The next talk is Dr. Jeff Marshall, who is going to talk about maximizing CalFab revenues to maximize CalFab margins, and that might help us mitigate some of the other topics. Yeah, I'm going to bring it down a notch. Really, this is show me the money. This is Jerry Maguire, okay? That's what I'm going to try to do here. I have no disclosures, and please don't think I'm some kind of expert coder. I am not, okay? But this is what I'm going to try to do. I think we should all understand the components of our CalFab budget, not that big spreadsheet, but the simple math about what makes the CalFab run. Accurate documentation and coding are our friends. It maximizes revenue, and I want to talk a little bit about strategies to increase volume, decrease complications, and shorten length of stay, and then I want to talk about something that I think is really important. I actually think that the culture in the CalFab is one of the most important things for making a CalFab successful and profitable, and then finally, expanding services in your CalFab. But remember, Chris is coming behind me. Quality is job one. That's the Hippocratic Oath. Don't ever forget it. Don't chase money. So these are codes and payments for guys like me. It's pretty simple. Why was it done? You need a code for the diagnosis. What was done? You need a procedure code, and then you need a way to get paid, and I'm just going to talk about hospital inpatient and hospital outpatient. Realize the ambulatory surgery centers and all the RVU stuff is there, but that's not what I'm going to focus on because there's too much to talk about. I'm pretty simple. I read this book the other night, How to Fix It for Dummies. Remember, if you're an inpatient, you get paid basically two ways, and I'm talking about Medicare patients, from DRGs and from major comorbidity complications. It's a little more complicated than that, but I don't understand it. I'm a dummy. If you're not going to be in the hospital for less than two midnights and you do that on the front end, then you go to these APC codes. Here is the cath lab budget. On one side is where we get the money from. Let's just keep it to CMS. On the other side are the expenses, and there are three types of expenses, and you need to know this. They're fixed direct expenses, and they don't vary with procedures. It's the capital equipment in your lab. It's the salary for the cath lab manager that's not doing clinical stuff, maintenance, getting the floors cleaned. There's fixed indirect. That's like paying the CEO. They can put whatever number they want in there, right? It's cutting the grass, okay? It's the interest on all the damn debt the hospitals have, okay? And then there are variable expenses. We can't control any of these things in red. The hospital does. CMS does. The thing that interventional cardiologists can manage a little bit are these variable expenses. So there are other things that you're going to see if you see these reports. One is EBITDA. That's earnings before interest, taxes, depreciation, amortization. That's a fancy accounting term that tells them, are you going to be profitable? The other thing that you're going to see is this contribution margin. That's reimbursements minus variable expenses, and that's a dollar amount per procedure, and then there's this contribution margin ratio, which is the ratio of what the contribution margin was divided by the reimbursements, and that's a percentage. Here's some examples of this. This is not from my hospital. I'm not going to tell you where I got it. But the bottom line is, look at these different procedures. Here's one. Just look at the right two columns. So you've got contribution margin and contribution margin percentage, okay? This procedure highlighted here, the contribution margin is high, but the contribution margin ratio is not as high compared to this one. Understanding what procedures actually are more profitable can actually help you as a cath lab director decide what you want to do in your cath lab. But trust me, the hospitals have it by this way, too, okay? Here are a bunch of people that do procedures, and here's the busiest person in this cath lab. They did 56 procedures, and they put the most to the bottom line, okay? $405,000 of contribution margin, and we don't have it by contribution margin ratio, but this is the net revenue per case of about 16 grand. Look at this person down here at the bottom that only did 11 cases. They only put $89,000 to the bottom line, but their net revenue per case was $19,000. Hospitals know this. You should know this. This is how hospitals make decisions, okay? So let's just go and do a simple thing about how documentation and coding matters. Let's say we've got a patient that's going to get an atherectomy and a stent. If you do it as an outpatient, you're going to get about 15-3. If you do it as an inpatient, 19-7. But there are all kinds of other things that go into this, okay? $4,400 more, basically, to do this as an inpatient. But what if you have to put in four stents? Well, there's actually an up code for that, a 50% increase in reimbursement, okay, through these modifiers, but you only get it if you code correctly. You've got to document it in the cath report, and you've got to code it right, okay? So this is pretend money, but basically, you go from about $4,000 difference to $14,000 difference. Here's a simple example about why accurate documentation in CONE are the roots or the foundation of profitability in cath labs. I know that's simple, and it's probably not perfectly right, but I think it gets the points across. You have to do some other things in documentation, okay? And I just put them under this for that. But, you know, you need to use structured reporting. Kind of a no-brainer, right? You need to know what you took out of the cabinet and used for that case. Somebody downstream needs to scrub and to audit everything that you send in to the payers the same way we do M&M in the cath lab. And you need ways to get submissions if you get inappropriately denied. I now want to talk about increasing volume, cath lab leadership, and expanding services real quickly. So the more cases you do, if you've got fixed income, I mean, fixed expenses, the more profitable you are. It's pretty simple. It's more profits. This is where on-time starts are important. If you don't come in until 8 o'clock and somebody's paying the cath lab staff to be there since 6, you're no longer an income center. You're a cost center. Don't do that. Start on time. Same thing with reducing turnover. There's a great paper that actually Kurt was talking about, talks about turnover as being very important. And less than 15, it's actually 17 minutes, would be ideal. If you decrease the amount of time that the lab is not occupied, you increase profits. Level loading cath labs, simple things that you can do. Don't leave cath labs empty because this guy over here wants to do all the cases and keep everybody in overtime, and these people over here are scrounging for cases. Damn, we're on a team. Let's work together. Level load the cath lab. Block scheduling can help here, especially if you've got lots of cardiologists. And things like lean principles where everybody in the lab kind of knows what's going on reduces waste. And reduced waste means more profit. Okay. Cath lab directors. This is really important. And there's actually an article actually from the same guys that talks about this. You need a really strong advocate as a medical director of a cath lab. The cath lab director sets the tone and creates the culture. And this is overlooked and it's bothersome. They have to have expertise both in clinical and fiscal things, but they need to be a person that's respected by everybody that comes to that cath lab. No matter who they work for, no matter who writes their check. Fair, open minded, approachable, respected and thoughtful. If you don't have that person, you're not going to be successful. It just doesn't happen. That cath lab director is a leader of the team, of the nursing manager, the prep recovery, and hopefully they're over the coders. Cath lab director is a standard bearer for culture. And this is really important in my mind. As Peter Drucker says, culture each strategy for breakfast. You go into a cath lab that's got a good culture, I guarantee you that it's profitable. Okay. Margins and profits. I wasn't going to this is kind of on the other side of the thing, but this is really important. Site selection and same day discharge has been proven beyond a shadow of a doubt to increase margins. This is from NCDR data. You can see the folks that did this, but basically they compared trans radial and same day discharge with transfemoral. If you do 30% change to trans radial and same day discharge and your hospital does 1,000 PCIs annually, your hospital is going to save a million bucks and nationally it can save hundreds of millions of dollars. Expanding services. If your cath lab is not full, fill it up. There are all kinds of new things coming from heart failure. Get into peripheral angioplasty. Do structural stuff. Put in loop recorders. There are ways to fill the time. Somebody is paying for that space and keeping the lights on. Well, this is not going to play any sound. But everybody has seen Jerry Maguire. This is the classic scene. Jerry Maguire is all about money. And he gets fired. This is his only possible patient. This is it. Show me the money. Show me the money. So you can think of Jerry Maguire at the beginning of this movie as a vascular surgeon. That's who gets to show you the money, right? But by the end of the movie, he's become the cath lab director. He's become a real human being. Somebody that really cares about people. And if you're going to chase the money, beware. In this valley, not too many months ago, modern vascular, $50 million whistleblower. Don't chase money. Here's the way to make your cath lab grow. Accurately do clinical documentation. Code appropriately. Get an expert coder. That's a hand in a glove. They work together. Fertilize it with volume. On time starts. Reduce overtime. Schedule evenly in all the cath labs. Get a great cath lab director. Radial access and same day discharge. Expanding and filling your lab. And if you do that, it will pay off with fruit. You will be successful. Thanks.

revenue maximization

accurate documentation

volume increase

positive culture

service expansion