in the audience? All right, where are you from? New Zealand. New Zealand, okay. I have no idea what the healthcare reimbursement system is like in New Zealand, but at least you'll get an idea of how crazy we Americans are, at least. All right, so it's $230, right? That is the fee schedule. Now you just spent two hours, and you're getting, and on the procedure, right, not the pre-post, the whole kit and caboodle is $230. Now, this is the fee schedule that I think are relevant to a lot of us, and this is available online. It's public knowledge. It's the 2023 Medicare fee physician schedule for all the things we do. Now, what do you think that last column, the last two columns that are all in red reflect? A decrease in reimbursement for the work we do compared to 2022. Okay, and I'm putting this, again, I'm trying to put this into context. Who makes these decisions? How do these decisions get made? And hopefully I could provide a little insight on the bigger picture about this. So the other thing I want to put into context here is there is the facility fees, which everyone kind of talks about and knows, and the physician fees. So which one of these do you think are the physician fees, and which one of these are the facility fees? Let's put that into perspective, right? I mean, we all know, I always hear, we always hear about, oh, the facility fees is where the money is. Let's put some dollars and cents on it. That's what it is, right? Now, this is the reimbursement schedule for HOPs, which is the facility fee. What's the big difference you see here? Wow, think about that. Who in the world made those decisions and decided the ambulatory surgery centers and the hospitals are gonna make more where the physicians make less? How many of you guys knew this? Anybody know about the final rule and how these things get made and how much we advocate for ourselves? I think we as Pulmonary Critical Care Docs, we attract a certain phenotype. And that phenotype is, I don't want to deal with that nonsense. Let me come in, do my work, take care of my patients. I'll bulldoze my way through any barrier for my patients to provide the best care I can. The business slide, let someone else care of. And that's our society as a whole. And we have to be a little bit more active, I think, in that area. Honestly, I don't want to do it. And I think most of the people don't want to do it, but it needs to be done, right? I'm trying to put things into context again. So now the US spent in 2021, $4,255 billion, right? Now, unless you're Bezos or maybe Elon Musk, do you understand what that means? Like, I have no idea. Like, how much money is that actually, right? Like, what does that mean? So let me try to do some math and break it down for you. 4,255 billion, now let's try to put it into numbers that we may be able to wrap our minds around. That's 116 million per, what do you think that's per? Day. Okay. How many years you think it'll take you to spend that money if you spend $116 million per day for the next 100 years? That's how much money the US is spending in healthcare for CMS. That's just mind-boggling, right? So that's what that money means, right? Like, when people throw up these numbers, I don't know what $4,000 billion is. Like, what does that mean, right? But when someone tells me I can spend $116 million a day for the next 100 years, I'm like, holy crap, right? How much of this comes to us? You hear in the news, physicians are the problems, right? All the money's going to these rich doctors. If you look at the breakdown, 14.9% go to physician-first services. We are a small piece of the pie, okay? The slides are a little out of order, but this is a nice paper put out back in 2015. I don't think this trend has changed. The green is the increase in physicians. The orange is the increase in managers. Wow, right? I mean, this is just absurd. Now, I'm going to break it down and bring it back to the one level down, right? Everyone knows this movie, Everything, Everywhere, All at Once. Like, how many different bronchoscopy procedures do you squeeze into one procedure? We're doing nodules and lymph nodes and dilating and tumor debulking and putting in stents. We're doing like a gazillion broncs in one, right? And we all suffer from the multiple endoscopy rule, right? So what does that mean? If you do like five different bronchoscopies in one bronchoscopy, you get value and charge, if you bill right and code right, for the most expensive procedure. So if the most expensive thing you did, the thing that is the highest complexity, and you put that as number one, let's say it's tumor debulking. That's what you get paid for. So how much do you get for all the other stuff you did? The amount you get for all the other stuff you did is what the reimbursement is for that next procedure, minus the base code for that family. And for bronchoscopy, it's 31622, which is $127 of reimbursement. So if you did something that's $130, it's $130 minus the base. So let's break it down into something that kind of makes sense. So now, I see some young faces in the room, and if you don't know what this is, this is money. It's dollars, papers, pennies, coins, right? And we used to use something called cash registers to use this and figure out, right? This may be more familiar to you with Apple Pay, and maybe those of you a little more adventurous, maybe use Bitcoin, I don't know. That's all voodoo to me, smoke and mirrors, but let's talk about dollars and cents here. So you do a bronchoscopy with a transbronchial biopsy and a BAL, pretty standard basic stuff, right? Your base code is 12728. The transbronchial biopsy is $169, the BAL is $129. So if you go by the multiple endoscopy rule, you don't get 169 plus 129. What you get is the transbronchial biopsy is the most expensive, so you get that, and then you get the BAL minus the base code, which is $2, $1.99, woohoo, right? But it's really important what your biller puts first, right, you don't want the BAL first, you want to squeeze everything you can get, so make sure your biller, if your biller doesn't do it right and puts the wrong code first, you get paid less, right? So that's how billing impacts, and your coding, and what you put into your note impacts your billing, and how your billers list the procedures impacts what you ultimately get back. So multiple endoscopy rules, I think, is a thing that hurts us the most in what we do, because we can do a lot of procedures in one, but we don't get credit for a lot of it. Some of the things that you remember here is that if you do an additional transbronchial biopsy, it's a different lobe, and it reimburses you $47, right? Different lobe is a different lobe, it's not the lingula and the upper lobe, left upper proper, if you will, are not different lobes according to Medicare. So if you biopsy the left upper lobe and the lingula, it's the same lobe. But if you do the left upper lobe and the left lower lobe, that's two different lobes, right? And then moderate sedation, they got rid of the additional 15 minutes. So you get credit only for your first, you just get credit, $12, if you do your own moderate sedation. Is that worth it to you? No, the anesthesiologists do it, right? But that's what you get, that's what you get for adding on moderate sedation by the same provider. Now, who knows what the RUC is? I'm gonna put this, now take a step back and put billing into the bigger question here. The RUC is the RVS Update Committee. So what the heck is the RVS Update Committee? It's the Relative Value Scale Update Committee. The full name is the AMA Relative Value Scale Update Committee. So then the full, full name is the American Medical Association Specialty Society Relative Value Scale Update Committee. So that's what everyone calls the RUC. Has anybody heard of that? Yeah, so let's talk about what the RUC does. What is the RUC? It's an independent group of experts, right? Mostly physicians, they're volunteer, and they're exercising their first amendment right to petition the federal government. And what does the RUC do? They use their independent judgment, they're not advocates for their own specialty, 32 members, 29 voting, and 18 of the 29 members are from specialties whose Medicare has allowed charges and who derives the provision of evaluation and management services, your codes, right? So the RUC looks at the codes. Here's the composition. The asterisks are the people that don't vote and the other specialties are in there of the members that make up the RUC. Again, volunteer. So how are RVUs, values, and codes actually created? Number one, CMS has the ultimate say. They can accept or reject any proposal. The CMS, the RUC, or the CPT panel can request a review of a particular code or create a new one. And they can also, the specialty societies for us, ATS, ACCP, et cetera, can review existing, and review current existing and new codes. Then they go out for comments and physician surveys. I have two minutes. Wow, I'm gonna go faster. All right. All right, so here we go. I'm gonna go break it down really quick. So the CMS, RUC, and CPT boards come down and it goes to the RUC and they review the things and they figure out what they wanna do. The code doesn't require new values. We're gonna keep it the same. They're like, I have no comment on this. You can comment on other people's proposals or what I wanna focus on here is they send out a survey to physicians. So when they send out a survey to physicians and then the surveys come back and decide what to do. What's in the survey? The survey has a code vignette and description of what the kind of code and new procedure is. Then they introduce and kind of provide some, you put your contact info and then you have a reference procedure. So let's say you have a new bronchoscopic procedure and they say, all right, your base procedure is your EBUS. They want you to compare it. They want you to compare it. Is it easier, it's harder or whatever, whatever, whatever. So if they send, all right, we have a new procedure called EBUS. We send it out to physicians. Then the physicians fill out the survey. And if you're like, it's an easy procedure, it's much better than what it was, Then the RUC says, oh, it's an easy procedure. You get 20 cents for doing it. If you say it's hard, it takes more time, more skill, more effort, it's complicated. The value that gets attached to it goes up. So if you get asked to do these surveys, you may be biased on what you want to put down. So put this into the perspective here on other things you do. 10 hours or if you see 10 patients, the first hour of critical care, which is actually 30 minutes to 74 minutes, right? So if you have 31 minutes of critical care, it's $200 plus $2,000 for seeing 10 patients for 31 minutes a day. In clinic, if you see five news and you do the bill and kill that's the equivalent to 45, kind of moderate high complexity and see 10 followups that are about 20 minutes, the total is 1800. If you do a linear EBUS in a day and you have a pretty efficient service and you can do five and you buy actually three targets and one or two targets in the other, you make $1,000. So that's to put perspective of what you do in the Bronx suite compared to the ICU and in clinic. So the guiding principles. You got to get credit for your work. Review your billing codes with your billers. It's I think useful to see what your top 20 codes are and see how they interact and what you do. And so talk with your billing people. Keep track. I used to do so much work and not get credit for it because I just didn't document or bother to bill for it because it's a nuisance. I took care of it. I want to move on to my next thing. I don't want to document and bill. Whatever, I'll just lose the money, right? Document and bill and get credit for the work that you do. Detailed documentation allows you to do better billing and coding. Also, I think seeing the patient before and after really adds value to patient care. It's good patient care. It's actually good billing practice, I think. And it also adds to your value of seeing the patient bill for the clinic visit before and after or the pre and post visit. I think it's really important because the procedure itself doesn't pay that much, right? So it really adds onto your practice. And depending on the infrastructure, you may want to consider doing some procedures in clinic versus the procedure suite. If your practice owns a clinic and you're in private practice, do the thoracentesis in clinic so you get the facility fee and the professional fee. Don't do it in the hospital and give the hospital the money. Keep it in your practice, right? So depending on your practice and your infrastructure, there may be certain things you should be doing in your practice and your clinic instead of the procedure suite. And data's important, right? You keep track of what you do so you can provide value. You can talk to your administrators down the line and help build the practice in the ways that everyone up here talked about. So I'll stop there. Thank you. So our next speaker is Dr. Otis Rickman, who is a professor of medicine at Vanderbilt and also one of my favorite people in the world, who I always enjoy seeing. So I'm going to put Russ on the spot here. So is it Roberto or Otis? No, I said Roberto is one of my mentors. Okay. Well, if I'm in the same category as Roberto, it's awesome. So, but thank you, Scott, for that segue. So his ending slide was the data, right? And so, welcome to the dry, no mayonnaise sandwich part of the lecture. And so, what we're gonna talk about is actually, so we've talked a lot about sort of how to build a program, that sort of thing. This is kind of how you're gonna keep your program. And so, I'm not gonna talk about financial, I'm not gonna talk about money, that sort of thing. We're gonna talk about really more quality improvement, quality insurance, that sort of thing. And of course, that can be part of the quality improvement and quality insurance is your dollars and what you bring to the institution. But we're not going to focus on that. So those are my disclosures and nothing really pertinent to this lecture. And we're keeping the learning objective small. So we got the limited amount of time. And so, really, I want you to leave here with three things, is I want you to recognize the importance of quality and safety. And I see a few of my fellows in the audience and every one of them have been harped on by me about filling out the red cap at the end of the case. It's just absolutely imperative that we do that. We'll talk about why. I want you to leave here with a few guidelines and that you can implement into your practice. And it's important to use guidelines. So you may be at some of these talks and you're gonna hear a case series, you're gonna hear stuff that, man, that sounds really important and I should probably do that. Maybe, but if you're looking like the quality of your program over a length of time, go for the guidelines, which is what you're gonna be held up to and measured against. And then hopefully you'll be able to, with some of these resources, develop a QI program that's gonna evaluate your patient outcomes. So, I like this definition of quality care. This actually came out of one of the EBUS guidelines. And it says the degree to which health services for individuals and populations increase the likelihood of a desired health outcome and that's consistent with current professional knowledge. And so if we sort of break that down, we can say, okay, well what are these quality indicators? So those quality indicators, that if you're gonna track them, they should be practical, meaning they're gonna have some sort of relevant use to your program. They should be measurable. They should be comparable to something else and improvable. So you don't want to track something that you have no control over. It's like, okay, well I'm gonna track the number of people that have coronary artery disease that come into my bronchoscopy suite. Okay, great. But you really have no control over that coronary artery disease, so it's probably not worth your time to measure that. Okay, I think that was, yep. So, why is this important? It's basically essential to any service because like Dr. Escobar said, the goal of your service is to provide effective, expeditious care. And so you want your customer, the referring physician or your patient, to know that whenever they entrust themselves to you or they entrust their patient to you, that you're going to do a good job for everyone. And we can all fool ourselves and think that we're doing a good job if we never look, right? So it's just like golf. We never remember our bad shot, right? We always remember that one, that, you know, the hole in one that we got. It's like, even in the game, you shot 104 that day, but you had that one birdie, you know, that you hit in four or whatever. It's like, okay, we remember that one. You don't remember everything else that happened. But if you were to go back and look at your scorecard over the years, you'd say, okay, well, you know, I'm really not that good. So that's me personally, so. And so how can you do that? Well, you can do that by following guidelines, implementing a program, and monitoring outcomes. So what guidelines are out there? There are a few. And it's very interesting is that a lot of these guidelines actually are not even from our societies. Some of them are, you know. So there are bronchoscopy guidelines out there, probably the best set of basic bronchoscopy guidelines are from the British Thoracic Society. You know, kind of looking at sort of nuts and bolts. Not necessarily an interventional program, but there are E-Bus guidelines that are published by CHEST. Cryobiopsy guidelines also published by CHEST. There are lung cancer guidelines by multiple organizations. So NCCN, STS, CHEST has some guidelines that are getting a little long in the tooth. And that need to be updated. And radiology guidelines from the Fleischner Society, like if you're looking at lung nodules, that sort of thing. Pleural guidelines, also probably the best set is from BTS. But there's also really great guidelines out there for indwelling pleural catheters that Russ put out there. So there's lots of guidelines that you can use. And the final slide will have basically sort of a reference bibliography for all of these. So how do you implement these? Well, you develop a quality assurance program. So what does that mean? So that means that you audit your procedures. And so the only way that you can audit your procedures is if you track your procedures. And then you need to have a system where you go back and you look at your outcomes at, you know, what's your mortality, what's your diagnostic yield. So a system in place that looks at those outcomes. And then are you complying with those guidelines? And so to comply with the guidelines, you need to set up a set of metrics that you're trying to hit. And we'll talk about what those are. And then you use a performance improvement program to identify those. And that performance improvement program, so now you said, okay, we've tracked this and we're kind of off a little bit. What can we do to get better, okay? And so those can be hard conversations with your partners or if they're not your partners and you're part of a hospital system, you know, it can get, there's a way to do it. And we're not gonna talk about that. But it can get pretty contentious. And then this last one you'll see that participate, so all the other ones are in bold. So we currently, you know, I think just now within the past year, we now have a national registry within the Interventional Pulmonary Society or Bronchoscopy. But before that, we really didn't have something that was built for us. We all remember the Acquire, the much maligned Acquire. And, but this was a good thing. I mean, so this was a quality improvement database and they used some of the data out of that to publish some papers. And it, I mean, still quoted to this day, you know, I mean, from, you know, a decade ago. That sort of challenged, you know, kind of what we think we're able to do on LinkedIn where everybody's got 102% diagnostic yield versus you come back and look at it. And it's like, well, you know, maybe not. And so, and so this was an incredibly important effort. And it sort of died from lack of support over the years. And, you know, somebody probably knows the inside story on that. I don't know what it is. But it was a good thing. The other thing that's out there is the General Thoracic Surgery Database. And so if you're in a thoracic surgery practice, they actually have bronchoscopy codes in there. You can track those outcomes. So they don't actually track those outcomes themselves. It's kind of, they're optional reporting things. But if that's the only thing that you have access to, you can use it and sort of get some information. It won't be very granular and it probably won't be detailed enough for what you're going to want to do with your bronchoscopy or pleural program. So the little thingamajigger in the bottom, they tell me that all the cool kids do that. You can take a picture of that. And it'll take you to this registry. So the AABIP has now created a database that you can submit sort of a request for. And I haven't personally used it. Anybody in the audience using it? No? No. So there we go. Rousing endorsement. Yeah, so you can start now. So anyway, so you can go online, you can fill that out. And you can actually compare yourself, you know, potentially to your peers, to your own internal data, that sort of thing. Or you can do like we did, which was develop an internal database. And so we have a REDCap internal QIQA database that we can look at, you know, pleural procedures, advanced diagnostic bronchoscopy, interventional bronchoscopy, you name it, that it's in there. We can look at, you know, what systems that we use. We can, you know, we can track our diagnostic yield. All of that sort of stuff is in there. And, but it, you have to put it in there. And so that can be one of the hardest things to do. And if you're interested in this, this database was modeled after Acquire. We've had it in production since 2015. And, I mean, it's REDCap. So if you have access to REDCap, I mean, I can send you the data elements. And you can do it in your place. And it's, you know, we've had over 2,000 interventional cases in this now. We can look at, we'll go to a slide. But anyway, so the whole point of this is that we can actually critically look at the things that we're doing, and we can change if we need to. So the monitoring of the outcomes is that we can identify areas where the service can improve. We can track diagnostic yield. We can track complications. We can track guideline consistent practice. And then you can take steps to correct those things whenever you're falling short. And so this is, you know, some potential metrics. And you can use guidelines to develop these metrics. Most of these are based off the guidelines. And, you know, so what should your serious complication rate be? Well, for bronchoscopy in general, it probably should be less than 1% if you take all bronchoscopies together. Pneumothorax should be less than 3%. That's based on all of the papers that are out there for advanced diagnostic bronchoscopy. Your Nashville bleeding scale greater than one probably should also be less than 3%. You know, if you're doing a therapeutic case, you know, there may be an asterisk by that. But if so for your diagnostic cases, it should be in there. You should have a high diagnostic success. Your EBUS adequacy rate should be greater than 90% per the CHESS guidelines. Your peripheral nodule biopsy, it probably ought to be greater than 75% now for diagnostic yield, you know. So the 50% is, I don't think that's a good benchmark anymore but you could, and if you're doing a robotic program, well, maybe your diagnostic yield needs to be 90%, you know, so these things can change as your practice changes. Low rate of infection, you should be working with your infection control people in your hospital. They're gonna monitor that for you so you don't have to do that. But if you have all of these things up, if you're tracking them and now you can track and see what you did in that case that might have created or tracked that infection. And then a high patient satisfaction. So a survey that goes out to your patients that come in for bronchoscopy. You know, that could be prescani, that could be whatever. But say, you know, how good a job are you doing? And then other things that are important is that did those complications occur within two hours of the procedure? Did they occur within a day of the procedure? You know, was there something within 30 days of the procedure? Was there a complication after 30 days? And so those are harder ones to track within a database. So our nurse practitioner goes back in at 30 days and gets those, you know, day one to, or day two to 30 complications and puts those in there. And then your mortality by ASA status or type of procedure, whether it's therapeutic or diagnostic. And so was it intraprocedural? Was it one hour, 24 hours, or 30 days? Those are some of the things that we track for complications. And then just a final slide here is to commit as a program or as an individual practitioner to a QI program. You can either subscribe to, create, or participate in some database so that you're aware of what you're doing. Complete the case information after the case. So don't wait three months down the road or 30 days down the road because you won't remember. A bonus of doing this also is that if, especially if you're an academic institution, this QI database, you know, with the appropriate IRB supervision or approval can also lead to publications, you know, so if you're tracking all this information. So 30 day completion of a morbidity report. Generate monthly reports for the outcomes and complications. As a group, review those complications. Or if you're the director, you need to review those with people who are practicing within your system. And then definitely should fishbone analysis all deaths that happen. So like a very formal M&M, it's a very powerful tool for change. And then share your processes and things that work for you with your colleagues. And that's all the references you can use for most of the guidelines that we have there. So thank you very much. I think we have time for maybe one or two questions. I have a quick one for Otis. So it's great to be able to know how you're doing. One area I think is difficult is to know how you can, what it is that is causing your numbers and how you can do better. For me, I work at two different hospitals and have close to a 30% difference in my diagnostic yield. I assume I do the procedure same at both places, but there's something happening between the two. Right. Yeah, I don't know if I have an answer for you to figure out what it is, but the key is that you identify that there's something. And so then that's gonna be your M&M or your fishbone analysis. So why is my diagnostic yield different? Is it the type of tool that I'm using there? Is it the type of anesthesia that I'm using there? Is it my pathologist? Is it how they're processing the slide? And so you have to go through those in a step-by-step fashion to try to drill down to what it is. But if you didn't track it, you wouldn't even know there was a difference. Hi, thank you. That was an excellent session, very refreshing. Just a comment and I wanna see what several of you mentioned it and fragmented it. I think we are victims of this arbitrary thing telling us that we don't pay for diagnostic procedures, but we will pay for therapeutics. My personal opinion, the system's broken, very broken, because you can give radiotherapy to something that is not cancer and get paid. But if you actually prevent a patient that doesn't have cancer from getting unnecessary treatment, you get paid a hundred and how many dollars? Right? So the number one Medicare biller in the US is radiation therapy. And the number two is chemotherapy. So when they put it on us to decrease cost and they put it on us as, oh, we're gonna lower it and we're gonna lower it. I'm like, who's driving this? And how can we influence the rock to change this? But just overarching comment. Yeah, I mean, when I started to look into this, I mean, just to give a little bit of background, you know, I'm a clinician-based physician and grew a clinical practice at UCLA, six faculty, started a fellowship and all that, and then started to get more and more into the business side and capital committees at the university, et cetera. And I started to look into all of this. It's sobering to see how the process is done. And I mean, this could be a whole session in of itself on how to try to influence the rock and Medicare dollars and how the pie gets split up. And when you ask to revise CPT codes, it gets revised. But in the family, what happens, the pie stays the same. So if you add like a new bronch procedure and they're like, all right, this is good, it's complicated, we're gonna reimburse it. Well, usually your piece of the pie for bronchoscopy stays the same. So if you're gonna add a code that increases it, the rock and the CMS decide what they're gonna cut. So the overall size of the pie stays the same. And rarely it seems like do they, I mean, I'm no expert by any means, but I went through the websites, convoluted websites a little bit. It seems they rarely cut from other things. So for example, if we come up with a treatment for cancer that doesn't require surgery that we treat bronchoscopically, it gets cut from other bronchoscopy procedures, not from lobectomies. So we end up shooting ourselves in the foot and to some degree by doing that. So I think that's what I was saying kind of early in the middle of my talk is, we as a society and we as a group of physicians need to advocate for more for ourselves and have, you know, lobby the decision makers and make our voice heard, which we don't do a great job of. We don't have a seat at the table. Permanent, so on the rock on that slide that Scott showed, you'll notice on there that pulmonary was not on there. We share a rotating spot with internal medicine with like ID and like cardiology has a spot, gastroenterology has a spot, but pulmonary doesn't have a spot at the table. So if you're not at the table, you know, you can't even get seconds. We also probably need to think about the fact that the group advocating for us is mostly people who make their money off of doing ICU bronchoscopy, which is in my opinion, a completely different procedure. So they're not gonna necessarily advocate for the small group of people that do these complex procedures because it will take away from the large group of people who do mucus plug removals. So, you know, finding a way to advocate for ourselves within our own organization is probably difficult as well. One of the things I'll add as well, we looked at this for our AABIP Advocacy Committee. Scott mentioned that if there's a preexisting procedure, that's what they'll base a new procedure on. If you take something like lung ablation, we would anticipate this being, you know, curative intent procedure for early stage lung cancer. Well, the rec may look at it and say, do you have anything close to ablation in your diagnosis or your procedure armamentarium? If you then look at APC, it's an ablative time-based procedure. You can bill argon plasma for ablation of lung tumors. Well, how will it then shake out? Will they make it look like peripheral lung nodule ablation is a similar procedure to argon plasma for essential airway debulking? So in some ways, the die is already cast. When you have procedures that are in our armamentarium, new procedures will be scheduled or codes created close to what's already in the armamentarium. So when the surveys go out, they used to send out, I learned, lots of surveys to lots of physicians. And there was one study that looked at how many surveys can you get away with? And depending on the code, it's 30 to 50 surveys. So only 30 physicians will get surveyed. And our tendency is like, okay, let's send out a survey about, like I use the thing of eBus, and they'll send it out to eBus. We're like, this is great. It makes it easier. But then you're not, like, it's not, I don't think people really understand what the surveys do and what they mean. So if you get a survey and like giving that example of ablation, we should say it's hard. It's complex. It takes time. It's not an easy thing to do. Like, it's way different. This base comparison is nonsense. Like, we should just make it so off the charts so that the rug has to like look at it and say, why is this so different? Let's reevaluate this. And we have to advocate for ourselves. And I think that's the bottom line. This is a societal level thing, right? This has to be a combined ATS, chest, and ABIP, SAB. Like, everyone's got to get together and kind of lobby for this. The people in this room will do these kinds of procedures who are grossly underrepresented in the decision-making process. Don't forget to fill out the evaluation. Yes, please. Thank you.

building a successful bronchoscopy and pleural service

strategies for program expansion

clear mission statement

gap analysis

market analysis

financial considerations

cost containment in bronchoscopy

reimbursement system

quality improvement

monitoring outcomes