David among Goliaths


Jack Rudnick, Jr.

Jack Rudnick, Jr.

Independent practices, such as Tri-State Gastroenterology Associates (TSGA) in northern Kentucky, are attempting sustainability through strategic execution governed by basic competitive principles of specialty- differentiation and low cost. Functioning as an independent eight-member David among several Goliaths (the many practices that serve patients owned by several formidable and prominent large health systems) requires ongoing vigilance and improvement. These local health systems include Christ Hospital, Mercy Health Systems, St. Elizabeth Healthcare, Tri-Health, and University of Cincinnati Healthcare.

TSGA focuses on the triple-aim paradigm of value-based reimbursement –high quality, low cost, high-level of patient satisfaction. Four fundamental pillars– access, quality, cost and continuity establish the foundation and focus of this strategy.


In an era of free-fall change and complex trends, navigating access into the TSGA system for patients has become more challenging and difficult. Tier-level consultation priority, based access through hospital -based electronic health records’ clicks, are designed to keep referrals internal to primary care referral networks within the system. Insurance products are narrowing panels, which impose de-facto penalties to prevent enrollees from seeking care outside-of-network services. Word-of-mouth referrals still help established physicians from a familiarity of referral habit. Specialists new to a system have little opportunity to interact with referring primary care physicians since hospitalists care for patients while hospitalized (and refer), for the most part. Relationships are formed differently than in years past making it difficult for these newer specialists to become known. Education, to let patients know that they have a choice, is critical to overcoming the referral-convenience barrier.


Aligning systems and processes to foster an environment for the highest possible caliber of care is critical to differentiation . TSGA’s board-certified physicians all exceed a key industry metric: the adenoma detection rate (ADR), which surpasses 50 percent as compared with the nationally benchmarked average of 23 percent. This is attributed to a coordinated patient-centric effort delivered by a team of physicians, nurse anesthetists, nursing and support staff.

In addition, the facility’s new state-of–the-art high-definition scopes along with tissue analysis by GI- specialty-trained pathologists combine to create an environment of excellence. Performance Improvement (PI) process review includes tracking industry specific indicators and quality benchmarking (including specialty -specific participation in GIQuIC).


In the wake of high-deductible policies and additional emphasis on patients’ personal responsibility in healthcare, cost is a critical determinant of care delivery. The cost of comparable non-complicated care and services approximates a figure of 65 percent less than hospital-based centers and owned centers where hospital out-patient department rates can be charged. (Uniform hospital out-patient department rates (H.O.P.D.) could add millions of dollars of cost to the local community care if, for example TSGA were not operating as an independent out-patient competitor.


In the context of ensuring that quality care for sub-specialty referral is provided with a minimal progression gap, TSGA chooses to assess the best possible fit among a host of options that are the best fit for the patient—not a referral pattern that considers the most profitable referral for a system. An internal care review process is examined and refined monthly against pre-established indicators to address needs and changes that may be introduced by third party payors or government compliance.

What This Means for Independent Practices

Strategically, cost and service differentiation are among key basics that will help practices to sustain its autonomy and independence while remaining financially viable. Independent practices are joining forces with other independent groups, locally, to let the public know that patients have choices and can request providers outside of the owned health system.

–Jack Rudnick, Jr., EdD, is with Tri-State Gastroenterology Associates in Northern Kentucky.