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Computers and improvements in modern anesthesia delivery have gone hand-in-hand. In 1952 Himmelstein and Scheiner reported that they began using an instrument called the cardiotachoscope and found it useful during surgery. In 1958 Ben Ettelson and James Reeves started Spacelabs to develop systems for the United States Air Force for monitoring vital signs of U.S. astronauts.1 This technology returned to earth, with the 1970s witnessing the expansion of digital electronics in operating rooms (ORs) and critical care units (CCUs). The 1980s saw clinical penetration of modularity and utilization of saturation and end-tidal carbon dioxide monitoring. As pharmaceuticals developed shorter and shorter clinical half-lives and microprocessor technology continued to improve, the concepts of closed-loop (CL) anesthesia, targeted-controlled infusion (TCI) devices and other computer controlled delivery systems moved from theoretical possibilities to clinically relevant systems.2 In the late 1990s Dr. Randy Hinkle, an anesthesiologist, formulated the initial concept that ultimately became Computer- Assisted...
“Transparency” is a word that you will encounter more and more frequently in health policy articles, including ABC’s publications.  Information transparency is a key for enabling healthcare purchasers to make value-based decisions concerning the quality and price of services.  Those data are slowly becoming more available, but they remain largely inaccessible to most potential users. CMS recently released the third year of information from the Medicare Provider Utilization and Payment Data: Physician and Other Supplier database.  The database is comprehensive and offers the following information for every physician or Part B supplier who submitted claims in 2014:  name, address, gender, specialty, procedure (by HCPCS/CPT™ code), place of service, number of services, number of Medicare beneficiaries, average payment amount, average allowed charge and average submitted charge.  What is missing is any information on patients or on outcomes.  This being a Medicare database, it excludes the two-thirds of patients who are not in...

Posted by on in Enhancing Quality
Effective anesthesiology group governance is no longer a luxury but instead an important survival skill. Why? The external environment is threatening— changes in reimbursement, threats from competitors, hospital consolidation—all add up to the need to make decisions, change and adapt. The internal dynamics of many groups are challenging—getting “the entire herd roughly moving west,” dealing with disruptive physicians, developing an agreed upon group strategy—all require a well organized governance system. Whether your group’s Board includes all the shareholder physicians, or you have chosen a subset of the shareholders to serve as the Board, there are a number of steps that you can take to strengthen your Board’s performance. Here are several of the most important steps that an anesthesiology group Board can take. Improve Board Meetings We begin with Board meetings. Why Board meetings? No matter your group’s size, meetings are a tool that all groups use in their governance processes....
“Patient Safety Issues Spur NIH Shake-Up” was an above-the-fold headline in the Washington Post on May 11, 2016.  NIH Director Francis Collins, MD is replacing top leadership at the 200-bed Clinical Center with a new management team with experience in oversight, compliance and patient safety in the wake of an independent review that found that safety had become “subservient to research demands.” Also in the news recently was a study published in The BMJ (BMJ 2016; 353 doi: http://dx.doi.org/10.1136/bmj.i2139 [Published 03 May 2016]) by researchers at Johns Hopkins urging the Centers for Disease Control (CDC) to list medical error, broadly defined, as the third most common cause of death in the U.S. after heart disease (611,105 deaths per year) and cancer (584,881 deaths per year).  According to the study, the annual number of U.S. deaths attributable to medical error is approximately 251,454—more than three times higher than the 98,000 preventable deaths cited...

Posted by on in Anesthesia
Deciding on new models for an anesthesiology practice is one of our very biggest challenges. It is not realistic for anesthesiologists to continue believing that if they consistently provide good quality care, all of their financial and business issues will take care of themselves. “The beliefs and strategies that have gotten us to where we are today will not get us to where we want to be tomorrow,” as ABC Vice President Jody Locke writes in his article The Road Not Taken in this issue of The Communiqué. The transition to value-based payment, combined with the strong trend toward larger anesthesia groups and tight affiliations with national anesthesia companies and/or with health systems, has changed the landscape for traditional independent practices. Bill Britton sums up the current environment in Critical Issues to Consider When Exploring the Sale of Your Practice: hospitals are facing mounting pressures to minimize operating costs, including the...
Last week’s e-Alert introduced our readers to the proposed regulations implementing the MACRA Quality Payment Program (Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models).  We focused in Part I on the MIPS pathway, which consolidates Medicare’s current quality, cost and EHR reporting programs and promised an overview of the second major physician payment pathway set forth in the proposed rule, the APM Incentive program. All eligible clinicians will be participating in either the MIPS or the APM program in the near future, as the Physician Quality Reporting System (PQRS), the Value-Based Modifier (VBM) program and the EHR Incentive-Meaningful Use (MU) program phase out, by the end of 2018.  Beginning on January 1, 2019, payments will reflect participation in MIPS or APM, based on each clinician’s performance in 2017.  The APM incentives are as follows: For...
In the Winter 2016 issue of The Communique, we offered Part I of a summary of state laws (Alabama through Iowa) involving the peer review process. Here we are continuing that summary with the remaining states (Kansas through Wyoming).1     1Special thanks is given to Amy Bell for her assistance in preparing this article....
We have known since Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA), just over a year ago, that big changes in the way that CMS pays physicians are coming. MACRA has already repealed the detested Sustainable Growth Rate formula. On Wednesday, April 27, CMS released the proposed regulations (Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models) that begin to define the new unified framework called the Quality Payment Program going forward. The 962-page proposed rule is just that: proposed. CMS will be receiving public comments through June 27 and will then consider them for several months before publishing the final rule later this year. We hope that the final will be released sooner rather than later, because anesthesiologists and other physicians will need to know what they must do before January 1, 2017....
Anesthesia Business Consultants (ABC), a leading provider in billing and practice management for anesthesia and pain management specialty, is pleased to announce they will be serving as Diamond Sponsor, as well as attending the Medical Group Management Association’s 2016 Anesthesia Conference, being held this weekend, May 5 – 7, 2016, at Gaylord National Resort & Convention Center, National Harbor, MD.  Whether you are new to anesthesiology/pain management or an experienced administrator, the MGMA 2016 Anesthesia Conference will provide practical education that will include peer-to-peer interaction, tools and techniques and in-depth learning experiences designed to help you and your practice succeed.ABC will be premiering the availability of its Qualified Clinical Data Registry (QCDR) program.  The QCDR is the next stage of the government’s transition to value-based payments.  ABC's new QCDR program demonstrates our strong commitment to clients, the industry and compliance with these governmental quality programs.Payment models are getting even more complex...
On July 13, 2015, we informed you of CMS’s Two-Midnight Rule.  After much pushback from industry stakeholders and from the judicial system since our alert, CMS proposes to eliminate the notorious payment reduction under the Two-Midnight Rule in its FY 2017 Medicare Inpatient Prospective Payment System (IPPS) Proposed Rule (Proposed Rule).  Though not slated to be finalized until the latter part of 2016, hospitals and their partners can be optimistic that the penalty under the Two-Midnight Rule may soon be a memory. The Two-Midnight Rule, effective beginning October 1, 2013, was enacted with the intent of curbing payment for inpatient hospital admissions (i.e., Part A).  The Two-Midnight Rule generally states that payment under Medicare Part A is appropriate if the admitting physician has a reasonable expectation that the patient’s stay would span at least two midnights.  For patients expected to stay less than two midnights, payment under Medicare Part B (i.e.,...
Correlation does not equal causation. One fresh demonstration of the truth of this axiom appears in an article in this month’s issue of Gastroenterology (Wernli KJ, Brenner AT, Rutter CM, Inadomi JM. Risks Associated With Anesthesia Services During Colonoscopy. Gastroenterology 2016; 150: 888-894). The research team, from the Group Health Research Institute in Seattle, performed a prospective cohort study of nationwide claims data from 3,168,228 colonoscopy procedures in adults aged 40 to 64 in the Truven Health MarketScan Research Databases from 2008 to 2011. Moderate sedation was performed in 65.6 percent of the procedures included in the study; deep sedation (in most cases using propofol) was provided by anesthesiologists or nurse anesthetists in 34.4 percent. The study authors found a correlation between use of anesthesia services and a 13 percent higher risk of any complication within 30 days: specifically, higher risk of perforation, bleeding, abdominal pain, complications due to anesthesia, and...
How would you like to know exactly what’s going to happen in the future so that you can prepare for and profit from it? I have a crystal ball. Here, let me share it with you. We’re going to review some of the trends currently impacting, and soon to impact, hospitals that will, I predict, lead to their destruction, at least as we know them. There is absolutely no question that these trends are going to have an impact on your anesthesia practice. Start preparing now. Trend 1: Hospitals Are Getting Bigger and That is a Weakness Government induces physician labor Obamacare favors the growth of hospitals with its incentives for aligning physicians. Think Accountable Care Organizations (ACOs) and other incentives to coordinate care, meaning coordination via hospitals. Although reports lag by several years, at least 20 percent to 30 percent of all practicing physicians are currently employed by hospitals. There...
Many pain medicine procedures, and, increasingly, perioperative and critical care procedures such as central venous access are performed using ultrasound guidance (U/S).  Indeed, U/S is an integral part of many CPT® codes, e.g., 20604 [Arthrocentesis, aspiration and/or injection, small joint or bursa, (e.g., fingers, toes), with ultrasound guidance, with permanent recording and reporting].  When and where, and by whom, must those permanent images be stored?  What if another entity, such as a hospital, is responsible for storing them?  According to Sonosite, All diagnostic ultrasound examinations, including those when ultrasound is used to guide a procedure, require that permanently recorded images be maintained in the patient record. The images can be kept in the patient record or some other archive--they do not need to be submitted with the claim. Images can be stored as printed images, on a tape or electronic medium. Documentation of the study must be available to the insurer...
One important voice sounding a warning or at least a heads-up about what is coming is that of Mark Weiss, Esq. The title of Mr. Weiss’s article— Impending Death of Hospitals: Will Your Anesthesia Practice Survive?—which is also the title of his forthcoming book—is intentionally provocative. He lays out several of the major threats confronting hospitals, starting with health system growth, through mergers and acquisitions, acquisition of physician practices and investments in integrated delivery networks. Others have predicted that the Federal Trade Commission will place a damper on hospital merger activity in 2016, but the quest for greater scale and scope is going to continue. Anesthesiologists may want to consider the wisdom of relying on the ongoing health of just one or two hospitals. This is especially true in light of the ability of physician-owned facilities, notably ambulatory surgery centers, and new technologies (think telemedicine) to disrupt hospitals’ traditional business. Mr....
If you receive a letter by email that begins like this:     You should respond within the 14 days mentioned in the letter.  Congratulations; you are participating in Phase 2 of the HIPAA Audit Program.   With this letter, OCR is seeking just to identify contacts to create a pool of HIPAA-covered entities (CEs) and their business associates (BAs) for possible audits.  In the next step, OCR will transmit a pre-audit questionnaire to gather data about the size, type, and operations of CEs and their BAs.  These data will then be used with other information to create potential audit subject pools.  Eventually more than 200 entities will face audits in Phase 2 of the HIPAA Audit Program, which will primarily be desk audits, although some on-site audits will also be conducted.   Phase 1 of the HIPAA Audits   HIPAA established national standards for the privacy and security of protected...
The anesthesia record, like medical records in general, should be complete and accurate at the time when the physician signs it—ideally.  In practice, it occasionally requires amendment. Given the huge role that accurate documentation plays in our medical payment system, compliance with the rules and regulations governing medical record amendments is important.  Altered medical records have great potential for fraud, especially if the added information helps to raise the level of a billable service, and no one should be surprised if auditors look at any changes closely. One basic principle was added to the first paragraph of the provision that regulates amendments in Chapter 3 of the Medicare Program Integrity Manual, Section 3.3.2.5, when that provision was updated effective October 2, 2015.  The intent of the new paragraph is to make it clear that amendment should be the exception.  All services provided to beneficiaries are expected to be documented in the...
“CMS’ pay-for-performance reimbursement changes are looming. As members of the Huntington Accountable Care Organization (ACO), anesthesia recognizes the need to improve surgical outcomes. Our collective financial future is tied to solid quality improvements that only increasingly coordinated care can deliver. We will double down on our cooperative effort with our hospital in order to improve medical outcomes, to lower costs and to improve the patient experience.” – Pacific Valley Medical Group, Pasadena, CA. Summary of Recent Events The Centers for Medicare & Medicaid Services (CMS) is pushing quality, the American Society of Anesthesiologists (ASA) is pushing the perioperative surgical home (PSH) and our 30-partner Pacific Valley Medical (anesthesiology) Group (PVMG) in Pasadena, CA is picking up both causes. In our commitment to a PSH clinic staffed and managed by anesthesiologists, we are fully embracing the concept of transitional care & perioperative medicine. This is our contribution to our patients and to...
Recent media coverage of surgeons operating in two concurrent cases raises three issues:  (1) patient safety, (2) compliance with the Medicare teaching physician billing rules and (3) transparency vis-à-vis patients. The Safety Controversy The question whether it is right or safe for surgeons to run two operations at once erupted publicly last year when the Boston Globe published a detailed report (Clash in the Name of Care) focusing on events that had occurred at Massachusetts General Hospital (MGH) in August 2012.  A 41-year old patient had undergone complicated spinal surgery from which he emerged a quadriplegic, and it revealed itself that his surgeon had been in and out of the operating room, attending to a patient undergoing spinal fusion in another OR for seven of the eleven hours that the first case took to complete.  A controversy among MGH surgeons and anesthesiologists over concurrent surgeries had been years in the making. ...
Donald Berwick, MD, senior fellow at the Institute for Healthcare Improvement (IHI) (and a former CMS administrator) described nine steps to advance healthcare into “the moral era” at an IHI forum in December, 2015.  One of those steps was to “stop excessive measurement.”  Dr. Berwick said: I don’t mean that we should stop measuring.  Indeed, I celebrate transparency in every form.  How else can you learn? But we need to tame measurement.  It has gone crazy.  Far from showing us our way, these searchlights training on us, they blind us. ... I vote for a 50 percent reduction in all metrics currently being used. Many anesthesiologists and pain physicians will agree that quality measurement has gone over the edge.  The ASA’s Anesthesia Quality Institute (AQI) has adopted 22 measures and has identified 26 official Physician Quality Reporting System (PQRS) measures that can be reported by anesthesiologists and/or pain physicians.  In proposing 48...

Posted by on in Anesthesia
When you received your 2016 Current Procedural Terminology (CPT) and American Society of Anesthesiologists (ASA) Relative Value Guide (RVG) books or discs, you probably noticed there were no new anesthesia code additions or deletions listed for this year. Since the CPT book usually arrives before the RVG, you may not have taken a good look through your RVG or may not have ordered a 2016 RVG as there were no coding changes. However, there are a number of important updates in the RVG New/ Revised RVG Coding Comments section which are not included in the Anesthesia section of the CPT. These comments may affect the way anesthesia coders assign procedure codes in the upcoming year. As this article will not include all updated comments, be sure to order your 2016 RVG. I’ve chosen a few that are certain to have an impact on 2016 coding for anesthesia services. Let’s start with...