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This blog was written by: Neda M. Ryan, Esq.Clark Hill, PLC, Birmingham, MI When was the last time you considered investing, or renting space, in an ambulatory surgery center (ASC)? While issues of whether the transaction makes good business sense are, naturally, at the forefront of any business person’s mind, often physicians (including anesthesiologists) fail to take into account the compliance considerations that are the drivers of many of the underlying business decisions. Unfortunately, in today’s healthcare regulatory arena, no anesthesiologist can ignore the importance of ensuring compliance with State and Federal Laws when considering a relationship with an ASC. For purposes of this article, an ASC is a distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed twenty-four hours following an admission. The entity must have an agreement with the Centers...
While we are all trying to understand how the landscape is evolving for anesthesiologists, nurse anesthetists and anesthesia groups, keeping our eyes on traditional practice management issues such as compliance remains as important as ever.  Similarly, we must maintain a dual focus on the big picture of system and organizational changes, on the one hand, and on the day-to-day requirements of providing and being paid for anesthesia and pain medicine services, on the other.  Our field of vision has to be both longitudinal and latitudinal. One of the frankest talks on system evolution at this past weekend’s Advanced Institute for Anesthesia Practice Management (AIAPM) in Las Vegas was that of Howard Greenfield, MD of Enhance Healthcare.  Dr. Greenfield, discussing The Anesthesia Workforce of the Future, quoted Kaplan’s and Porter’s observations that “some facilities that serve patients with unpredictable and rare medical needs … carry extra [personnel] capacity” and that “Much excess...
Looking back fourteen years ago, Y2K was all a buzz and everyone, especially the IT department, was busy waiting for the impact of Y2K to reveal itself. The ball dropped in 2000 and nothing happened. No planes fell out of the sky, computers did not crash. All of the preparation and expenditure for naught, or was it? What did we learn from the Y2K experience? Even though the impact was negligible, preparation was the key. We know that had something occurred, some were not prepared and many were well prepared. Let’s fast-forward to 2014. ICD-10 is this years’ Y2K. Rest assured, ICD-10 will have a profound effect on providers; in fact, it is the largest modification ever to hit the healthcare arena. Providers who delay or ignore their implementation process will suffer a negative financial impact whereas those who work to prepare should be able to steer themselves through the issues...
  When it comes to Medicare payments to physicians, plus ça change, plus c’est la même chose.  Last week Congress adopted the 17th “patch” to prevent the huge cut mandated by the Sustainable Growth Rate (SGR) formula from going into effect for another year.  The legislation also kept in place the antiquated ICD-9 coding system until at least October 1, 2015. Larger sectors of the healthcare economy are evolving in interesting directions, however.  Shrinking revenues from traditional sources as well as increasing awareness of where the quality/cost relationship, i.e., “value,” can be improved are driving changes that anesthesiologists and others should keep in mind as they seek new roles and opportunities. Hospitals and health systems are expanding their activities into areas beyond the traditional furnishing of acute care services.  Two of these new areas are post-acute care (PAC) and the payer function.  The specific roles for anesthesiology groups in connection with...
ICD-10 is coming, as we have all heard many times.  Will full implementation be here on October 1, 2014, though, or on October 1, 2015?  As of the time this is written, the Senate is expected quickly to take up the House-passed Protecting Access to Medicare Act of 2014 (H.R. 4302), legislation that will prevent Medicare payment cuts from going into effect on April 1st—and that contains a provision delaying the implementation of ICD-10 for a year.  Whether we are six months or 18 months from the start date, however, it is none too early for clinicians to gain an understanding of what ICD-10 will require of them, as well as to practice meeting the new requirements. We have all heard, too, that ICD-10-CM (“CM” stands for “Clinical Modification” and distinguishes the codes used for diagnosis from those used to identify procedures, the ICD-10-PCS or “Procedural Coding System” codes) requires more...
The Advanced Institute for Anesthesia Practice Management (formerly the Anesthesia Billing & Practice Management Seminar) will be held April 11–13, 2014 at The Cosmopolitan of Las Vegas. The 2014 Advanced Institute for Anesthesia Practice Management (AIAPM) will focus on practice management issues with the goal of enlightening attendees on broader group strategy issues, including numerous talks on billing, coding and compliance.For full conference information and to register for the AIAPM Conference, please visit www.AIAPMConference.com. Discounts are offered for four or more members/employees from the same practice.  To see if you qualify contact This email address is being protected from spambots. You need JavaScript enabled to view it. . Conference SpeakersOur speakers are experts in the industry and have knowledge to share.  Please join us at the AIAPM to benefit from our panel of experts.Frank Rosinia, MDChairman, Department of Anesthesiology, Tulane University School of MedicineMichael Hicks, MD, MBA, FACHEPresident and Chairman, Pinnacle Anesthesia Consultants, PAHoward Greenfield, MDPrincipal, Enhance HealthcareSonya Pease, MD, MBAChief Medical Officer, TeamHealth AnesthesiaPam Upadya,...
Patients who receive an advance premium tax credit under the Affordable Care Act (ACA) may lose their insurance coverage if they fail to pay their premiums—and leave their providers holding the bag.  With more than 4.2 million individuals now signed up for policies through the ACA health insurance exchanges, every provider is at some risk of loss.  There are steps that anesthesia practices can take to avoid such losses. A little-known ACA rule gives patients who purchase subsidized coverage through the exchanges a 90-day grace period before their coverage is canceled for nonpayment of premiums.  Although insurers are required to pay for claims for services provided during the first 30 days of the grace period, they are permitted to pend any claims submitted for services performed during the 31st through 90th days.  They may ultimately deny such second- and third-month claims if the patient never makes the missed payment.  The patient...
The Advanced Institute for Anesthesia Practice Management (formerly the Anesthesia Billing & Practice Management Seminar) will be held April 11–13, 2014 at The Cosmopolitan of Las Vegas. The 2014 Advanced Institute for Anesthesia Practice Management (AIAPM) will focus on practice management issues with the goal of enlightening attendees on broader group strategy issues, including numerous talks on billing, coding and compliance.For full conference information and to register for the AIAPM Conference, please visit www.AIAPMConference.com. You may register directly by clicking here. Discounts are offered for four or more members/employees from the same practice.  To see if you qualify contact This email address is being protected from spambots. You need JavaScript enabled to view it. . Please note: The last day to reserve rooms at the discounted block rate at The Cosmopolitan is Monday March 24th. Be sure to reserve your room as soon as possible.  Additional information is available on the website at http://www.aiapmconference.com/location-accommodations.  You can also click here to register directly with The Cosmopolitan. Conference...
More than one-third of the total cost of a hip or knee replacement can be attributable to the cost of the implantable device used in the procedure.  In some cases, the device may account for up to 87 percent of the cost, according to a recent Health Affairs article that has attracted a good deal of attention (Okike K., O’Toole RV, Pollak AN, Bishop JA, McAndrew CM, Mehta S, Cross WW, Garrigues GE, Harris MB, Lebrun CT.  Survey Finds Few Orthopedic Surgeons Know the Costs of the Devices They Implant.  Health Aff (Millwood). 2014; 33(1):103-109.  DOI: 10.1377/hlthaff.2013.0453). The variation in price of functionally equivalent devices is just as impressive.  The average per-case cost of the implant alone ranged from $1,797 to $12,093 for total knee replacement procedures and from $2,392 to $12,651 for total hip replacement procedures in a 2012 study based on 2008 data published in the Journal of Bone and...
The Affordable Care Act, which last week was the object of a fiftieth attempt at repeal in Congress, is moving the healthcare system toward greater integration of providers.  Classic antitrust law, however, aims to increase competition and the number of competitors.  The conflict between the two values finds it most recent expression in the January 24, 2014 decision in the St. Luke’s antitrust litigation in Boise.  The U.S. District Court for the District of Idaho ruled that St. Luke’s Health System, Ltd. must unwind its acquisition of the 40-physician multispecialty Saltzer Medical Group, after finding that the deal violated federal and state antitrust laws—despite its determination that the integration of the physicians with the hospital system was intended primarily to improve patient outcomes. The Federal Trade Commission (FTC) and the Idaho Attorney General filed their joint complaint in March 2013, alleging that St. Luke’s acquisition of Saltzer was in violation of...
Introduction A silent revolution is under way in anesthesiology, one that will have a lasting impact on our patients and our practice. I refer to the research potential of ‘big data’ in anesthesiology, driven by the rapid uptake of Information Age technology in our offices, clinics and hospitals. Electronic healthcare records (EHRs) are changing the way we care for patients, the way we document and bill, and how we understand our practice. In the long run they will do much more: they will provide a fundamental ability to link clinical decision-making in the operating room with patient outcomes in a way that lets us learn from every patient encounter. This article will provide a brief overview of existing large datasets describing anesthesia patients, procedures and outcomes. I will review their current contents and structure, their future development, and their long-term potential for comparative effectiveness and health services delivery research. Existing Anesthesia...
  Have you checked how your information appears on Medicare’s Physician Compare website?  Is it accurate? What Is Posted on Physician Compare—From Physician Demographics to Quality Measures Mandated by the Patient Protection and Affordable Care Act, launched in 2010 and redesigned in 2013, the Physician Compare website is intended to serve a two-fold purpose: To provide information for consumers to encourage informed healthcare decisions; and To create explicit incentives for physicians to maximize performance. (http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/physician-compare-initiative/Physician-Compare-Overview.html.)  The website provides the public with the following information for all physicians, nurse anesthetists, anesthesiologist assistants and certain other healthcare professionals: Names, gender, addresses, and phone numbers; Physicians’ primary and secondary specialties; Group practice affiliations; Medical and clinical training information; Written/spoken languages other than English; Hospital affiliations, which link to the hospitals’ profile on Hospital Compare “when possible;” American Board of Medical Specialties (ABMS) board certification information; Whether physicians and other healthcare professionals accept Medicare Assignment; 2012...
As we enter 2014, we expect to see the term “Big Data” become increasingly familiar. Wikipedia defines Big Data as the “collection of data sets so large and complex that it becomes difficult to process using on-hand database management tools or traditional data processing applications” and notes that “The trend to larger data sets is due to the additional information derivable from analysis of a single large set of related data, as compared to separate smaller sets with the same total amount of data, allowing correlations to be found to ‘spot business trends, determine quality of research, prevent diseases, link legal citations, combat crime, and determine real-time roadway traffic conditions.’ [Citations omitted].” In healthcare, the value of large data sets for clinical research and for prevention of disease is clear. The Multicenter Perioperative Outcomes Group registry and the National Anesthesia Clinical Outcomes Registry noted in Dr. Richard Dutton’s article, Using Big...
  There are now more than 500 Accountable Care Organizations (ACOs) up and running in the U.S.  Since they first appeared on the health care horizon, interest in their potential to improve quality while reducing or at least holding down costs has continued to grow.  Specific approaches and strategies for shifting the quality/cost equation such as ASA’s Perioperative Surgical Home model are developing with a view toward participating in future ACOs.  How—and how well—are ACOs working as the health care system’s transition to value-based care proceeds?  Overall, the results are a mixed bag. Of the 114 ACOs that joined Medicare’s Shared Savings Program (MSSP) in 2012, only 54 achieved savings in their first year of operations.  Still, 106 new ACOs joined the MSSP in January 2013, and another 123, covering 1.5 million patients, signed up to participate in 2014.  Many of those ACOs may have opted for the low-risk, one-sided model in which...
On Friday, May 2nd, the JDRF Metro Detroit and Southeast Michigan Chapter will host its 29th Annual Promise Ball at MGM Grand Detroit.  As Honorary Co-Chairs for the gala, Tony and Sue Mira of Anesthesia Business Consultants, invite you to join them in the celebration and ask you to consider lending your support for this event.Diabetes impacts the lives of some 26 million Americans.  JDRF is committed to finding a cure for Type 1 diabetes (T1D) and its complications through the support of research.  JDRF also focuses on science and developments that help people with diabetes live better lives now.  Each year, nearly 15,000 children are diagnosed with T1D, with another 15,000 adults receiving the same diagnosis. With 30,000 new cases every year, it is clear there is work to be done. We ask you to be part of the solution.  Your contribution will help the many children and adults living...
The current upheaval in the business of anesthesia has been previously reviewed in various issues of the Communiqué. While complex forces are involved in these changes, one aspect of practice management is vitally important for both individual anesthesia professionals and their anesthesia services: disruptive change.1 Disruptive innovation occurs when processes are improved and adopters of these new processes have operational and financial advantages over their competitors. Disruptive innovation is most likely to start in service niches rather than engulf an entire industry. Anesthesia professionals in ambulatory surgery centers (ASCs) are most likely to undergo disruptive innovation. Why will these changes occur in ASCs? With increasing out-of-pocket expenses, patients are going to be more cost conscious than ever before. Demands from patients, referral sources, and insurers will require ASCs to provide high quality services at the lowest possible costs to survive. ASCs are fertile ground for disruptive change because their lower acuity...
  The Office of the Inspector General (OIG) in the Department of Health and Human Services released its Work Plan for 2014 on January 31, several months later than usual in part, at least, because of the sequestration and government shutdown engineered by our dysfunctional Congress last fall. The Work Plan explains the OIG’s priorities and provides a brief description of the activities it will initiate and continue during each fiscal year.  The document identifies the year in which the OIG expects to issue one or more reports as a result of the review, and indicates whether the work was in progress at the start of the fiscal year or will be a new project during the year.  As reports are issued, they are posted to OIG's website. Perhaps the best news in the 2014 Work Plan is the lack of any new anesthesia issues, although review of the use of the...
Higher acuity cases such as joint replacement and spinal fusions have moved into the ambulatory surgery center setting over the past few years as minimally invasive techniques allow surgeons to perform traditionally inpatient procedures in an outpatient setting. The anesthesiologist plays a crucial role in making these cases successful. If patients have a great experience, appropriate pain expectations and continue to make progress after they return home, they’re likely to recommend the center to others and revisit the next time they need a procedure. “When a patient says they didn’t have a good experience and felt sick, we just can’t cut that person loose. We have to check up on them and I think ASCs do a great job of looking at the patient surveys and following up,” says Charles Tullius, MD, an anesthesiologist in Savannah, Ga. “If the patient has one knee done at the center, they’ll return when they...
Leaders in medicine and health policy are focusing on a new component of care:  appropriateness.  Only those medical services and interventions that are likely to help and not harm the patient and that represent value (cost/quality) are appropriate.  The real issue is, of course, knowing which services are appropriate. The Choosing Wisely® campaign, an initiative of the American Board of Internal Medicine Foundation, aims to promote conversations between physicians and patients by helping patients choose care that is: Supported by evidence Not duplicative of other tests or procedures already received Free from harm Truly necessary In response to this challenge, more than 40 national organizations including the American Society of Anesthesiologists have stepped up to the ABIM Foundation’s invitation and identified one or more sets of five tests or procedures commonly used in their field the appropriateness of which should be questioned and discussed with patients.  The resulting lists of “Five Things...
Securing the Future for Anesthesia PracticesAs the health care world continues to evolve, offering new technological advances and business models, along with changing laws and regulations, it’s imperative to keep informed. Anesthesiologists, Practice Administrators, CRNAs and others in the anesthesia marketplace now have a great new option when looking to attend a conference on anesthesia practice management:  The Advanced Institute for Anesthesia Practice Management.The Advanced Institute for Anesthesia Practice Management is an exciting new conference with new sponsors and a fabulous new venue. Previously known as the Anesthesia Billing & Practice Management Seminar, this new name reflects our commitment to position our conference as the premier educational opportunity for decision makers of anesthesia practices, including Anesthesiologists and Practice Administrators. The conference will take place at the hottest property on the Las Vegas Strip, The Cosmopolitan of Las Vegas, from April 11-13, 2014.The Advanced Institute for Anesthesia Practice Management offers the anesthesia...