Anesthesia time “starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area,” according to the Medicare regulations and the ASA Relative Value Guide®, or “begins to prepare the patient for the induction of anesthesia” as stated in the CPT® Anesthesia Guidelines.  What do those words mean—and can there be any remaining controversies after all these years? To “begin to prepare the patient” involves “doing something to the patient” or placing “hands on,” in the memorable words of a former chair of the ASA Committee on Economics.  Thus anesthesia time starts with an intervention performed after completion of the preoperative assessment, whether that assessment is done in the holding area or in the operating room itself.  The start of anesthesia time occurs before anesthesia is induced.  Our concern is with the period of time from the first act of physical preparation, such as the placement of...

Date night with my husband usually involves going out to one of our favorite restaurants where we get to enjoy each other’s company in a relaxed atmosphere without worrying about who’s doing the dishes. So how can a night out at a restaurant have anything in common with having a total joint replacement? My husband and I feel that every waiter or waitress generally deserves a 20 percent tip. From the time we get seated at the table to the time we pay the tab, my husband and I are unconsciously measuring both the restaurant’s and the servers’ performance and quality. We are not concerned about the fact that our waitress has to go to the bar for our glasses of wine or that the bartender may be busy serving happy hour drinks; we just want our drinks timely and exactly as we ordered. Same goes for the food we order....

Anesthesiologists are wondering how to respond to questions about an article that appeared in the New York Times on September 20, 2014, reporting on a $117,000 bill received by a spinal fusion patient from a neurosurgeon who had assisted in his procedure. We cannot come up with a better justification for such a charge than can anyone else.  That includes the presidents of the American Association of Neurological Surgeons and of the Congress of Neurological Surgeons, who co-signed a letter to the editor of the Times declaring themselves “outraged” and the “practice of ‘surprise’ medical bills … indefensible.”  The orthopedic surgeon in the case was paid $6,200, or less than five percent of his $133,000 bill.  The anesthesiologist charged $4,300 and was presumably paid a smaller amount.  The difference is that the neurosurgeon did not participate in the patient’s health plan.  And the health plan eventually sent him a check for the full amount. Accounts...

On October 1, 2014, the start of the fiscal year for hospitals, Medicare’s maximum penalties for “preventable” readmissions increased from two percent to three percent.  At the same time, CMS added three new conditions, including two frequently performed orthopedic procedures, to the list of conditions for which readmissions are deemed preventable, which now consists of the following: heart failure acute myocardial infarction (AMI) pneumonia chronic obstructive pulmonary disease (COPD) knee arthroplasty hip arthroplasty Authorized by the Patient Protection and Affordable Care Act, the Hospital Readmissions Reduction Program (HRRP) began in October 2012 (FY 2013) with a maximum penalty of one percent of total Medicare payment.  Historically, about one in five Medicare patients discharged from a hospital is readmitted within 30 days.  Readmission rates vary considerably by hospital and by geographic area after controlling for case mix and severity of illness.  According to a Health Affairs Health Policy Brief, studies have estimated the...

An article in the September 21 New York Times Sunday Review asked the question Can a Computer Replace Your Doctor?  The author, Elisabeth Rosenthal (who identified herself as a “former physician”)  opened with the following:I shivered a bit when I heard Dr. Vivek Wadhwa say he would rather have an artificial-intelligence doctor than a human one.  “I would trust an A.I. over a doctor any day,” he proclaimed at a recent health innovation conference in San Francisco, noting that artificial intelligence provided “perfect knowledge.” When asked to vote, probably a third of those in attendance agreed.Artificial intelligence is obviously far more than data collection and management.  Data collection and reporting is where much health care technology is today, however.  Rosenthal noted devices that could turn an iPhone into an otoscope, blood alcohol measurement gadgets, home cholesterol test kits, cardiac trackers worn for more than a few days, devices that record sympathetic...