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August 2019 marks the end of Northwest Endometriosis and Pelvic Surgery’s first year of operation, and it has been a wild ride!
The decision to start NWEPS was not an easy one. From 2015 to 2018 I was an associate of Richard Rosenfield within Pearl Women’s Center in Portland, OR. PWC was a wonderful practice with a beautiful office and great staff, and it was a great place to start after coming to Portland. It gave me a chance to develop great relationships with many referring doctors in Portland and around and Pacific Northwest, and to do a great deal of traditional laparoscopic surgery. However, as my practice focused more and more on endometriosis care, it became apparent though that if I was going to offer the kind of care I wanted to offer, without compromise, I would need to start my own operation. It also became apparent that in order to make the finances work, I would need to operate outside of insurance networks.
Many people told me that this would never work in Portland and that I would fail. People said that there are other surgeons on various endometriosis referral lists in Portland that still take insurance, and that I would get no patients. Nonetheless, I had the feeling that if I focused myself like a laser on providing the best possible care and the best possible service to my patients, that everything else would fall into place and we would have success. And so far, I have been right.
In our first year in practice as subspecialty surgical practice, we performed almost 100 surgical cases, the vast majority endometriosis excision cases. While this is actually a fairly low number for a solo surgery practice, I think it is a great start for our first year. It also showed us that even at this number, we could provide great care while maintaining a solvent and successful business.
While I can take personal credit for the quality of surgical care we deliver, it is thanks to the hard work, dedication, and talents of others that the operation has had the success it has.
It is without question that our success could not be what it is without the hard work of my trusted assistant Milissa Burbank.
When I started NWEPS I put out an ad for an assistant and Milissa answered, along with 120 other people. I was overwhelmed with the choices. Ultimately I interviewed 5 and hired Milissa. I wasn’t that clear on what I wanted, because what I knew is that all the job really required is someone who was compassionate, intelligent, and willing to learn. Milissa has been all that and more. As my sole full time employee, Milissa answers our phones, handles insurance authorizations, schedules appointments, and assists me clinically as well. More important than all of that, Milissa helps our patients with anything they need, from figuring out insurance issues to scheduling hotels to getting them a cup of coffee when they come in. I am so lucky to have her and so are the patients.
The second great thing for NWEPS has been the work of Tom Force and Patriot Compliance, my attorney and billing agent, and our primary biller Susan O’Connor. Tom has been a tremendous asset to the practice, helping us get paid appropriately from insurance companies for the complex cases we do for patients. Because he and Susan do such a great job at what they do, we are able to keep patient costs quite low compared to some of our colleagues in advanced endometriosis care.
Rather that setting extremely high fees for surgical services, we set our fees at a level that most people can afford, while leaving the opportunity to be paid well from insurers when patients have excellent out of network benefits. We rarely have a case where an insured patient is out of pocket more than a few thousand dollars in professional fees, yet we remain solvent and adequately profitable. Tom and Susan are our billers, but in many cases Tom also acts as attorney for our patients, representing them against their insurer to ensure proper payment on their behalf. When claims aren’t being paid correctly, he writes appeals that would curl you hair. In most cases these appeals succeed, allowing us to keep patient costs low. He has even helped patients negotiate with third parties on several occasions. He also is of great assistance at helping patients get out-of-network exceptions when they truly do not have good in-network options. I couldn’t do it without him and his fantastic billing staff. At least a few times a month someone asks me why we don’t charge more when the other national surgeons are asking for so much. I guess the answer is that my goal was not to get rich doing this. My goal was to be able to do what I wanted to do in medicine while providing adequately for my family and my staff. And in that, we set our fees where they are. In combination with our great billers maximizing our insurance reimbursement, so far things are working out and we are getting it done.
I have always been cognizant of the effect that being out of network would have on access to care in our office, and have strived to make care affordable. In this desire, in our first year we developed relationships with several surgeons in the community that are willing to post cases for patients with Oregon Medicad (Oregon Health Plan), who can then bring me in as a surgical assistant. By doing this, we can get the state to pay for all facility fees for care (which they would not if I were the primary surgeon), and then I can come in as the surgical assistant and make sure we do quality work and get the same outcome we have in my office. In most cases, we have been able to reduce our fees adequately so that we can still provide care to these patients.
From a clinical point of view, I also have to thank my great community colleagues who help with our most complex patients. In general surgery, we work a great deal with Mark Whiteford, Amanda Heyman, and Khayree Butler in colorectal surgery, and also general surgeons Avishai Meyer and Daniel Tseng. I have also the pleasure to work with thoracic surgeon Jeff Watkins on our thoracic cases. In urology, we collaborate with a great urologic oncologist Dr. Jeff La Rochelle. While the endometriosis surgeon is the captain of the ship, a world class endometriosis program requires the collaboration of great colleague surgeons who really want to be a resource to women with endometriosis, and I am honored and lucky to have them.
In education, we have been able to make contributions this year as well. I gave grand rounds at Baylor-Dallas College of Medicine and blew some minds of some young physicians who had no idea endometriosis could be treated this way. The same day we also did a guided cadaver dissection, demonstrating the entire pelvic anatomy to the young surgeons. I also was honored to proctor a laparoscopic hysterectomy course at last year’s AAGL meeting, as well as to present several videos and abstracts. Milissa and I also put on quite a few lunches for practices in and around Portland, educating local doctors on what endometriosis excision is, and who they should consider referring to our practice. Amazingly, when you show video of what we do to another generalist OB/GYNs, they see the difference and they refer patients. Sometimes endo docs just talk about how the generalists don’t understand endometriosis. True enough, but their ears are open to learn, and they want somewhere to send the patients they can’t help. So we try to do that.
In the last quarter of our first year, we really got our research goals off the ground as well. In the last few years, I have had an informal relationship with Juneau Biosciences, a genetics company from Salt Lake City, UT that is exploring the genetic origins of endometriosis. In the last few months this relationship has been formalized, as we are formal consultants and also a recipient of a research grant from Juneau. As part of this grant, we are beginning to collect samples of endometriosis tissue for genetic analysis. By understanding exactly what mutations exist within the tissue, and what RNA are being expressed, we get closer to understanding exactly why endometriosis exists and how it functions, and thus closer to a genetic cure. We are also on the precipice of starting a clinical outcomes database that will formally track the outcomes of our patients over time. Overseeing all of this is our new research assistant, none other than Libby Hopton of Endometropolis fame. We are lucky to have Libby on our team and no doubt in the coming years you will see many Fogelson / Hopton et al publications in the peer reviewed literature. Libby and I are also hosting The Endometriosis Podcast, which in theory comes out every month but in reality we seem to get out every 2-3 months.
On personal education, I continue to push forward to try to absorb any information from any source that could possibly help my patients. This year I completed Level 1 training in Neuropelveology, a field that aims to understand the neurologic and neuroanatomical origins of pain. This field has opened my eyes to new ways of thinking about pain, and in many cases, informs my surgical planning and technique. Later this year I will be doing the level 2 training in Stuttgart, Germany, which will advance my skills further. We are already starting to do advanced cases of sacral nerve root and sciatic endometriosis, as well as medical and surgical care for pudendal neuralgia, and these offerings will grow over the years. We may even start offering laparoscopically implanted neurostimulation for intractable pain issues, something pioneered by Possover in Zurich and taught to his students. In time, I may also be able to branch into offering implants that help spinal cord injured patients restore lower extremity motor function.
The year has had its ups and downs, but really mostly ups. Any time there is a down, I just redouble on a commitment to focus entirely on providing the best possible care, and let everything fall in behind that.
Serving this goal, we have appointments that are long enough to do the best we can at the first visit. Be available to patients. Pursue every educational opportunity that might help develop skills to help patients further, even if they are expensive. Have faith that those skills will pay for themselves and more. Practice, practice, practice, read, read read, then practice some more. Do every surgery better than the last one. Never be satisfied that it is good enough. Celebrate the successes, but study the cases that had less success more. What could we have done better? Was our diagnosis correct? Is there more we can still do? Is there someone out there that knows more or does better that we can learn from?
As we start our second year in practice, we have some nice things on the horizon to look forward to. In a few months we will start construction of our new office in Downtown Portland. The current plan is to occupy the 8th floor corner office of the historic Medical Dental Building in downtown Portland. It has great light and beautiful city views, and will be a wonderful environment for our patients to receive care. Valet parking too! We will be building for current use, but also with an eye to the future, with enough space to one day bring in a partner as well. It may even be that Joy Roberts will be donating a great piece of original endometriosis themed art for our walls! One thing I really look forward to is our great waiting and conference room, where we will be able to hold some great workshops and educational talks for interested parties in Portland.
And so to all of the women who have put their faith in me and honored me to be your doctor and surgeon in our first year in practice, you have my thanks. And to other women suffering from endometriosis or other gynecologic issues that want world class care, give us a call and we would love to see you.
Sincerely,
Nicholas Fogelson, MD Founder
Northwest Endometriosis and Pelvic Surgery
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