eAlerts

The Challenges are Great—And So Is the Expertise in Our Specialty

No fewer than four experts in anesthesia practice management have contributed articles to the Communiqué for the first time in this issue. We are struck—not for the first time—at both the vast knowledge reservoir in our community and the generosity of so many professionals who go the extra mile to share their expertise. Let us take this opportunity to thank our regular authors and especially newcomers Danielle Reicher, MD; Steve Boggs, MD; Pat Everett, CPA, CMPE and Ron Booker, JD, CPA.

Anesthesiologists have been seeking out the best electronic health record systems (EHRs) to improve data collection for both clinical and administrative purposes, not to mention for purposes of qualifying for the Medicare Meaningful Use payment incentives. Dr. Reicher describes a specific and very important application of EHR technology in Making Meaningful Use More Meaningful: communicating with patients. Have you thought about the value to the patient of documenting the medications and doses given and any unusual reactions or airway difficulties, particularly if the patient has concerns about anesthesia? In one of her examples, Dr. Reicher notes that anesthesiologists may sometimes “observe hives or anaphylaxis after giving a combination of medications. We know that the most common allergic reactions are due to antibiotics or muscle relaxants. … We may need to refer the patient to an allergist and we certainly want them to be aware of all the medications they received. All of this information can be recorded in the electronic record after a thorough discussion with the patient.” Does this not suggest an excellent way of affirming the role of the anesthesiologist in the management of the entire perioperative episode? And as Dr. Reicher, who has been recording her patients’ care through F1RSTUse for several years, makes clear, EHRs are an excellent way to “become more engaged with our patients and the healthcare system in general.”

One of Dr. Boggs’s areas of particular interest is GI sedation—an interest that is sadly timely, with the September 4 death of comedienne Joan Rivers a week after undergoing an endoscopic procedure during which she suffered a cardiac arrest. For the past several years, Dr. Boggs has been working closely with endoscopists at Mount Sinai in New York and elsewhere, evaluating turnover time and safety metrics. He will be presenting both at a Point-Counterpoint session and on a panel at the ASA Annual Meeting in New Orleans in October, and he gives us a detailed preview of his arguments in Computer-Assisted Personalized Sedation (CAPS): Will It Change the Way Moderate Sedation is Administered? We were pleased to have the opportunity to provide Dr. Boggs with claims data showing that the cost of anesthesia and anesthesia providers may be quite competitive with cost of CAPS.

Pat Everett’s name is very familiar in the anesthesia community. In his article Anesthesia Practice Attributes Your Hospital Leadership Teams Value Most, Mr. Everett distills an extraordinary amount of hands-on experience with both anesthesia providers and hospitals into a list of the top five attributes of highly successful anesthesia groups with whom he has worked. The list starts with “strong leadership.” The idea that leaders should be strong is familiar enough—but does everyone realize that the kind of strong leadership that really matters to hospitals entails the ability to make decisions quickly, without the “need to take this back to my group first?” Another attribute of a great group is consistent application of clinical standards and protocols to patients across all the anesthesiologists in the group. Read Mr. Everett’s article and take very seriously his conclusion that what hospital leaders want most is “a group of anesthesia professionals who ‘fly under the radar’ and about whom they rarely hear complaints.”

Look closely, too, at The Value of a Quality Practice Administrator, written by another extremely experienced anesthesia practice administrator, Ron Booker. There is more—much more—to the business side of anesthesia than revenue cycle management; anesthesiologist, CRNA and AA recruitment and retention, and managed care and hospital contracting. Mr. Booker uses carefully chosen examples of typical and atypical practice challenges to show the value of a high-quality administrator who possesses sound skills in four essential domains: decision-making, problem-solving, communication and relationships.

Laura Dyrda’s is another new name in the Communique—but Ms. Dyrda is in fact well known and much appreciated under her previous byline, Laura Miller. Ms. Miller serves as the Editor-in-Chief of Becker’s ASC Review and Spine Review. An ever-growing majority of anesthesiologists, CRNAs and AAs provide services at ambulatory centers and certainly need to be sensitive to the specific pressures weighing on the facilities with which they partner—or hope to partner. Ms. Dyrda’s summary 10 Concerns Facing ASCs Heading Into 2015 highlights concerns that may not be immediately apparent to clinicians, such as the lack of any government incentives to begin using EMRs like those offered to hospitals and physicians, patient familiarity with outpatient surgery and competition with hospitals to recruit physicians.

We welcome returning contributor Rick Dutton, MD, MBA who brings us up to date on a vitally important new mechanism for anesthesia professionals to report performance data to Medicare: The Qualified Clinical Data Registry (QCDR). Going forward into 2015 and beyond, physicians must report such data to Medicare in order to avoid payment penalties under both the Physician Quality Reporting System (PQRS) and the Value-Based Modifier program. The claims-based method of reporting that most anesthesiologists have used to date is being phased out in favor of registries. At the same time, the number of quality measures that physicians must report in order to avoid penalties is increasing. The National Anesthesia Clinical Outcomes Registry (NACOR) run by the Anesthesia Quality Institute (AQI), which is headed by Dr. Dutton, solves both problems by having obtained QCDR certification. Dr. Dutton will be presenting at the ASA Annual Meeting and we encourage you to hear him as well as to read his article.

Within ABC, we have a wealth of knowledge that it is also our privilege to share in these pages. Darlene Helmer, Vice President of Provider Education and Training covers Medicare’s Modifier 59 Expansion in this issue’s Compliance Corner. Joette Derricks, Vice President of Regulatory Affairs and Research, alerts readers to Potential Revenue Losses with Health Insurance Exchange Patients Due to Premium Payment Default. Both article titles are mercifully self-explanatory!

Let me once again express our deep gratitude to the anesthesiologists, administrators, journalists and compliance and regulatory experts who have given us the content for this issue of the Communiqué. The sophistication and energy of all these individuals benefits and inspires us all.

With best wishes,

Tony Mira
President and CEO

Computer-Assisted Personalized Sedation (CAPS): Will it Change the Way Moderate Sedation is Administered?

Steven Dale Boggs, MD, MBA
Director of the OR and Chief of the Anesthesia Service, James J. Peters VA Medical Center, Bronx, NY
Associate Professor of Anesthesiology, The Icahn School of Medicine at Mount Sinai, Manhattan, NY

I. Background

The medical specialty of anesthesiology is recognized for being in the forefront of adopting technology to enhance patient safety. The rapid dissemination of pulse oximetry and capnonography in anesthetic practice are two classic examples of early adoption of technology by the medical community to make our practice safer. The creation of the Anesthesia Patient Safety Foundation (APSF) further exemplifies our specialty’s commitment to both patient welfare and technological progress.

Over the past few decades, a new factor has prominently inserted itself into the equation, influencing the introduction of new technology. That is cost-effectiveness. In evaluating a new product, whether it provides ideal patient care or cost-effective care may give different answers.

The professional cost of anesthesia services is only a small percentage of total physician services (three percent of Medicare spending in 2010). Yet, the increase in spending on monitored anesthesia care (MAC) for esophagogastroduodenoscopy (EGD) and for colonoscopy has grown significantly over the past decade. A 2012 RAND study found that from 2003 to 2009, the number of colonoscopies and upper gastroenterology (GI) procedures increased 26 percent. In this same period, payments to anesthesia providers tripled among Medicare beneficiaries and quadrupled among commercially insured patients.

Striking regional variation exists. An anesthesia provider (2012) is most likely to be involved in a GI procedure in the Northeast (48 percent), followed by the South (38 percent), the Midwest (26 percent) and the West (14 percent). This RAND study concluded that $1.1 billion per year was spent on payments to anesthesia providers for care in what this study deemed to be low-risk patients.

Several questions come to mind. Why has there been such a significant increase in anesthesia involvement in EGD and colonoscopy? Studies suggests that both GI physician preference (clinical and financial) and patient preference for propofol versus traditional methods of GI sedation (midazolam and narcotic) are the primary drivers. For GI physicians, sedation of any type increases the rate at which cecal intubation is achieved and polyp detection rates are also increased. Moreover, with propofol, patient flow through the GI unit is quicker, patients are discharged sooner without lingering effects and more cases can be performed per day. For patients, they can truly “not remember anything,” and still emerge without nausea or lingering effects to be discharged promptly from the GI unit.

While there is regional variation in the payment model for MAC anesthesia for GI procedures, some vindication may be seen for anesthesia providers who have argued for our involvement in these procedures in the recent Centers for Medicare and Medicaid Services (CMS) Proposed Rule for the 2015 Medicare Fee Schedule. CMS has gone on record acknowledging that the prevailing standard of care for endoscopies in general and screening colonoscopies in particular is undergoing a transition and that anesthesia separately provided by an anesthesia professional is becoming “the prevalent practice” (Proposed Rule pp. 186-187). Therefore, CMS is revising the definition of “screening colonoscopy” to bring anesthesia furnished in conjunction with the service within the scope of the provision that Medicare Part B waives beneficiaries’ deductible and coinsurance and pays 100 percent of the Fee Schedule amount established for certain colorectal cancer screening tests.

By proposing to pay 100 percent of the fee for an anesthetic for a screening colonoscopy under the regulation to be revised (42 C.F.R. §410.160(b)(7)) and by waiving the patient’s share in every instance, CMS has admitted that anesthesia provided by an anesthesia professional is at least as “medically necessary” as the sedation that is currently bundled into the gastroenterologist’s fee. It would be anticipated that Medicare would pay the anesthesiologist. However, there are a number of Local Coverage Decisions (LCDs) in which various Medicare contractors have predetermined that anesthesia for routine screening colonoscopies is not medically necessary. LCDs may need to be modified accordingly.



II . Computer-Assisted Personalized Sedation

In the US, if an anesthesia provider is not available to provide sedation, the alternative has been for the patient to receive either traditional sedation administered under the supervision of the GI physician (midazolam/narcotic) or no sedation. Because of this, Ethicon, a subsidiary of Johnson & Johnson, became interested in the concept of a device that would permit the administration of propofol for moderate sedation. Per FDA labeling, propofol had previously only been permitted to be administered by an anesthesia provider or to a patient in an ICU setting.

The approval process was quite lengthy, with the Sedasys® system not receiving approval initially. However, in May, 2013 the Sedasys system received premarket approval (PMA) from the FDA¹. Sedasys is presently the only FDA-approved computer-assisted personalized sedation (CAPS) device on the market. Function of the system is outside the scope of this article, but information can be found on the company website (http://www.sedasys.com).

Ethicon specifically states that Sedasys is not intended to replace an anesthesia provider, but rather to permit the administration of mild-to-moderate sedation to patients who would otherwise not be able to receive propofol. Sedasys is approved for use for the following:

• Initiation and maintenance of minimal-to-moderate sedation
• American Society of Anesthesiologists (ASA) physical status I and II patients ? 18 years old
• Colonoscopy or (EGD)

Sedasys is not indicated in the following patient populations:

• Patients <18 years old.
• ASA physical status IV and V.
• Patients using a fentanyl patch.
• Patients with abnormal airway or diagnosed sleep apnea.
• Patients with gastroparesis.
• Patients with Body Mass Index ?35.
• Patients undergoing both colonoscopy and esophagogastroduodenoscopy during the same procedure visit.
• Patients undergoing emergent colonoscopy or esophagogastroduodenoscopy.

Sedasys is contraindicated in the following patients:

• Patients with a known hypersensitivity to propofol injectable emulsion or its components.
• Patients with allergies to eggs, egg products, soybeans or soy products.
• Patients with a known hypersensitivity to fentanyl.
• Pregnant or lactating women.
• Delivery of any drug other than propofol emulsion.
• Patients with a full stomach.



Notably, Sedasys is not approved for use in ASA III patients, but it is also not contraindicated in this patient population. One thing must be made clear. Repeatedly in the Sedasys literature, “the pivotal study”² is cited by the manufacturer. It must be kept in mind that Sedasys administration of propofol was compared against “traditional” sedation with midazolam and narcotic, not against propofol administered by an anesthesia provider. Secondly, the numbers of patients over the age of 70 and in ASA class III were extremely limited. Out of 1000 study subjects, 28 were ASA III patients and “there were very few patients over 70 years of age.” With 1,000 subjects in the study, it can also be argued that this study was significantly underpowered to reach the conclusions that the authors made.

For anesthesia providers, perhaps the most concerning aspect of the Sedasys system is the inability of the system to prevent or manage loss of consciousness. The manufacturers have addressed this concern two ways. First, they have developed a clinical training program that is endorsed by the International Society for Anesthetic Pharmacology and is provided by an independent, qualified third party with expertise in airway management. Clinical training consists of online knowledge-based training (approximately 4 hours) and simulation-based training (approximately 6 hours). This training (from their website) provides clinicians with the:

• Knowledge base underpinning moderate sedation practice
• Skill set necessary to rescue patients from deeper-than-intended sedation states
• Additional knowledge and skills required when propofol is used to provide sedation

A further safety measure for Sedasys is the requirement that, “an anesthesia provider must be immediately available.” What “immediately available” means is left to the discretion of each facility.

III. Critique:

I have been informed that the Sedasys system has been placed into practice in one location, so Ethicon is just starting to market the device. In discussion with industry representatives, the ideal pattern would be for its use in a high-turnover GI suite. In this circumstance, appropriately selected patients would be managed with Sedasys, with non-candidates being managed by anesthesia personnel. However, once the device is utilized clinically, there will be strong cost pressures to widen the indications for its use.

Airway training may appear to be a simple skill, but it could be reasonably argued that the skill set required to rescue a patient from a deep anesthesia or general anesthesia cannot be taught in 10 hours.

Gastroenterologists, indeed many specialists, may look on airway management quite differently than anesthesiologists. In the Sedasys FDA application, one gastroenterologist said, “I’ll say another word about airway management for gastroenterologists. I have performed over 10,000 endoscopies. I have seen more larynxes and backs of the throats than probably most anesthesiologists. So, a gastroenterologist’s familiarity with the anatomy of the throat and the vocal cords and the esophagus is probably more than most anesthesiologists and I think there is a disservice done to gastroenterologists to think that we don’t know how to manage an airway because we don’t intubate patients regularly. Remember, we do intubate patients regularly. We just intubate their esophagus regularly. We don’t intubate their bronchus.” The point here is precisely that anesthesiologists are focused on intubating the trachea to preserve the airway, not the esophagus for diagnosis. That constitutes a significant difference.

Five percent of the population is known to have a difficult airway. Identification of these patients poses problems for anesthesia providers who deal with this issue daily, let alone for the provider whose background is not in airway management.

The risk of MAC anesthesia has been demonstrated to be roughly equivalent to that of general anesthesia, in large part because of airway events. Airway events are also the most common cause of closed claims against anesthesiologists, especially in GI endoscopy. Furthermore, mild to moderate anesthesia can heighten the problems with the management of a reactive airway. Therefore, while the pharmacologic studies to date have revealed that patients will start breathing with the redistribution of propofol, a finite risk to the patient remains.

Simulation training is an excellent technique for training coordinated teamwork and a systems approach to managing critical issues. However, few would argue that current simulation models are effective in actually training airway management. The approximation of the best simulation models to human tissue and various morphologies is poor. Consequently, utilizing simulation training to teach GI and nursing providers airway rescue skills is an unproven proposition.

Scheduling in the GI suite has the potential to become problematic. What will occur when an ASA III patient is assigned to the Sedasys room? Who will make the ultimate determination of the ASA physical class? There will be pressure to downgrade the ASA physical class, changing the ASA class from ASA IV to III or from III to II. What will prevent this change? Or, if downgrading does not occur, will the patient be rescheduled for another suite, perhaps having to wait for the availability of an anesthesia provider?

Cost savings is also controversial. A 2009 RAND³ study sponsored by Ethicon Endo-Surgery made the following observations:

The potential demand for CAPS is huge, being 98 million procedures in 2005 and a projected 106 million in 2015. In 2005, the overall size of the sedation market delivered by anesthesia providers was approximately $5 billion. Approximately 40 percent of this market, or $2 billion, was considered by the study’s authors as suitable for moderate sedation and therefore redistribution to CAPS. Specialties for which CAPS could be used include Gastroenterology (fastest growth rate), Cardiology, Ophthalmology, General Surgery, ENT and OB/Gyn.

Proceduralists would be affected by CAPS in two ways, first by additional payments for use of the technology and second, by shifting procedure settings away from hospitals. For GI specialties, the study considers that nearly 45 percent of total expenditures on anesthesia would be available for reallocation. However, the study authors note that, “not all of these changes will fully materialize, because presumably payers will compensate (providers) for the use of the CAPS technology in lieu of anesthesia providers.”

CAPS is expected to save insurers significant money, with most saving coming from reduced facility revenue and anesthesia professional fees. For a total of 38 million procedures, the average cost reduction would be $11.35 per procedure ($431 million).

In June 2014, the Agency for Healthcare Research and Quality (AHRQ) released its Healthcare Horizon Scanning System – Potential High-Impact Interventions Report on Cross-Cutting Interventions and Programs⁴. The key expert comment was that “Sedasys^® has significant potential to disrupt the current methods of delivering propofol-mediated sedation.” However, the authors were unsure “whether the potential benefits of wider access to propofol-mediated sedation were significant enough to offset safety concerns about potential over sedation of patients in a setting without an anesthesiologist present.”

In discussion with representatives from Ethicon, tentative costs figures for the Sedasys system are as shown in Figure 1.

It should also be noted that the Sedasys system requires that a nurse specifically monitor the patient and have no other duties during the procedure. This—in addition to the cost of the machine and disposables—significantly adds to the cost model for Sedasys.



To compare projected Sedasys costs with cost data from actual claims submitted for anesthesia providers, a representative national sample of claims submitted for Anesthesia Business Consultants’ clients from October 2013 through March 2014 and excluding self-pay, government payers and pending claims was analyzed. The results appear in Figure 2. These values include payments for anesthesiologists providing care, nurse anesthetists providing care alone and to anesthesiologists and nurse anesthetists (care team model) together. The numbers are consistent with the Rand study(3) which found that the average payment of Medicare patients was $150 and for commercially-insured patients was $500.

Measuring ASA Physical Status for 155,139 upper GI procedures, 51 percent of the patients were ASA I and II, 39 percent were ASA III and 8.5 percent were IV, V or VI. For upper GI procedures in patients over 18 years of age, out of 141,259 patients, 61 percent were between the ages of 18 and 65, while 38 percent were over the age of 65. Twenty-one percent of these patients were over the age of 75.

It can be seen that payments to anesthesia providers at these rates may be competitive with the cost of Sedasys, the disposables and the required nurse. Moreover, a large percentage of patients in this population who received care from an anesthesia provider did have a high ASA class and advanced age.

It is not entirely clear that CAPS will save the money that is alleged. It may be more effective at redistribution of revenue away from anesthesia providers and toward insurance companies and proceduralists. Also, GI nurses have voiced concerns about their responsibilities in administering a medication which is specifically labeled to be “administered by an anesthesia provider.” For the proceduralists, the savings may not be as dramatic as heralded, because with a nurse focused exclusively on monitoring the patient, the cost of the entire model is significantly increased.

IV. Conclusion

Anesthesiology has a proud history of continually providing better and safer care to patients. Now, as a specialty, we have to recognize an additional commitment, to provide cost-effective care for our patients. The seal of our society has a lighthouse on it with the word, Vigilance emblazoned above it. Anesthesia providers have always taken this to mean personal vigilance in the care of their patients. However, new models of providing care for our patients will continue to emerge and will challenge this interpretation of our motto.

CAPS is an interesting development and anesthesiologists have typically been “early adopters” of technology. Sedasys may find a place in large GI units, where an anesthesiologist is always available, where patients assigned the wrong ASA class can be moved to a room with an anesthesia provider and where the volume of patients permits amortization of Sedasys costs across a large pool of patients.

Conversely, the Sedasys model as presently is not likely to be useful in small GI offices, in smaller units where an anesthesia provider is not available and where the number of cases is not sufficient to recoup the substantial expenditure required for the system and its components.

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¹ Birnbach DJ (Chair) USA, DHHS, Center for Devices and Radiological Health, Medical Devices Advisory Committee, Anesthesiology and Respiratory Therapy Devices Panel. May 28, 2009. Transcripts from Free State Reporting, Inc. 1378 Cape Saint Claire Road, Annapolis, MD 21409
² Pambianco DJ, Vargo JJ, Pruitt RE, et al. Computer-assisted personalized sedation for upper endoscopy and colonoscopy: a comparative, multicenter randomized study. Gastrointest Endosc. 2011;73(4):765-772.
³ Dick A, Mattke S, Yu, H. Assessing the Budget Impact of the Computer-Assisted Personalized Sedation Technology for Key Stakeholders. RAND Health, 2009.
⁴ http://effectivehealthcare.ahrq.gov/ehc/assets/File/Crosscutting-Horizon-Scan-High-Impact-1406.pdf

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Steve Boggs, MD, MBA is the Director of the Operating Room and Chief of the Anesthesia Service at the James J. Peters VA Medical Center in the Bronx, NY. He is also Associate Professor of Anesthesiology at the Icahn School of Medicine in Manhattan, NY. Dr. Boggs has been involved in the administration of anesthesia departments for over a decade. For the past several years, he has been working closely with endoscopists at Mount Sinai and elsewhere, evaluating turnover time and safety metrics and is involved in developing a curriculum for GI sedation for low-and-middle income countries and in evaluating new methods of training providers in bag/valve/mask ventilation. He can be reached at stevendaleboggs@gmail.com.

The Qualified Clinical Data Registry (QCDR)

Richard P. Dutton, MD, MBA
Chief Quality Officer, American Society of Anesthesiologists
Executive Director, Anesthesia Quality Institute
Clinical Associate, University of Chicago Department of Anesthesia and Critical Care, Chicago, IL

By now, many readers of the ABC Communiqué will have heard about the Qualified Clinical Data Registry (QCDR) and will be wondering (or dreading) what this means for them and their practice. This article will lay out the basic definitions and requirements.

The QCDR is a new mechanism for eligible professionals (EPs) to report data on their performance to the Centers for Medicare and Medicaid Services (CMS). CMS currently reimburses about one-third of anesthesia care in the United States, and almost every practice derives a portion of its income from CMS. As a federal agency, CMS has been at the forefront of responding to public demand for transparent reporting of healthcare quality from both hospitals and providers. This has led to a steadily escalating requirement for performance reporting.

Under the QCDR, EPs contributing data to a clinical registry can get credit for meeting the requirements of the Physician Quality Reporting System (PQRS) and the Value Modifier (VM) program.

Technically, a QCDR is designated by CMS under the provisions of the ‘Final Fee Schedule Rule’ published in November, 2013. Registries could nominate themselves for this designation during January 2014, and were then required to meet more than 30 requirements before certification. Among the requirements, the registry must have been in existence for a while, must represent a specific specialty or discipline of medicine, must collect data from multiple sites and healthcare systems, must maintain a public list of performance measures and definitions, must provide regular feedback to contributors and must be able to collect, analyze and transmit data to CMS in an approved format.

As noted above, the QCDR is a new vehicle for providers and practices to report performance data to CMS, under the existing Pay for Performance (P4P) systems. The original PQRS program, now more than five years old, was created to encourage individuals to publicly report performance on one or more established quality measures. Through 2014, CMS offered small incentives to do so—for example, providers reporting successful performance on at least three measures in 2014 will receive a bonus payment from CMS equal to 0.5 percent of their Medicare billing for the year. Beginning in 2015, however, this carrot becomes a stick. The PQRS bonus changes to a ‘payment adjustment’ of negative two percent of reimbursements for those who are not reporting successfully, with increasing penalties in the years ahead.

The VM system is a new program, which overlaps and expands on PQRS. In 2016, CMS will assess physician performance data from 2014. EPs not reporting their performance will be penalized; those who do report successfully will be eligible for incentive payments under a complex formula designed to redistribute money from worse performers to better ones. Successful VM reporting requires nine measures, from three different domains of the national quality strategy, and must include at least one outcome measure.

The original method for reporting PQRS performance to CMS was the ‘claims-made’ mechanism. This is still used by the large majority of practitioners who participate in PQRS (61 percent of all anesthesiologists participated in 2013; about the same percentage of nurse anesthetists), including many through ABC. This mechanism requires the billing company to append a code to each eligible case indicating compliance with a given measure. For example, the code for ‘anesthesia for upper abdominal laparoscopic surgery’ would be accompanied by an additional code indicating ‘prophylactic antibiotics were given at the correct time.’ CMS then conducts an annual audit of all cases for every provider to determine which cases were eligible for each measure, whether performance was met and whether the provider is eligible for an incentive payment based on their results.

A newer mechanism for reporting performance under both PQRS and VM is the group reporting option, whereby aggregate performance for the year for an entire practice group is sent to CMS as a single file by a certified vendor. This moves some of the burden for scoring performance from CMS to the vendor, without changing other aspects of the program. In 2014 group reporting became mandatory for groups of 100 or more providers, and in 2015 this requirement will be extended to all groups of 10 or more, as CMS seeks to de-emphasize the claims-made approach.

PQRS and VM use the same set of CMS-approved measures. Most of these are derived from a larger set of measures collected and endorsed by the National Quality Forum (NQF), set up as a public-private partnership a decade ago specifically for this purpose. The process of creating a measure, validating it, and achieving NQF endorsement and CMS inclusion can take years of work. In theory, any EP can report on any of the 300+ approved measures, but in practice this is hard to do because eligibility for a given measure is usually determined by a billing code (e.g., the Current Procedural Terminology™ or CPT code for anesthesia providers). If the EP is not billing that code, then they are not eligible for that measure. For example, an anesthesia provider might feel that they have some involvement in the measure developed by the Society for Thoracic Surgeons to encourage early extubation after coronary artery bypass surgery. But because this measure is specific to the CPT codes for the surgery (not the anesthesia care) this measure is not actually available to our specialty. Most medical disciplines—including anesthesia—do not have enough measures approved by CMS for the average clinician to meet the new nine-measure requirement of the VM system.

Performance reporting to CMS through a QCDR is similar to group reporting through a certified system—the registry will send a single report to CMS summarizing the provider’s performance on a given measure for the entire year. Unlike PQRS and VM, however, a QCDR can use specialty-specific measures drawn from outside the existing pool approved by CMS. These ‘non-PQRS measures’ can be from any credible source, and must be clearly defined, publicly transparent and valid for the stated purpose.

Plans for the future of P4P programs can be glimpsed in existing regulations, in comments by officials and in legislation being debated in Congress. First, it is clear that P4P will not go away. A steadily increasing percentage of every provider’s reimbursement from the federal government will be linked to documentation of compliance with performance measures, and will be publicly reported. In 2015 this is a two-percent risk—or $2000-$5000 per year for most anesthesia practitioners—but the planned evolution of PQRS and VM will bring the total at risk to about ten percent by 2020, or tens of thousands of dollars per EP. Further, it is likely that where CMS leads, the entire fee-for-service universe will follow; PQRS requirements have already been extended to some state Medicaid programs and private insurers are likely to follow suit. It is clear that registry-based reporting is the most favored mechanism going forward. Federal officials believe that physician participation in clinical registries, with regular public benchmarking, is an important tool to achieve the triple aim of improved outcomes, improved efficiency and improved patient experience. Strategies to enhance registry reporting can be seen in the evolution of the Meaningful Use program, in proposals and demonstrations for alternative payment models and in Congressional efforts such as the proposal to reform the Sustainable Growth Rate formula. More cynically, the QCDR approach also relieves CMS of much of the burden of collecting, cleaning and scoring performance data from individual providers.



QCDR and the Anesthesia Practitioner

The American Society of Anesthesiologists (ASA) recognized in 2008 the value of a specialty-specific clinical registry, including the ability to meet regulatory requirements. The ASA has invested millions of dollars in development of the Anesthesia Quality Institute (AQI) and its product, the National Anesthesia Clinical Outcomes Registry (NACOR), to which many ABC practices contribute. NACOR was certified for group reporting of PQRS measures in 2012, and earlier in 2014 became one of the first QCDRs approved by CMS. In doing so, AQI scoured the existing NQF and CMS measure lists, then combined this with years of work by the Committee on Performance and Outcome Measures to propose a list of measures comprehensive enough that almost any clinical anesthesia provider will be able to find the minimum nine measures required to earn future incentives. The 19 measures approved for submission through NACOR include eight PQRS measures and 11 non-PQRS measures, and are briefly listed in Table 1. Specifics are available on the AQI website at http://www.aqihq.org/PQRSOverview. aspx. In this pilot year of the QCDR, both CMS and the AQI will be assessing the value and reportability of these measures, with anticipation of adjustments in future years. The 2015 proposed final rulemaking will allow up to 30 non-PQRS measures for inclusion in the QCDR; this will enable AQI to include subspecialty measures for pain, obstetrics, pediatrics and cardiac practitioners.

QCDR submission of performance data to CMS is available to any eligible professional in a practice that is contributing data to NACOR. Participation in NACOR is on a per-group basis at a fee of $1000 per attending physician anesthesiologist or independently-practicing nurse anesthetist. This fee is discounted to $0 for ASA members; most practices in the care team model thus participate in NACOR at no cost, as a benefit of ASA membership. QCDR reporting to CMS will be available at no additional charge to ASA members and for $295 per year to non-member EPs, with discounts available to large groups. To meet PQRS and VM requirements through the QCDR, practices must self-nominate to CMS, must complete waivers and submit National Provider Identifier (NPI) numbers for each EP to AQI, must collect and code the primary measure information in their electronic systems (either billing or medical record) and must transmit this information to NACOR as part of their regular data contribution. ABC is positioned to facilitate this activity on behalf of their client practices.

While QCDR reporting appears to be the favored approach to P4P in the next decade, the claims-made and group reporting options for PQRS are still a reasonable approach to avoid negative payment adjustments. The lack of sufficient measures for anesthesiologists in these systems will make it difficult to qualify for incentives in the years to come, however. At present, NACOR is the only QCDR available to anesthesia practitioners, but in time practices may have several alternative QCDRs to choose from, using the same or similar measure sets. Which one is most appropriate for a given group will likely depend on other aspects of the registry, such as its interaction with the electronic medical record and its utility for quality improvement activities, clinical research or other regulatory reporting.

As has been the case over each year in the past decade, specific requirements for P4P will continue to change going forward. The AQI follows this evolving landscape closely, and recognizes that facilitating performance reporting for anesthesia providers is an important mission of the registry. In this way, we hope to continue to serve our participants and advance the quality of anesthesia care.

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Richard P. Dutton, MD, MBA is Executive Director of the Anesthesia Quality Institute (AQI). He also serves as Chief Quality Officer for the American Society of Anesthesiologists. Dr. Dutton is a Clinical Associate at the University of Chicago Department of Anesthesia and Critical Care. To contact Dr. Dutton or the AQI, visit www.aqihq.org.

Anesthesia Practice Attributes Your Hospital Leadership Teams Value Most

Patrick C. Everett, CPA, CMPE
Founder and President, ProSTAT Anesthesia Advisors, Alpharetta, GA

Since establishing ProSTAT in 1995, I have had the pleasure of working for more than 325 hospitals/health systems, physician-owned and Certified Registered Nurse Anesthetist (CRNA)-owned anesthesia practices, academic medical centers and related anesthesia businesses in 46 states and the District of Columbia.

My consulting business has evolved over the years from an exclusive focus on anesthesia group practice to one that now include hospitals and health systems (just over 150 at last count). That evolution has helped me better understand the viewpoints and value structure of hospital leaders as I spend time in their offices now discussing anesthesia challenges, solutions and strategies for the future with their perspective in mind. It is the substance of those detailed discussions that I hope to share with you in this article.

Five to ten years ago, I feel safe in saying, many (though not all) anesthesia practices didn’t place a top priority on what hospital leaders (and surgeons, for that matter) wanted from their anesthesia provider. Patient care and safety and practice management topics filled the agendas of most anesthesia group meetings I attended. If you were an anesthesia stakeholder prior to 2007, you probably recall when it was a constant struggle to both recruit and retain anesthesiologists and anesthetists. Many wise hospital leaders at the time, understanding the great value of a strong anesthesia department, were very hesitant to push their group toward service improvements because those informed leaders knew there were better paying or better lifestyle anesthesia jobs available, often just down the street at a competing hospital or surgery center.

But viewing the anesthesia specialty through the lens of today’s much changed patient care, service and business environment, the facility-contracting leverage enjoyed by even small private practices has been deeply eroded, although certainly not eliminated. With anesthesia residents, CRNAs and Anesthesiologist Assistants (AAs) being trained in greater numbers, combined with a much slower hiring trend since 2009 and a growing number of anesthesia management companies (AMCs) and expansion-minded private practices offering their services to hospitals, the picture looks very different.

Despite the greater range of options in the market, I find that the overwhelming majority of hospital/health system leaders I encounter are not actively seeking a replacement for their incumbent anesthesia group. Instead, they are looking for ways to better partner with their anesthesiologists and anesthetists to achieve the overarching goal of better care at a more affordable price, albeit on more aggressive terms than in the past.

The secret to keeping those hospital leaders in a “partner,” not “adversary,” frame of mind is to develop an anesthesia service that not only provides topnotch clinical care, but that is viewed by your stakeholders as one that is indispensable to the institution. In fact, your goal as it relates to these stakeholders—hospital administrators, OR nursing staff and your surgeons—is to create uncertainty and perhaps even a level of anxiety about the prospect that your group might not be there tomorrow. In my many one-on-one interviews with hospital/health system leaders, I always make it a point to ask what anesthesia-related concern keeps them up at night. Those who have a high regard for their anesthesia team often cite the possible loss of their group when I pose that question.

Following is a discussion of the Top 5 attributes of these very highly regarded groups who have greatly, though not totally, insulated themselves from the external market forces that exist today.

1. Strong leadership in terms of a single voice speaking for the group with the proven ability to effect change and ensure buy-in by all group members. Any anesthesia group president, chairman or clinical chief who has served as the primary liaison with hospital leaders has experienced the incredible pressure to respond to allegations about the group’s and individual member’s flaws and/or transgressions, and promise immediate action to rectify the problem. Each time an anesthesia group leader listens to this kind of criticism but responds, “I need to take this back to my group first,” her personal credibility and the value of her group in the eyes of the hospital leadership undoubtedly suffers to some degree. A hospital client of mine in the Midwest went through that back-and-forth constantly with the president of the contracted group. He expressed to me his frustration that the group president either took weeks and sometimes months to get back with a solution to the problem, or the matter was more often than not simply forgotten. As of this writing, that private practice group is being viewed as a strong candidate for health system employment, and there are plans to hire an anesthesiologist from the outside to be the new department head.

A hospital in the Northeast hired my firm about two years ago to evaluate their contracted anesthesia care team group and help that group develop a cost saving strategy to slowly reduce the annual support payment. The plan I developed was presented to both the hospital and anesthesia group leadership teams, and both initially agreed to support the plan, with the hospital committing to further support the group financially if the plan’s implementation resulted in significant attrition of clinicians (it didn’t). But after six months the anesthesiologists had not implemented any suggestions because of an inability to make decisions, coupled with threats by some members of the Board of Directors to quit if certain suggested measures were initiated. When the hospital contacted four national staffing companies to obtain bids for the contract, however, the majority of the anesthesia group shareholders were jarred enough to vote to replace their Board and empower the newly-elected members to “act in the best long term survival interest of the group” without having to obtain the previously necessary 100 percent of group membership support. As a result of a series of wise decisions by that new Board, the contract was renewed for three years with far less damaging financial ramifications for the group than were initially envisioned.

2. An ability to police/discipline bad actors proactively. When groups are quick to recognize physician or anesthetist clinical practices or behavior that are detrimental to the practice’s reputation and credibility, and to initiate corrective action before the hospital leaders bring up the concern, they are viewed in a far more positive light than those groups who visibly resist terminating bad actors because “they are a good doctor” or “they are a good anesthetist.” Dr. Alan Rosenstein’s 2011 research with medical professionals (published in the American Journal of Medical Quality) found a very strong correlation between disruptive behavior and medical errors (resulting in compromised patient safety—51 percent, adverse events—67 percent, compromised quality—71 percent). So while strong clinical skills are highly coveted attributes, the environment in which those skills are deployed cannot be toxic, or the patients, hospital personnel and ultimately the institution itself is at risk.

3. An accommodating philosophy toward surgeons and their desires to work at their (reasonable) convenience. In nearly every institution I visit today, I hear varying levels of frustration voiced by anesthesiologists (and often hospital leaders) about the inefficiencies for anesthesia and nursing personnel created from a far greater emphasis on providing surgeons with easy access to operating rooms at times convenient to them. Granted, more hospitals today are coming to understand that over-accommodating surgeons is not always good business for their organization or the anesthesia group, but offering an inviting environment to surgeons is critical to their market share growth objectives, and that is an unmistakable priority for every hospital leadership team. The best barometer I can think of that alerts you that the anesthesia accommodation level is below where it ought to be is when the reasonable and rational surgeons on your medical staff begin lodging frequent complaints with you or the hospital about the anesthesia availability or service.

4. A willingness by the anesthesia practice to apply clinical standards and protocols to patients consistently as a single group, not as individual clinicians. The confusion and frustration that arises among nurses and surgeons when anesthesiologists and anesthetists in the same group diverge widely on their assessment of a patient or their approach to care is one of the more common complaints I hear in my consulting engagements. Of course, the clinician’s perspective is frequently that one’s clinical judgment in a patient’s plan of care is sacrosanct and cannot be compromised under any circumstances. While reasonable hospital leadership understands this perspective, most will still want to explore areas for compromise. Unfortunately, some anesthesia groups make the mistake of pointing out that “surgeons don’t have to always follow standardization in the way they operate.” I am told that these kinds of comments undermine the professional stature of the anesthesia group in the eyes of hospital leadership, and astute anesthesia groups (and astute surgeons) already understand that the day is coming in the not-too-distant future when surgeons will have fewer and fewer preferences they can request if they veer outside the standard without adding value commensurate with cost.

5. A priority for all members of an anesthesia group to act as positive ambassadors, not only for their group and medical staff, but for the facility where they practice. Most hospitals consider their anesthesia team as one of many strategic advantages they reference when recruiting surgeons and marketing their facility to patients, employers and community leaders. When hospital administrators find themselves too frequently apologizing for the negative acts, omissions or behaviors of the anesthesia organization, the whole group ceases to be viewed as an asset and instead can be very quickly viewed as a liability that requires fixing through some concrete action (RFPs, employment, stipend reductions, etc.). I saw this “positive ambassadorship” expectation fully tested some years ago when the lead anesthesiologist, when confronted, readily admitted she had told members of her church and country club to drive the extra 60 minutes to a larger hospital up the Interstate for their elective surgery because the care at the local hospital where her group held the contract was “unsafe.”

In addition to these five, there are a number of desirable characteristics of anesthesia groups that may get less press, but that are still very important:

• Transparency/good faith when contractual fair market value and financial support is determined
• Compensation systems that allow the hospital and anesthesia group to align incentives
• Active involvement and leadership on important hospital committees
• An open mind to technology solutions for care delivery challenges
• Staffing models that make care delivery and economic sense in today’s environment
• A group that contracts with all major governmental and commercial payers

But more than anything, incisive hospital leaders I know want a group of anesthesia professionals who “fly under the radar” and about whom they rarely hear complaints, so when they sign that monthly or quarterly financial support check they are smiling, not cursing.

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Patrick C. Everett, CPA, CMPE is a nationally-recognized independent consultant who focuses exclusively on all business aspects of the anesthesiology specialty. After careers with an international accounting firm and a practice administrator position with a large care team private anesthesia group in Atlanta, he founded ProSTAT Anesthesia Advisors, celebrating the firm’s 20th year in business in 2015. He can be reached by email at pateverett@anesthesiaadvisors.com.
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