Ambulatory or outpatient anesthesia accounts for approximately 60 percent of surgeries in the U.S. today.  The majority of anesthesia practices provide services at one or more of the 5,300 Medicare-certified ambulatory surgical centers (ASCs).  The challenges faced by ASCs—whether hospital-owned or independent—affect us all.  In order to be your ASCs’ valued partners, anesthesiologists and nurse anesthetists need to understand how healthcare’s challenges in general and ASC’s challenges in particular affect your facilities. FinancialLike all other providers, ASCs are confronting declining payments.  Health insurers are squeezing their margins and ASCs are threatened by exclusion from provider networks, especially those dominated by hospitals with whose outpatient departments the ASCs might be competing.  Hospitals are rushing to create integrated networks while simultaneously growing horizontally through mergers.  Integrated networks not only lock up physicians who might otherwise refer to the ASCs; they may also limit the number of payers who will enter into contracts with...

Some of the most controversial provisions of the Affordable Care Act (ACA) are those that require individuals to either sign up for health insurance or to pay a tax.  Differing interpretations of the statutory language regarding the tax credit or “subsidy” that would enable lower-income individuals to afford coverage have given opponents of ACA a hook on which to hang a small but powerful legal weapon.  Contrary to the claims (and hopes) of some observers, recent federal Appeals Courts decisions are not the death knell for Obamacare, however. The statute provides for a premium tax credit for “health plans offered in the individual market within a State which cover the taxpayer, the taxpayer’s spouse, or any dependent (as defined in section 152) of the taxpayer and which were enrolled in through an Exchange established by the State under 1311.”  The question is whether tax credits would only be available for policies purchased through...

  In a health plan featuring a “narrow network” (NN), the carrier substantially reduces the number of participating physicians, hospitals and other providers.  Limiting the panel to providers offering lower prices is nothing new.  In the mid-1990s, HMOs and PPOs sparked a backlash from patients and a multitude of state laws requiring that insurers include any willing provider in their networks. The dynamic has changed since the Affordable Care Act (ACA) went into effect, however. Previously, employers imposed NN plans on their workers.  In May, the National Business Group on Health (NBGH) conducted a poll of 46 large employers and found that 17 percent already have a narrow network in place.  The poll results, which were made available to NBGH members, also found that an additional 24 percent of large employers were considering narrow network health plans for 2015 and 2016, and another 20 percent were mulling narrow networks for 2017. With the...

The first thing that most of us look for when CMS publishes the Proposed and then the Final Medicare Fee Schedule Rules is the payment update.  CMS chose to say nothing about payment rates for 2015 in the Proposed Rule that appeared on July 3rd, however, because the Fee Schedule update and Sustainable Growth Rate (SGR) “calculations are determined under a prescribed statutory formula that cannot be changed by CMS.”  (CMS Fact Sheet on Proposed policy and payment changes to the Medicare Physician Fee Schedule for Calendar Year 2015.)  Instead, the current conversion factors will remain unchanged through March 2015, pursuant to the Protecting Access to Medicare Act (PAMA) of 2014.  Before Congress passed PAMA, CMS had estimated the update 2015 at -20.9 percent.  That is still a reasonable approximation—unless, as everyone hopes, the SGR is repealed or at least suspended again by legislation. The Proposed Rule nevertheless consists of 608...

It’s summertime and vacation plans are high on everyone’s list.  Sometimes arranging coverage is difficult and groups resort to using locum tenens.  Somewhat surprisingly, a recent survey by physician staffing firm LocumTenens.com revealed that 16 percent of the respondents who hire locum tenens physicians do not bill for their services, because they do not know how or because the exercise seems too complicated.  Medicare and most commercial payers allow payment for the use of locum tenens providers, however, and it is worth knowing the rules. Vacations are clearly appropriate for the use of locum tenens as long as the practice follows the applicable guidelines when filling the gaps.  It’s more than just determining who is working for whom; there are certain billing requirements depending on which carrier the claim goes to.  Don’t get stuck providing services and paying a locum tenens for cases that aren’t billed.According to Medicare’s locum tenens payment...

What did the 2014 attendees think of the AIAPM?"I always learn new things to bring back and share with our group. I think the speakers do a great job in covering a lot of information in a short time, and are always willing to answer questions during the meeting and after.  Thank you.""It was a pleasure to be a part of such an amazing arena of providers, lecturers and vendors.""It was the best anesthesia business conference that I have either spoken or attended." "Fantastic conference all around."The 2014 session of The Advanced Institute for Anesthesia Practice Managment (AIAPM) was a tremendous success.  Over 300+ Anesthesiologists, Nurse Anesthetists, Practice Administrators, Billing Personnel and Pain Management Professionals participated in sessions hosted by some of the finest experts in the field of billing and practice management.The conference experience was enhanced by the 32 industry-specific exhibitors and sponsors who participated.  Based on the excellent feedback received...

Keeping patient information confidential has become a major challenge since we all began storing so much of it in electronic form.  Computers, tablets and smart phones containing unsecured electronic Protected Health Information (ePHI) go missing and are reported in the press on at least a weekly basis. Last week a Long Island radiology practice informed 97,000 patients of a discovery that "an employee radiologist accessed and acquired protected health information from [the] billing system without authorization."  (Newsday, June 24, 2014.)  Other breaches in the past month include: A thumb drive with patient X-ray information was stolen from an employee’s locker during a burglary at a medical group office recently acquired by St. Joseph Health System in Santa Rosa, California, requiring notification of 34,000 patients. Health risk assessment results were mailed to the wrong patients, resulting in a potential compromise of the PHI of 3,675 patients covered by Highmark. A Penn State...

Two recent Alerts focused on the growing movement toward transparency of medical prices.  (How Much Did Medicare Pay Each of 32,641 Anesthesiologists in 2012?, April 21, 2014 and Private Payer Information on Anesthesia and Other Services: Claims Data to Be Available Next Year, May 19, 2014.)  The first of these discussed CMS’ April 9th release of a massive database with information on the approximately $77 billion that Medicare paid out to more than 800,000 physicians and other non-hospital providers in 2012.  The May Alert examined three large insurers’ announcement that they were establishing an online database of paid claims that would provide public information about the price and quality of healthcare services. Also evolving very rapidly are state-level All-Payer Claims Databases (APCDs).  APDCs are large databases that systematically collect medical claims, pharmacy claims and provider files from private and governmental payers to meet demands for multipayer data that allow states and...

Until now, claims-based reporting has been the only Physician Quality Reporting System (PQRS) option for most anesthesiologists.  While the method of reporting, inserting the five-digit PQRS codes for the PQRS measures on one’s Medicare claims, has been easy enough, finding enough quality measures that apply to anesthesia practices has been more of a challenge. The picture changed when the Anesthesia Quality Institute’s (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) received Qualified Clinical Data Registry (QCDR) status a little more than a month ago.  As stated on the CMS QCDR web page: A qualified clinical data registry (QCDR) is a new reporting mechanism available for the Physician Quality Reporting System (PQRS) beginning in 2014.  A QCDR will complete the collection and submission of PQRS quality measures data on behalf of Eligible Professionals (EPs).  For 2014, a QCDR is a CMS-approved entity that collects medical and/or clinical data for the purpose of patient...

Make Better DecisionsEffective monitoring of patient satisfaction levels is essential to decision making. Consistent updates help you make the most educated decisions. The ability to view patient data and review patient comments leads to a fuller view of the process. Improve your anesthesia process with an effective patient monitoring system.Anesthesia practices considering patient satisfaction surveys should consider the ease of ready-made options, including the system offered by SurveyVitals™, which is available on its own or together with ABC’s partner ePREOP.  SurveyVitals has been psychometrically validated and approved by the American Board of Anesthesiology for Maintenance of Certification purposes.  The system, which includes questionnaires for surgeons, for anesthesiologists, for employees and for the hospital to evaluate the group, is being used by hundreds of practices.Survey Vitals is hosting a series of online introductory meetings to help groups manage the survey process via their patient satisfaction system, Survey Vitals. This meeting will take...

For the first time, we are using an issue of the Alert to reproduce a third-party article in full.  Dr. Steven Boggs’s thoughts on “anesthesiologists as operating room directors” add such a lot to the concept of “anesthesiologists as medical directors” that they deserve to be read unabridged, undiluted and unencumbered by extraneous ideas.  We are grateful to Dr. Boggs and to PhySynergy for granting us permission to publish this article, which appeared on PhySynergy’s AnesthesiaReviews Blog on March 10, 2014.  Anesthesiologists as Operating Room Directors: The Advantages . “The only thing worse than a coach or CEO who doesn't care about his people is one who pretends to care. People can spot a phony every time.”Jimmy Johnson   What is the advantage or even usefulness of having an anesthesiologist as an Operating Room (OR) director? I have been asked to answer that question, However, I first must consider some of...

  Under CMS’ current Medicare and Medicaid electronic health record (EHR) incentive program regulations, eligible professionals (EPs) must use 2014 edition certified EHR technology (CEHRT) to demonstrate meaningful use for either Stage 1 or Stage 2 in 2014.  Many EHR vendors have not yet met the criteria to obtain certification for the 2014 edition, or they have too large a backlog of installations to comply with the timeline, however.  On May 20th, CMS issued a proposed rule that would push back the deadlines for implementation of 2014 edition systems for the Medicare program. The proposed rule offers EPs substantial flexibility in selecting meaningful use criteria from 2011, 2013 and/or 2014 to attest for Stages 1 or 2 in 2014. An EP who cannot fully implement 2014 criteria this year can attest using 2011 criteria (including enhanced criteria under a 2013 upgrade of the 2011 edition).  Thus, EPs (1) would be able...

Are there any anesthesia or pain medicine practices that have not yet implemented a patient satisfaction survey? The answer is of course “yes.”  Quite a few anesthesiologists question the relevance and usefulness of patients’ opinions regarding their care, asking, for example, whether patients are evaluating “pain-free surgery or pain-free parking.”  Others are leery because there are no standards for patient surveys and because so few instruments have been validated.  The subjective patient experience is, however, an outcome measure that is here to stay.  Current and projected uses include quality assessment, for anesthesiologists as well as for hospitals and ambulatory surgery centers; quality improvement; provider comparisons; competency assessment; pay-for-performance programs; marketing, and education and coaching. The vast majority of health systems have deployed patient experience surveys, if for no other reason than under CMS’ Hospital Value-Based Purchasing program, hospitals can either lose or gain up to 1.25 percent of their Medicare payments...

Nobody stands up to argue against quality and value in healthcare. You might as well argue against motherhood, or puppies. Yet many physicians are inherently skeptical of definitions of “quality” that are imposed from above, whether by outside evaluators like The Joint Commission, or (worse) by the government.     There’s good reason for skepticism. Some of the “evidence” behind “evidence-based medicine” has turned out to be flawed, tainted by financial conflict of interest or outright fraudulent. Any experienced physician knows that there are fads in healthcare just as there are in fashion, and today’s evidence-based medicine may be tomorrow’s malpractice. Let’s take a closer look at what’s really going on in the world of quality metrics, and why it matters if payments to you and your hospital are increasingly linked to how you score.   Surgical Site Infections   The financial toll of surgical site infections (SSIs) is huge, estimated...

Aetna, Humana and UnitedHealthcare have announced plans to establish an online database of paid claims that will give consumers, employers and federal and state governments information about the price and quality of healthcare services.    The announcement follows closely behind CMS’ public release, on April 9, 2014, of line-item data on $77 billion paid out to more than 880,000 physicians and other Medicare Part B suppliers in 2012.  (See April 21, 2014 Alert:  How Much Did Medicare Pay Each of 32,641 Anesthesiologists in 2012?) In 2011, Aetna, Humana, UnitedHealthcare and Kaiser Permanente created the Health Care Cost Institute (HCCI) to provide data to qualified researchers on more than 5 billion claims dating from 2000.  This database allowed HCCI to release three annual healthcare cost and utilization reports that tracked trends in national healthcare spending. The purpose of compiling the data was to promote better understanding of the drivers of escalating healthcare costs.  The database also...

No anesthesiologist has ever told me that he or she thought that the measures established by Medicare’s Physician Quality Reporting System (PQRS) or even the Surgical Care Improvement Project (SCIP) provided much insight into the quality of his or her practice. To the contrary, clients and friends have often asked me, “Why are we reporting these process measures? What do they prove?”   We are very pleased to welcome the well-known anesthesiologist and writer Karen S. Sibert, MD to the pages of the Communiqué and to bring you Dr. Sibert’s thought-provoking reflections on the PQRS and SCIP quality measures. In The Dark Side of Quality, Dr. Sibert systematically reviews the literature and leads the reader to share in the conclusion that, at best, the PQRS/SCIP measures have not reduced surgical site infection rates and, at worst, in the case of tight glucose control for cardiac surgery patients and preoperative beta blockade...

Anesthesiologists are automatically exempt from the meaningful use requirement and from penalties in 2015 as long as they have registered in the Provider, Enrollment, Chain and Ownership System (PECOS) using anesthesiology’s specialty designation (05).  Any anesthesiologist who is at all unsure should check that he or she has created an account in PECOS and that the information is correct—also before July 1, 2014.  Hospital-based anesthesiologists are not merely excepted; they are excluded from the EHR incentive program altogether and can neither earn the bonus nor be subjected to penalties.  “Hospital-based” is defined narrowly under the program’s rules, however:  the EP must provide 90 percent or more of his or her covered services in a hospital inpatient or emergency room setting.  Most anesthesiologists do not provide anything like 90 percent of their covered services in the hospital inpatient or ER setting unless their practice is limited to cardiac, transplant or critical care work....

In today’s healthcare environment anesthesia groups have many issues to deal with, including Accountable Care Organizations (ACOs), pressure on reimbursement, quality tracking, the perioperative surgical home and pressure on hospital subsidies. Despite these concerns, it is important to remember that for groups that enjoy exclusive arrangements with one or more facilities, their key asset is their hospital contract. Without a contract for services, the patients at that facility might well be serviced by another entity, and all other issues would become irrelevant. Since hospital contracts are awarded and retained at the pleasure of facility administration, a fundamental consideration for groups should be to understand the expectations of facility leaders from their anesthesia providers. This article will address that issue from the perspective of the author, an anesthesiologist who consults for both hospitals and providers, giving a unique perspective on these expectations. As the world of healthcare continues to shift from pay-for-volume...

When is it acceptable for anesthesiologists, or nurse anesthetists or anesthesiologist assistants, to use their smart phones in the OR? It is obviously not acceptable when the patient requires the anesthesiologist’s attention and the distraction is gratuitous.  A Dallas, TX jury will consider, in a malpractice trial due to start in September 2014, whether the anesthesiologist’s checking email, exchanging texts, looking up scheduling and accessing the Internet may have contributed to a patient’s death.  The 61-year-old patient died 10 hours after undergoing an AV node ablation at Medical City Dallas, according to the Dallas Observer.  The surgeon (and co-defendant) testified in his deposition that the anesthesiologist was distracted during the case and didn't notice the patient's low blood-oxygen levels until 15 or 20 minutes after she had turned blue. If the trial results in a verdict for the patient’s family, the anesthesiologist’s own deposition testimony about posting to Facebook will have helped...

A Management Services Organization (MSO) is a legal entity created to provide management and administrative services to other organizations. For the purpose of this article, we will describe the physician-owned MSO that provides services to multiple independent anesthesiology groups and is owned and governed by the owners of the anesthesiology groups the MSO serves. The physician-owned MSO is designed to allow private practice physicians to maintain 100 percent control of their practice while optimizing operating efficiencies, enhancing the care they provide and building long-term financial assets. The MSO model allows anesthesiologists to provide services to healthcare facilities, surgeons and patients in a more efficient and cost-effective manner. Following are the specifics of how this is accomplished. An anesthesiology group can divide its general functions into clinical and business. Over the years, anesthesiologists have found that their business operation has increased in importance and complexity as adequate reimbursement becomes more of a...