December 29, 2014

As we write this Alert on Christmas Day, we are thinking about the tumultuous year gone by.  So much is changing so fast that it’s hard to stop long enough to catch our breath.  Below are some of the developments through 2014 that are going to shape our future, immediate and long-term.  Inclusion of a particular change or trend does not mean that it was necessarily among the most important; nor does omission mean that a given development was less momentous.  There are far too many issues for an exhaustive list.

Anesthesia

1. The Perioperative Surgical Home (PSH).  The PSH model of care—a patient-centered, physician-led system of coordinated care striving for better health, better health care and reduced costs of care—gained traction throughout 2014.  In April, ASA announced the selection of Premier, Inc. to develop a first-of-its-kind learning collaborative for the PSH.  The first learning collaborative cohort consists of 44 provider organizations currently working to define the model, pilot the model and assess whether the model proves superior to conventional perioperative care.  The first collaborative is expected to continue until November 2015.
2. The Quality Clinical Data Registry (QCDR).  Also in April 2014, the Anesthesia Quality Institute’s National Anesthesia Clinical Outcomes Registry (NACOR) received certification as a QCDR.  A QCDR offers, among other things, an alternative method of reporting quality measures and avoiding the PQRS penalty for 2015 and beyond.  The greatest advantage of NACOR as a QCDR is that it includes 19 measures selected for their applicability to anesthesia practice.  More measures relevant to anesthesiology and its subspecialties are expected to be added in 2015.
3. Safety of propofol in outpatient facilities.  The shocking death of Joan Rivers shone a spotlight on the safe use of propofol in endoscopy centers.  The 22-page CMS Statement of Deficiencies and Plan of Correction regarding the care provided to Joan Rivers at the Yorkville Endoscopy Clinic showed numerous problems and inconsistencies in the medical records.  The corrections that the endoscopy center must undertake to keep its certification serve as a reminder that propofol must be handled like other anesthetic agents.  They include:
   1. imposing stricter procedures for credentialing physicians and observers who are admitted into ORs,
   2. performing full assessments of patients' weights, allergies and medical histories before administering propofol,
   3. ensuring that supplemental oxygen is routinely used and immediately available for patients sedated with propofol, and
   4. having anesthesiologists check vital signs at least every 5 minutes for propofol-sedated patients.

Healthcare Reform

1. The Affordable Care Act (ACA).  The ACA will come under renewed attack with the Republicans having won solid majorities in both Houses of Congress and now controlling 31 governorships.  Few observers expect full repeal through legislative action.  The Supreme Court, however, will decide whether the ACA allows insurance subsidies in all states, or only in those states that establish their own marketplaces, when it considers King v. Burwell on March 4, 2015.  If the Court limits the subsidies, there would be serious consequences for the affordability and availability of individual health insurance and on the insurance marketplace itself.
2. Accountable Care Organizations (ACOs). More than 600 ACOs, both public and private, are in operation, covering some 20 million individuals.  Eighty-nine ACOs will join the Medicare Shared Savings Program in January 2015.  The proportion of “value-based” private insurance payments is now as high as 40 percent of the market, according to some estimates.
3. Increased patient financial responsibility.  The rise of high-deductible health plans and increased cost-sharing have made patients responsible for a larger share of their healthcare bills.  This has made collections more challenging, especially during the earlier part of the year when patients have not met their deductibles.  Longer term, the shift of financial responsibility may be leading to more patient awareness and to a serious brake on healthcare spending.
4. Rise of multi-institution hospital networks and physician employment.  During the past year, hospitals and health systems underwent approximately 98 consolidations, a 51 percent increase over 2010.  Some are concerned that the consolidation will constrain patient choices within a narrowing marketplace.  The most recent AMA Physician Practice Benchmark Survey showed a decrease in practice ownership of eight percentage points since 2007-2008, with 41.8 percent of physicians employed in 2012.  Reasons for the increase in health system employment of physicians included stagnant payment rates and a desire for better work-life balance on the physician side and a drive to expand market share on the hospital side.
5. Spread of Health Information Technology (HIT).  Eighty percent of eligible professionals and 98 percent of eligible hospitals have qualified for a total of $25.4 billion in Meaningful Use incentive payments by adopting electronic health records (EHRs).  (Commonwealth Fund Blog, December 23, 2014.)  This success rate was based on Stage 1 of the EHR incentive program.  The Stage 2 requirements have been much harder to satisfy both for physicians and vendors and the AMA has estimated that more than 50 percent of eligible professionals will face penalties.  Interoperability issues are slowing down but not stopping the digital revolution.  Electronic transactions could save healthcare providers $6.7 billion and health plans $1.4 billion each year, according to a report for the Council for Affordable Quality Healthcare.  The introduction of wearable technologies—the Internet of Things—will transform aspects of healthcare including patient monitoring.

The lists above are retrospective; we are not making any predictions other than that 2015 promises to be another year of dramatic challenges and opportunities.  We hope that it will be a successful year for each and every one of you.

With best wishes,

Tony Mira
President and CEO