November 26, 2012

Memorial Hospital—a hypothetical “Memorial Hospital”—considers itself extremely fortunate to have renewed its contract with Associated Anesthesiologists—a hypothetical “Associated Anesthesiologists”—for another three years.  Although one newly-formed anesthesia management company (AMC) and one freshly-capitalized market leader among AMCs have approached Memorial, the hospital let the anesthesia group know that it would not be entertaining any proposal.  If Memorial were to enumerate the attributes of Associated Anesthesiologists for which it is so grateful, the list would be as follows:

1. Associated Anesthesiologists keeps the surgeons happy.
Surgical volume is up slightly and the trend line is positive.  The last surgeon to approach hospital administration with a complaint about OR time and the service provided by the anesthesiologists herself left the area several years ago.  The rumor about the orthopedic surgeons building their own ambulatory surgery center pops up every year, but the chief of the service is not interested.

2. Associated Anesthesiologists no longer receives income supplementation.
The last contract with the group, like those that preceded it, provided that the hospital would supplement the anesthesiologists’ income up to the 75th percentile according to MGMA survey data.  Thanks to more efficient scheduling of cases both inside and outside the OR, to better relations with and utilization of the nurse anesthetists (whom the group employs) and to an increasingly successful pain medicine program, Associated Anesthesiologists’ revenues from patient care now places their partner income at the 80th percentile.

Memorial pays the group fair market value compensation for providing the medical director services that allow the OR to operate smoothly.  The anesthesiologists run the board and adjust to changing requirements for opening and closing ORs, handling add-on cases without difficulty or complaint.  The medical directorship payment is less than the value of improvements in the efficiency of the OR.

3. Associated Anesthesiologists continues to enhance OR efficiency.
Associated Anesthesiologists have been tracking OR efficiency metrics for ten years.  Block scheduling is well established.  Beyond providing information on cyclical/weekly/seasonal variations in case volume, and other basic utilization statistics, Associated Anesthesiologists’  data allow them—and the hospital—to know almost immediately whether the number of late starts for the first case of the day is increasing, for example, and which surgeon, anesthesiologist or other member of the OR team may be responsible.  Ninety percent of all cases start within ten minutes of the scheduled time.  The anesthesiologists’ focus on communicating patient information to the right people at the right time helps to hold down the number of day-of-surgery cancellations.  Patients’ charts are completed, and missing lab or other data obtained, the day before surgery.  The group coordinates transportation to and from the OR, and it benchmarks turnover time.  The group president belongs to the American Association of Clinical Directors and regularly attends AACD meetings.

4. Associated Anesthesiologists runs a solid pain medicine program.
Anesthesiologists are readily available and are valued by the surgeons and nurses for their post-operative pain management services.  They have worked well with other clinical staff to develop policies and procedures and to provide training for hospital nursing staff.  They are committed to tracking outcomes.  Memorial scores ten points above the national average on the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) measure for “pain ‘always' well controlled” on Medicare’s Hospital Compare website. 

5. Associated Anesthesiologists runs an effective pre-operative clinic.
Associated Anesthesiologists’ oversight significantly reduces charges to patients and their health plans for pre-operative testing.  They have implemented guidelines to order basic rather than comprehensive metabolic testing consistently, where appropriate, and to administer x-rays only when indicated by symptoms or previous examination findings. 

Patients who have been seen in the clinic are always prepared for smooth starts when they arrive in the OR suite.

6. Associated Anesthesiologists provides coverage for endoscopy, radiology and other out-of-OR cases.
Covering the growing demand for out-of-OR anesthesia is a challenge.  The best way to avoid losing valuable time traveling from the main OR to GI labs, MRI suites and other remote locations is to consolidate scheduling of cases in those locations, which Associated Anesthesiologists has achieved to a considerable degree.  The group has also helped Memorial to develop policies on “anesthesia” and “analgesia” consistent with the Medicare Hospital Conditions of Participation Guidelines and takes responsibility for training nonanesthesia  personnel in the provision of sedation services—all while maintaining the highest standards of quality.

Transparency is key.  Associated Anesthesiologists keeps medical staff and administration up to date on Medicare Part A (hospital, as enforced by The Joint Commission) and Part B (professional services) requirements.

7.  Associated Anesthesiologists has great leadership.
The group president meets regularly with the hospital CEO and other leaders.  He understands the hospital’s needs, and he communicates them effectively not just to the group, but also to the surgeons and nurses in the OR.  An anesthesiologist or a CRNA serves on numerous hospital committees, including peer review, quality assurance, credentialing, pain management, trauma and pharmaceuticals and therapeutics.  Group culture supports hospital committee participation.

The group is involved with all disciplines in the hospital.  It is a strong driver for procedure-specific coordinated care protocols, a prerequisite for participation in a future accountable care organization. 

8. Associated Anesthesiologists helps Memorial meet its Hospital Value Based Purchasing targets.
Memorial expects to receive a Medicare bonus in 2013 for its scores under the new Value Based Purchasing program.  The bonus is based on the hospital’s performance on 12 “clinical process of care” measures, including the Surgical Care Improvement Project (SCIP) prophylactic antibiotics, postop serum glucose control, perioperative beta blockade and venous thromboembolism prophylaxis measures, and also on “patient experience of care” measures, many of which depend on the anesthesia staff.

9. Associated Anesthesiologists participates in almost all health plans.
Associated Anesthesiologists fields an excellent negotiating team that has entered into participation agreements with health plans representing more than 95 percent of Memorial’s privately insured patients.

10. Members of Associated Anesthesiologists are active in the American Society of Anesthesiologists and several subspecialty societies.
The group maintains not just its clinical skills, but also its administrative and business know how, by facilitating the participation of its members in their national specialty and subspecialty (Society for Cardiac Anesthesia, American Society of Regional Anesthesia and Pain Medicine, Society for Obstetrical Anesthesia and Perinatology) organizations. Several group members serve on ASA committees, which gives them, and in turn, Associated Anesthesiologists and the hospital access to the latest information on anesthesiology and its intersection with healthcare reform.

There probably are some anesthesia groups across the country that are as saintly as the hypothetical Associated Anesthesiologists—and on even more dimensions.  The majority work and hope for good relationships with their hospitals but may fall short in some areas (not necessarily those listed above).  Anesthesia leaders looking for ways to enhance their hospital relationships may find the discussion here helpful.  We certainly hope so.

With best wishes,

Tony Mira
President and CEO