May 18, 2015

Post-acute care services are a major driver of spending, particularly for the Medicare population.  Nationwide, one in seven surgical patients is readmitted within 30 days, stated Michael Schweitzer, MD, MBA, who chairs ASA’s Future Models of Anesthesia Practice task force and who gave a very thought-provoking talk on “The Future of Anesthesia Practice” at the MGMA Anesthesia Conference in Chicago on May 1, 2015.

Such readmissions are difficult for patients—and they are costly.  In 2009, the average cost of a total hip replacement readmission was $12,300, with an 8.2 percent readmission rate.  (Rizzo E. 6 Stats of the Cost of Readmission for CMS-Tracked Conditions.  Becker’s Hospital Review, December 12, 2013.)  Dr. Schweitzer cited a study published in Health Affairs in 2012 showing that surgical complications could increase the costs of care up to $58,000 per case.

One out of every six Medicare fee-for-service program dollars goes to care provided in rehabilitation facilities, nursing homes, long-term care hospitals and home-based services  (Rau J.  Medicare Seeks to Curb Spending on Post-Hospital Care.  Kaiser Health News, December 1, 2013).  Within that national statistic, there is a startling amount of variation.  Uneven spending on post-acute care accounts for 73 percent of the variation in Medicare spending.  Three times as many Medicare beneficiaries in Chicago receive post-hospital services as do their peers in Phoenix.  Many post-acute providers are paid per day, up to a certain maximum number of days (e.g. nursing home stays, for which Medicare pays 100 percent of the cost for the first 20 days), without controls on the medical necessity for all the days of care that are billed.  Policy-makers understandably question the appropriateness of all the care that is being furnished in high-utilization areas.

Value-based payment models seek to change that calculus by removing the incentives for more extensive health care services and shifting the risks of excess costs to those who can best manage them.  The Center for Medicare & Medicaid Innovation (CMMI) is overseeing numerous bundled payment experiments in which hospitals and post-acute providers collaborate to offer an episode of care, including all pre-, intra- and post-surgical services for the patient, for a single predetermined amount.  Mark Froimson, MD, an orthopedic surgeon, discussed one of the CMMI pilot programs at last October’s ASA Annual Meeting.  He was quoted in Anesthesiology News (April 2015, pp. 25-26) with the following interesting observations on the team approach and complete management program followed:

Surgical teams must change their workflow.  Instead of approving patients for joint replacement, scheduling them and then optimizing them, which often leads to cancellations, the team should put patients into an ‘indicated’ pool.  Then the team can create a checklist to review with each patient—diabetes, smoking, body mass index, anemia, staph colonization, narcotic dependence, anticoagulation and lack of a supportive home environment—before scheduling a procedure.

This approach is consistent with Dr. Schweitzer’s vision for replacing the preoperative clinic with a perioperative care clinic providing “physician-led, professionally managed” care coordinated across disciplines and sites of service.  Planning for post-acute care can begin at the preoperative stage, and preop clinics can expand to “Post-Discharge Transitional Care Clinics” as shown in this graphic from Dr. Schweitzer’s talk:

The activities listed in the graphic are being handled by departments and providers everywhere—but not necessarily in a coordinated fashion.  There is an oversight vacuum to be filled as well as substantial dollars to be saved and redistributed, and Dr. Schweitzer argued persuasively that anesthesiologists could and should take the opportunity.

The transitional care management (TCM) codes that were introduced in 2013 make it more attractive to furnish post-acute care.  CPT^® code 99495 pays approximately $164; 99496 pays close to $200.  These two codes cover communication with the patient or caregiver within two business days of discharge, which can be done by telephone, by email or in person.  They involve medical decision-making of moderate or high complexity, respectively, and a face-to-face visit within 14 or seven days of discharge.  Specific activities targeted by the TCM codes (and that anesthesiologists should consider) may include:

• Clinical staff (under the supervision of a physician or other qualified clinician):
  • communicate with the patient or caregiver (by phone, email, or in person),
  • communicate with a home health agency or other community service that the patient needs
  • educate the patient and/or caregiver to support self-management and activities of daily living
  • provide assessment and support for treatment adherence and medication management,
  • identify available community and health resources, and facilitate access to services needed by the patient and/or caregivers

• Physician or other qualified clinician:
  • obtain and review discharge information,
  • review need of or follow-up on pending testing or treatment,
  • interact with other clinicians who will assume or resume care of the patient’s system-specific conditions,
  • educate the patient and/or caregiver, establish or reestablish referrals for specialized care, and assist in scheduling follow-up with other health services.

The availability of a $160-$200 payment is of course not a sufficient rationale for expanding the role of the anesthesiologist so far beyond the time of discharge from the post-anesthesia care unit.  Economic accountability and the explosion of Value-Based Purchasing are compelling, however. 

Within the VBP context, anesthesiologists are beginning to establish Perioperative Surgical Homes, taking the responsibility for managing the surgical care episode from the preoperative phase through at least the first 30 days postoperatively.  Is there anyone in a better position to lead the team of professionals who will deliver the right care, in the right way, during the all-important post-acute period?

With best wishes,

Tony Mira
President and CEO