"Physicians’ relationships with the pharmaceutical industry should be transparent and focused on benefits to patients." (Jeremy A. Lazarus, MD, President, American Medical Association, Statement on Final Physician Payment Sunshine Act Rule, February 1, 2013.)“You should know when your doctor has a financial relationship with the companies that manufacture or supply the medicines or medical devices you may need. Disclosure of these relationships allows patients to have more informed discussions with their doctors.” (Peter Budetti, MD, JD, CMS Deputy Administrator for Program Integrity, quoted in Rule Increases Transparency in Health Care, press release, February 1, 2013.)Have you ever received a consulting fee, a meal, a textbook, a mug or a pen set from a drug company or a device manufacturer? If the value of the item was more than $10, it would likely be reportable to a new registry under the Physician Payment Sunshine Act and the final regulations (“Final Rule”) published by CMS on February...
The creation of Health
Insurance Exchanges (HIEs) is among the most important changes to the
health care system made by the Affordable Care Act (ACA). The HIEs are
marketplaces where consumers and small businesses can shop for private
health insurance plans. Many anesthesia and pain medicine patients will
be covered by health plans participating in HIEs beginning as soon as
October 2013. Payment rates under such plans have the potential to make
or break providers. Additionally, some group practices may choose to
offer coverage through the HIEs. A basic familiarity with HIE structure
and operations is therefore in order.
Who
The ACA provides that
effective January 1, 2014, there shall be at least one HIE in each of
the fifty states. States have the option of (1) setting up their own
HIEs, (2) partnering with the federal government to run an exchange, or
(3) opting out—in which case, the Department of... 
The Anesthesia Quality Institute (AQI) is a non-profit corporation created to improve outcomes in anesthesia, based on aggregating, analyzing and reporting electronic data. Over the past three years AQI has recruited more than 220 anesthesia practices, from 44 states, to contribute data to the National Anesthesia Clinical Outcomes Registry (NACOR). The aggregate data has provided a unique and valuable perspective on the specialty of anesthesiology: What we do, what we know, and how we do it. At the same time, a picture is emerging of the other side of our national practice: What we don’t know and what we don’t do.
The widest performance gap in anesthesia today is our collective lack of insight regarding outcomes of the care we provide. Even among the participating groups in NACOR—a self-selected ‘choir’ of early adapters—fewer than 1 in 5 have the infrastructure to recognize and respond to the following event:
Mrs. Smith,...
Gastrointestinal endoscopy
is one of the safest and most commonly performed adult procedures. The
record of safety extends to the sedation or anesthesia for both upper
and lower GI endoscopy. Because of both the safety and the frequency of
the procedure, anesthesia for GI endoscopy has been under scrutiny by
health plans for a decade or more. Lately, the number of claims denied
for lack of “medical necessity” for endoscopic anesthesia services have
once again been growing. Without taking any position on the merits of
anesthesia vs. moderate sedation in connection with endoscopies and
especially colonoscopies, we would like to remind our audience of the
principles followed by payers in evaluating the medical necessity of
anesthesia for these procedures.
The differences between anesthesia and moderate sedation
Moderate sedation (aka “conscious sedation”)
is a “drug-induced depression of consciousness during which patients
respond purposefully to verbal commands, either alone or accompanied by
light tactile...
Everyone involved in the
healthcare industry will inevitably learn about the confusing aspects of
medical health insurance. Just when you thought you had a grasp on the
insurance marketplace another complexity presents itself. Sometimes
what you might have thought of as an insurance plan turns out not to be
insurance at all.
There is a variety of
well-known insurance plans available in the market today. Some of these
plans are government-run, starting with Medicare and Medicaid. Others
are private or commercial managed care plans offered by entities that
include Blue Cross and Blue Shield, United Healthcare or Aetna. Then
there is a less well known group of companies that market themselves as
health benefit plans but that are in reality simply claims repricers, or
discount brokers and vendors, i.e., “rental networks” or ”silent PPOs.”
What is a “Rental Network PPO?”
A rental network preferred
provider organization or medical discount network or...