One of the biggest takeaways from the ASA Practice Management Conference held in San Diego on January 29-31 was the need for anesthesiologists to start thinking about what the Medicare and CHIP Reauthorization Act of 2015 (MACRA) will mean for their practices. Physicians are already benefiting from the MACRA provisions that repealed the Sustainable Growth Rate (SGR) formula that would have driven Medicare payments down dramatically had Congress not overridden it every year.  Instead of a 27 percent SGR cut that would have been implemented on April 15, 2015 absent the legislation, payments increased by 0.5 percent on July 1st.  They were to increase again by 0.5 percent on January 1st of this year but adjustments for budget neutrality and a target reduction for allegedly misvalued codes in each of the next three years caused them to decrease by 0.2 percent.  Beyond 2016, MACRA provides for 0.5-percent conversion factor increases in 2017-2019...

The Medicare requirement that eligible professionals and hospitals demonstrate “meaningful use” (MU) of electronic health record (EHR) technology has received a lot of attention from provider organizations and in the media recently.  Two significant MU developments have occurred in the last few weeks:  (1) the Centers for Medicare and Medicaid services (CMS) launched a streamlined process for claiming a hardship exemption and (2) CMS Acting Administrator Andy Slavitt stated publicly that the MU program “will now be effectively over and replaced with something better.” Before explaining those two events, let us first assure readers that the MU program has not changed as far as its impact on anesthesiologists is concerned:  all physicians with the specialty designation “anesthesiology” (“05”) in the Medicare Provider Enrollment Chain and Ownership System (PECOS) continue to benefit from an automatic exemption from the MU requirements.  Let us remind you, too,  that any physician who satisfies the MU requirements...

Anesthesia Business Consultants (ABC), a leading provider in billing and practice management for the anesthesia and pain management specialty, is pleased to announce it will be attending PRACTICE MANAGEMENT 2016 hosted by the American Society of Anesthesiologists, held January 29-31 at the San Diego Hilton Bayfront in San Diego.  This event is the premier business event for physician anesthesiologists and practice administrators. ABC will be demonstrating its new anesthesia-specific ICD-10 documentation application, F1RSTCode.  Unlike other apps in the industry that are not specialty-specific, F1RSTCode assists anesthesia providers in understanding documentation requirements without burdening them by requiring a search through the entire ICD-10 code sequence. In a very logical and intuitive way, F1RSTCode takes you from the surgical procedure through the logic of ICD-10.  It not only provides invaluable guidance for documenting the diagnosis, but will also provide a framework for discussing the post-operative diagnosis with the surgeon during the post-op time out. PRACTICE...

There are more nearly 50,000 hospitalists practicing in the U.S. today and the specialty continues to grow rapidly.  A recent American Society of Anesthesiologists (ASA) Health Policy Research paper entitled “Prevalence of Hospitalists in U.S. Community Hospitals” found that between 2012 and 2013, 34 out of 50 states showed an increase in the percentage of hospitals using hospitalists and that the percentage of community hospitals using hospitalists increased by almost five percent during that period. Hospitalists in general are trained as internists.  (The American Board of Medical Specialties does not include a “hospital medicine” board nor offer subspecialty certificates.)  Their roles encompass the following, according to the Society of Hospital Medicine's (SHM's) website for residents and medical students, Future of Hospital Medicine: Care of patients who do not have primary care physicians (ED unassigned) Coordination of care: improving hospital throughput, decreasing length of stay and discharge planning Cost-effective, resource utilization Surgical...

The past several years have, once again, brought major changes to the anesthesia community and have greatly impacted private practice anesthesia. Whereas the early nineties were a time of “anesthesia surplus” when anesthesiologists struggled to find opportunities paying as little as $100,000, those days were followed by a shortage of anesthesia providers. Supply and demand economics dictated that during the days of anesthesia staffing shortage, prices and compensation for anesthesia staff increased to the highest levels in history. Now, a new day is on the horizon where hospitals have many choices for anesthesia coverage. Smaller, private practice anesthesia groups struggle to sustain financial viability. Many groups are exploring mergers to achieve economies of scale and hoped-for negotiation leverage with private payers. Larger and mega-groups continue to liquidate their value and sell to publicly traded companies such as EmCare or MedNax. A growing number of large anesthesia staffing companies continue to enter...

Depending on one’s standpoint and experience, the peer review process can bring about mixed feelings in healthcare providers. Opinions about the effectiveness of the process, those who sit on the panel and the outcome are often debated. However, what is often less debated until long after the process has taken place is whether the information reviewed during the peer review process is subject to discovery in other settings. Generally, the peer review process is a retrospective review of an event or series of events conducted in an effort to improve quality of care. In order to encourage candid review, many states have enacted laws to limit the discoverability of the proceedings, the records reviewed and the records created during the peer review process. In other words, in a civil proceeding, the contents of the peer review meetings and the records discussed are not discoverable and are not subject to a subpoena...

More than 14 million screening colonoscopies are performed each year.  Anesthesiologists and nurse anesthetists participate in a large proportion of these procedures.  There are several developments that may bring down the numbers or at least slow the rate of growth of screening colonoscopies that our readers, especially those whose practices include a significant volume of anesthesia for colonoscopy services, should note.   The first of the changes going forward is the reduction of Medicare payments for lower gastrointestinal endoscopies that went into effect on January 1, 2016.  CMS announced, in the Final Fee Schedule Rule issued in November 2015, that it was reducing the relative value units (RVUs) for the physician-work component of the Fee Schedule payment for screening colonoscopies by nine percent, from 3.69 to 3.36 RVUs, the value recommended by the AMA/Specialty Society Relative Value Update Committee (RUC). There were also changes to the RVUs for practice expenses. The...

Historically anesthesia information management system (AIMS) adoption has lagged significantly behind overall hospital electronic health record (EHR) adoption. However, in more recent years, the pace of AIMS adoption has accelerated with the implementation of meaningful use and with the increasingly apparent “gap” that a lack of electronic anesthesia encounter information leaves in a patient’s electronic clinical record. “In 2014, about 70 percent of hospitals in the U.S. had some form of electronic medical record and 45 percent of anesthesia practices utilized electronic anesthesia records, otherwise known as anesthesia information management systems (AIMS).” Unfortunately as hospitals increasingly adopt AIMS solutions, anesthesia providers (let alone anesthesia practice management teams) have had little input in the selection, build and implementation of the AIMS. However, input from anesthesia providers and practice managers is essential in order to get optimal use and benefits out of a system, regardless of the organization’s stage of adoption. For new...

We begin this new year with a list of the key changes to CPT coding and Medicare payment policies.The 2016 CPT edition had more than 300 changes, including 140 new codes, 132 revised codes and 91 deleted codes. It is important to understand the changes and what should be documented to support the new or revised codes. The majority of changes for 2016 appear in the Pathology/Laboratory section of CPT.  Radiology also had major CPT changes, including several for bundling along with “written report” guidelines. There have been gastrointestinal changes made in both 2014 (upper) and 2015 (lower) and in 2016 there were several additional changes.The Office of the Inspector General (OIG) has included non-covered services under Anesthesia Services to the 2016 Work Plan, stating:  “We will review Medicare Part B claims for anesthesia services to determine whether they were supported in accordance with Medicare requirements.  Specifically, we will review anesthesia...

As we barrel toward the end of 2015, let us stop briefly to consider some predictions for the year ahead in healthcare.  Below is a set of ten predictions that appeared in Fortune magazine earlier this month, along with several comments. The Federal Trade Commission (FTC) will block a major hospital merger based upon data showing clearly that consolidation leads to price increases more than quality gains.  In fact on December 18th the FTC moved to block a proposed mega-merger between Advocate Health Care and NorthShore University HealthSystem in Illinois—the third hospital deal the FTC sought to block in the past seven weeks.  The Illinois Attorney General joined the FTC in filing for a preliminary injunction to halt the merger pending Commission review.  The Illinois systems, which, if the merger went through would have a combined 15 acute-care hospital campuses, a children's hospital and a large group of employed and affiliated...

The late great Yogi Berra was famous for his humorous and wise observations. It is true that “the future ain’t what it used to be.” Until a few years ago, the future did not encompass the perioperative surgical home (PSH), but the potential impact of the PSH model cannot be doubted now. It is hard, if not impossible, to argue with the relevance of the model as value-based purchasing takes hold within the governmental and private payer markets. The lead article in this issue, The Perioperative Surgical Home: “Right for our Group?” by Rick Bushnell, MD, MBA, a private practice anesthesiologist in Southern California, is a shining example of the response that the proponents of the PSH hoped to bring about. The PSH is emphatically “right” for Dr. Bushnell’s group—a single specialty private practice, which, like many others, has been successful at providing traditional surgical anesthesia care but is wondering not...

“Patient satisfaction” and the patient experience are considered key measures of quality and  performance in our increasingly value-based healthcare system.  The American Society of Anesthesiologists’ Committee on Performance and Outcomes Measurement (ASACPOM) has acknowledged that “monitoring of patient satisfaction has already been incorporated into payment for performance plans and will be an important component of other payer, healthcare plan affiliations.  It is a given that this trend will continue and that assessment of patient satisfaction will affect payment for anesthesiologists in the near future.”  (White Paper on Patient Satisfaction and Experience with Anesthesia, as revised June 9, 2014.)  Health plans use patient satisfaction surveys to evaluate physicians and to determine incentive compensation, and consumer web sites such as HealthGrades often report patient satisfaction ratings as the sole physician measure.  Patient satisfaction surveys are also playing a growing role in medical boards’ assessment of physicians’ competency.The ASA-Anesthesia Quality Institute’s Qualified Clinical Data...

Our Pacific Valley Medical Group (PVMG) in Pasadena, California consists of 29 partners. We’re an independent, single specialty group primarily serving Huntington Memorial Hospital and Shriners Hospital for Children, Los Angeles. We love our practice, our hospitals and our community, and as a group we think we do a great job. As is true for most anesthesia practices, the delivery of our standard, elective anesthetic involves meeting a patient three minutes ahead of time, delivering anesthesia in the OR, landing that person in recovery and moving on to the next; “wash, rinse and repeat.” We delegate pre-operative management and post-discharge care to others. But many of us are now asking “Is this the best we can do? Is this our best effort?” Many think not. Patients, payers, administrators and our partner surgeons are beginning to expect more from our practice in this pending era of ‘pay for performance.’ The healthcare funding...

CMS released the Final Medicare Fee Schedule Rule for 2016  on October 30, 2015.  The November 9th issue of F1RSTNews discussed the conversion factors for anesthesia ($22.4426) and for other services ($35.8279) and some of the changes to the measures and registry options for the Physician Quality Reporting System (PQRS).  The final rule addresses a number of other matters of interest to anesthesiologists and pain physicians.  In this issue, we will summarize developments concerning the Value Based Payment Modifier (VM). The VM adjusts Medicare fee-for-service payments either upward or downward by assessing both the quality of care and the cost of the care provided, as explained in our November 3, 2014 Alert What Anesthesiologists Need to Know about the Value-Based Payment Modifier.  It is an adjustment made on a per claim basis to Medicare payments for physician services.  It is applied at the Taxpayer Identification Number (TIN) level to physicians (and beginning...

Sometimes those of us in the healthcare industry become so immersed in the multitude of applicable regulations, and their evolution and ambiguities, that we need to take a step back and be reminded of the basics. So for a few moments, let’s push aside the status of healthcare reform, the future of independent anesthesiology practices, the abstract and sometimes conflicting guidance governing anesthesia joint ventures and the nuances of ICD-10. Let’s refresh our recollection regarding a federal law that has been with us in various forms for about 25 years and that continues to impact us each day. This is a broad overview of the federal Stark law1 in 10 quick bullet points. It’s important to understand what Stark is and what it is not. It is relatively common for healthcare attorneys to receive calls from clients requesting a Stark review of a relationship when the Stark law is not even...

Are you using social media for professional purposes?  If so, you are in the vanguard of specialist physicians generally, and of anesthesiologists in particular.  Many doctors are still skeptical of the benefits, and leery of the potential to waste a lot of time. Primary care physicians are among the more engaged with social media.  Media such as Twitter and Facebook are useful tools for connecting with patients who research their doctors; nearly 70 percent of all patients go to the internet either before or after a doctor’s visit, said cardiologist Kevin Campbell, MD, in an October 31, 2015 interview with Forbes magazine (Doctors Using Social Media To Reach The New Consumers Of Healthcare).  That ability to educate and influence patients—and potential patients—is relevant to chronic pain specialists, who are much more accustomed to marketing their practices than are anesthesiologists.  Dr. Campbell addressed the benefits of social media for anesthesiologists and their...

CMS has now finalized its proposal to cover total joint replacement (TJR) procedures through a bundled payment methodology.  Under the Final Rule issued on November 16, 2015, some 800 hospitals across the country will be financially responsible for all of the inpatient and postoperative care of patients undergoing total knee or hip replacements from admission until 90 days after discharge.  CMS estimates that the new bundled-payment test will cover about 23 percent of TJR surgeries for which Medicare pays and save Medicare $343 million over the five performance years of the model. Through the Comprehensive Care for Joint Replacement (CJR) payment model, hospitals in 67 Metropolitan Statistical Areas (MSAs) will receive additional payments if quality and spending performance are strong or, if not, potentially have to repay Medicare for a portion of the spending for care surrounding a lower extremity joint replacement procedure.  The goal of the CJR model, according to...

The Scene: Monthly Board Meeting  Gotham Anesthesia Associates is a 45-physician anesthesiology group providing services to patients in and around Gotham, New Jersey. Several years ago the group agreed that it was too large to have all members of the group involved in every issue the group considers. At the time they developed a five-physician “Board” that was to guide the day-to-day, week-to-week operations of the group. The group settled on five members to allow for representation of each of the major service locations and/or subspecialty area. The Board meets once a month at 6:15 PM. Unfortunately, typically only Dr. Jones (the group’s President) and the Administrator are present at 6:15 PM. Other physicians join the meeting at various points and business typically gets started by 6:45 PM. Dr. Peters never arrives before 6:45 PM because, he says, “we never start until then anyway.” The group’s agenda is sent out three...

particular, the ever-growing complexity of the Physician Quality Reporting Program (PQRS) and the newer Value Based Payment Modifier seems more likely to generate frustration than to lead to major improvements in healthcare safety and outcomes. As noted in last week’s Announcement (The Anesthesia Conversion Factor and PQRS Changes in the Final Medicare Fee Schedule Rule for 2016), CMS is adding five items advocated by ASA to the list of PQRS measures that can be reported to a registry: Measure # 404:  Anesthesiology Smoking Abstinence; Measure # 424:  Perioperative Temperature Management  (which revises and replaces Measure # 193); Measure # 426:  Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) (using a checklist or protocol); Measure # 427:  Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU), and Measure # 430:  Prevention of Post-Operative...

Anesthesia practice management used to be relatively simple. Bill correctly, collect aggressively, and everyone is happy. It is true that Medicare and managed care made getting paid a little more challenging, but a good day’s work in most facilities generally resulted in enough revenue to cover the cost of the providers, and when it didn’t most hospitals have been willing to make up the difference with some level of stipend or revenue guarantee. Most anesthesia providers would argue that for all the payment challenges created by diverse payer rules, fee for service medicine is still the preferred system. They like the fact that you get paid to provide services. What they don’t like are the increasing layers of complexity being imposed by efforts to measure quality and appropriateness of care. Especially concerning is the perception that what started as a trickle of inconvenient reporting requirements is gaining momentum to form a...