A sign posted in the waiting room of Teton Outpatient Services tells patients which local doctors are investors in the surgery center.
“We do disclose to people that we are investors,” said Dr. Doug George, an OB-GYN. “Of course we do — that’s the ethical thing to do.”
Physician investors in both Teton Outpatient Services, known as TOPS, and Teton Sports and Spine Imaging, known as TSSI, have become a hot topic in Jackson. Two physician investors are running for the St. John’s Medical Center Board of Trustees, prompting concerns of conflicts of interest. Hospital administrators have also expressed fears that the surgical center and more recently, a new MRI, could siphon profitable services away from the public hospital.
Such worries even prompted longtime Jackson resident Sandy Ress, who is running as an independent for the Teton County Board of County Commissioners, to buy a “clunker” and mount a call to action to the top of the car and park it in front of Teton Orthopedics. The sign urged patients to get their MRIs done at St. John’s. Ress’ stunt and the medical community’s response demonstrates how visceral the debate has become.
So who are the physician investors? Why did they choose to invest locally, and does their investorship sway where they recommend patients go for health care?
Two investors willing to speak on the record for this story — George, who invested in TOPS and TSSI, and Dr. Giovannina Anthony, an OB-GYN who invested in TOPS — said their investments do not influence where they direct patients for care.
“That’s not even in the equation,” Anthony said. “I would have done some of my surgeries there anyway.”
Many investors at both facilities didn’t return requests for comment. But those who commented said they have no desire to have a negative relationship with St. John’s Medical Center and pushed back on the narrative that they’re lining their pockets at the expense of patient well-being or the hospital’s financial health.
Surgery and imaging are two big moneymakers for St. John’s, and that money, in turn, subsidizes other services.
Doctors said their focus is on patient care and always will be. Like many professionals, physicians follow a strict code of ethics.
“We like to provide people choices and do that in an accurate way,” George said.
He doesn’t think investing in TOPS or the new MRI facility, TSSI, is a conflict. It becomes a conflict if you limit patient choices based on your own preferences, he said.
“I feel like I’m on solid ground,” George said.
OB-GYN’s like George rarely order MRIs. If they do, it’s for breast or, rarely, pelvis imaging if there’s trouble interpreting a CT scan or an ultrasound.
Other factors influence where surgeries are done, Anthony said. In her experience, the facility fee (which varies procedure to procedure) at TOPS is cheaper for her patients than the hospital. A lot of patients in Wyoming, she said, have high deductibles and pay out of pocket, especially for infertility procedures. As such, she needs to explain all their options to them, she said.
“It’s only fair to offer them a lower price,” Anthony said.
She also said TOPS runs an efficient operating room for things like laparoscopies, hysteroscopies, dilation and curettage procedures, and endometrial ablations.
“It’s an efficient place to do minor procedures,” Anthony said. “It’s more about efficiency. The investing aspect never comes into my decisions.”
Since the hospital takes emergency cases and is a bigger facility, minor surgeries can get bumped. Both OB-GYNs said they do more complex procedures that require overnight stays or might have complications at the hospital.
With having to juggle her schedule, the facility schedule and a patient’s schedule and needs, Anthony said, she thinks it’s “good for patients to have the option.”
And options also include medical centers outside Jackson. A facility in the Salt Lake City area, for example, charges roughly $1,000 less for a hysterosalpingogram, a procedure that uses an X-ray to look at fallopian tubes and the uterus.
“I don’t feel like I can not tell them that when 99 percent of the time they’re paying out of pocket,” Anthony said.
A surgery schedule is displayed on a whiteboard in Anthony and George’s office in Women’s Health and Family Care. The day the News&Guide visited, there was an even split in surgery location between TOPS and St. John’s. Anthony and George do all of their baby deliveries at St. John’s.
“I feel like I support the hospital 100 percent,” Anthony said.
George thinks the physician investor conversation is part of a broader philosophical disagreement about who should provide health care here — the hospital or the hospital and a patchwork of other entities.
“I think they’re using taxpayer dollars to limit patient choice,” he said of the hospital.
Patients are their own best health care advocates, and health care needs are best served when patient choice isn’t limited, he said.
“I don’t think monopolies work,” George said. “I think competition will provide choices. It’s up to physicians to provide accurate information when patients grill us on their choices. I don’t make that choice.”
George said the conversation needs to change for the patients’ sake.
“We should all be on the same team, singing the same song,” he said. “We’re all striving to provide better patient care at cheaper prices. That needs to be the focus.”
Self-referral laws vary
There’s no list of physician investors posted at TSSI. CEO Shaun Andrikopoulos said that’s because the facility is subject to different regulations and some of his physician investors refer more patients to the hospital instead.
“Not all of our investors refer here, which is kind of interesting,” Andrikopoulos said. “All of our physician investors do disclose that there are choices in the market. And then they also talk about the facts, the pros and cons.”
The News&Guide obtained the names of TSSI investors through a Freedom of Information Act request from the Centers for Medicare and Medicaid Services. There’s significant crossover between investors in TOPS and TSSI, but not all investors are investing in both. Most of the investors are orthopedic surgeons or OB-GYNs.
A complex set of federal Stark physician self-referral laws prohibit physicians from making a referral to an entity for the provision of Medicare-covered designated health services if the referring physician has a financial relationship with that entity. Radiology, including MRIs, is one of 11 categories subject to Stark laws.
A rural provider exception makes that OK locally in the case of TSSI. According to a 2004 statement by Centers for Medicare and Medicaid Services, the exemption was made with the intent to ensure adequate access to health care services “for residents in rural areas that might otherwise have a difficult time attracting a sufficient number of providers and suppliers.”
The intention behind the original statute was to eliminate financial motivation for physicians to send patients for unnecessary testing that could raise overall health costs. Sean Haling, the head of the hospital’s imaging group, Jackson Hole Medical Imaging, said he thinks that’s happening here.
In a one-month period, Haling said, the hospital group performed three imaging tests for further evaluation of findings on an MRI done at TSSI. The findings, he said, were already noted on previous scans done at St. John’s and could have been compared had the patient chosen the hospital in the first place.
“If those MRI scans would have been performed at St. John’s, those additional tests would not have been needed or performed,” Haling said.
While physician investorship in outpatient surgical centers like TOPS is not restricted by Stark laws, critics still point to an anti-kickback statute that prohibits anyone from offering, paying, soliciting or receiving any remuneration in exchange for the referral of Medicare or Medicaid business. But, again, an exception exists. Outpatient surgical centers are one of several exceptions to anti-kickback laws.
Anthony said the choice to invest in her own industry made sense. For example, she said she was already informed on the topics that came up in board meetings for investors.
“I know medicine,” Anthony said. “It’s all I’ve been doing since I was 18 years old. I feel comfortable in the arena.”
Hot topic at candidate forum
Next week’s election has made the physician investor debate an increasingly public conversation.
Though George and Anthony are not running for office, Dr. Joshua Beck and Dr. Geoffrey Skene are candidates for the hospital board. (See all of the candidates’ answers about conflicts of interest and competition in the general election section inside this week’s paper.)
During an election forum last week at Teton County Library, hospital board incumbents and hopefuls questioned how Beck and Skene would handle potential conflicts of interest as investors. Beck and Skene did not attend the forum and did not respond to requests for comment afterward.
Chris Schroeder, a physician’s assistant who also wasn’t there, provided a statement read during the forum saying he was in Afton for a lumbar fusion surgery the next morning.
When the panel of seven candidates — 10 candidates are running for four seats — was asked about conflicts of interest, incumbent Joe Albright said, “I’d really like to hear how the remaining three candidates for this office would answer that question.”
Likewise, Linda Aurelio said, “I, too, wish the other three candidates were here to answer this question.”
Although the three physicians were not at the forum, their answers to a News&Guide candidate survey count their various involvements with medical facilities outside of the hospital as an advantage, not a liability. The physicians say they hope to help smooth relations between the hospital and doctors.
Until 1995 physicians were prohibited from serving on hospital boards.
Candidate Susan Crosser said she didn’t understand all the concern about physicians being on the board now when Dr. Bruce Hayse, a current board member, is also a practicing physician. Hayse isn’t an investor in TOPS or TSSI.
“It’s curious that Bruce Hayse, who is not running for re-election at this point, has been on the board for a very long time, and only now are we suddenly afraid that if we elect other doctors, they might have a conflict of interest,” she said.
Fitting the turbulent theme of the evening, Dr. Marc Domsky, St. John’s chief of staff, stood at the microphone to reply.
He also brought up the physician candidates not in attendance, saying that, unlike the candidates, Hayse was active in medical staff meetings and the hospital’s organizational structure, spending “many years going through the ranks” before getting on the board.
“The other physicians running who I’ve known for quite some time … none of them have participated in any medical staff activities,” Domsky said. “So from within the organization itself, I can freely state that none of them have played any active role in trying to change the organization from within. So I find it a little odd that they’re trying to take this approach.”
To the amusement of the crowd, Hayse walked into the room during Domsky’s remarks.
“Perfect timing,” Domsky said. “This wasn’t even planned. I’m defending your honor.”
But tensions remain between the hospital, TOPS, TSSI and physician investors because where patients spend their money affects the bottom line. Rural hospitals around the country are closing for a variety of reasons, one of which is private competition that doesn’t play by the same rules.
Since 2010, 89 rural hospitals have closed, with almost three-quarters of those closures in states that have not expanded Medicaid. The University of North Carolina’s data shows no such closures in Wyoming, but 673 more rural hospitals are “vulnerable or at risk for closure” according to the National Rural Health Association. And according to the Chartis Center for Rural Health, there are 25 health care providers in Wyoming — 11 of which have a negative operating margin.
The Casper Star-Tribune reported that a privately owned specialty hospital in Casper “siphoned off enough business from the Wyoming Medical Center that the larger facility lost its ‘sole community provider’ status in 2011, costing it millions in federal dollars.” That’s the fear for Ress and other St. John’s supporters.
But for George, the question of physician investors shouldn’t create such a rift between doctors and the hospital. He thinks cooperation is the best strategy for the long haul.
“I shouldn’t be in a position where lines are drawn, and it’s us versus them,” George said. “We just want to be doctors. The lines were drawn and not by us. These divisions are unnecessary.”