The Role of Anesthesiologists in the Intensive Care Unit
Jody Locke, MA
Vice President of Anesthesia and Pain Management Services, ABC
For all the time most anesthesiologists spend in the operating room and the Post-anesthesia Care Unit (PACU) there is a curious firewall when it comes to the Intensive Care Unit (ICU). Most anesthesia practices are actively pursuing ways to generate additional revenue and further strengthen their relationship to administration and yet rarely do such considerations include any discussion of the ICU. As a large national billing company with hundreds of clients across the country, we only bill for a few clients that cover the ICU. One might therefore ask, “Are these practices visionaries of a future reality or isolated exceptions?” What is the opportunity and what would be involved in exploring it? Why are the very physicians who promote themselves as ideal managers of the entire perioperative continuum not pursuing a more active role in the ICU? It would appear to be a logical and integral part of the Perioperative Surgical Home.
The scope of billable services for an intensive care unit is limited to specific intensive care service Current Procedural Terminology® (CPT) codes, (99291 and 99292), subsequent hospital visit codes (99231-99235) and a relatively short list of interventional modalities including the insertion of arterial lines, CVPs and Swan-Ganz catheters. In certain, limited situations there could also be an opportunity to bill for ventilator management. Anesthesiologists who provide anesthesia to cardiac patients must be careful in their use of these codes, however, because ventilator management is included in the scope of cardiac anesthesia.
The ICU codes are time-based. Code 99291 is intended to reflect an hour of management of a critically ill patient. As a practical matter, not all patient encounters last exactly 60 minutes and so CPT established a convention whereby the code can be used for any encounter lasting longer than 34 minutes or less than 74 minutes. The second code, 99292, is intended to reflect each subsequent half hour of care. Key to code selection is the acuity of care. Once patients are stabilized and no longer at significant risk, then subsequent hospital visit codes must be used. (For further information, see Joette Derricks’s article Reporting Critical Care Services on page 18.)
The economics of ICU coverage hinge on three factors: volume of patients, payor mix and the nature of the services provided. It is not uncommon for busy academic centers with multiple step-down units to have enough patients such that the typical provider will bill for 10 or more hours of care per day. Managing a small population of post-cardiac surgery patients, on the other hand, would not typically result in very significant billings. The impact of payor mix is the same as in the operating room where the Medicare payment rate of approximately $120 per hour is at the low end of the spectrum. This implies that 10 hours of billable time for a Medicare population would result in $1200. If even a few commercial PPO patients are included in the mix, the daily yield could approach that of the operating room. Given current levels of anesthesiologist compensation, most services must be subsidized by the facility.
As an outgrowth of the PACU, critical care units are now found in all major medical facilities throughout the United States. Anesthesiologists are uniquely qualified to coordinate the care of patients in the intensive care unit because of their extensive training in clinical physiology/pharmacology and resuscitation. Some anesthesiologists pursue advanced fellowship training to subspecialize in critical care medicine in both adult and pediatric hospitals. In the ICU, they direct the complete medical care for the sickest patients. The role of the anesthesiologist in this setting includes the provision of medical assessment and diagnosis, respiratory and cardiovascular support and infection control.
Anesthesiologists also possess the medical knowledge and technical expertise to deal with many emergency and trauma situations. They provide airway management, cardiac and pulmonary resuscitation, advanced life support and pain control, all of which are essential skills to the intensivist. As consultants, they play an active role in stabilizing and preparing the patient for emergency surgery.
The staffing requirements of ICUs may also create an opportunity for anesthesia practices. Given the level of activity and service provided it may be more cost-effective for anesthesia to rotate members of the group through the unit. This might also provide greater flexibility in staffing and coverage.
Lutheran General Hospital in Park Ridge, Illinois is a useful case study. Park Ridge Anesthesia has four intensive care-trained anesthesiologists who cover the ICU five days a week. The origin of the service goes back in time to a point where the hospital believed that its patients would be better served by a single service that could provide a continuum of care to patients undergoing major surgery. The assumption was that anesthesiologists who were familiar with the care received in the operating room would be better qualified to manage post-surgical complications in the ICU. The Park Ridge anesthesia team argues this has been the explanation for the consistently low levels of post-surgical complications and high levels of patient satisfaction.
Two common factors deter most anesthesia practices from any consideration of ICU coverage. The first is the revenue potential and the second is the politics of cardiac care. Because the reality of most intensive care services is that they are inherently unprofitable, they are not viewed as good opportunities for expansion in an era when Ambulatory Surgery Centers (ASCs) and endoscopy centers have tended to be such logical places to look for additional revenue potential. Why mine the unprofitable when the profitable is so readily at hand? Ironically, chronic pain management has become the next area of exploration, despite the fact that many chronic pain practices deliver such disappointing results. The underlying thread is the potential for independence. Rare is the practice that wants to build a practice model based on the need for subsidy from the facility. There may come a point, however, where all opportunities for independent, profitable expansion are exhausted.
If the primary focus of an intensive care service is post-cardiac surgical patients then this implies competition with the cardiologists who referred the patients to the facility for surgery in the first place. The cardiovascular surgeon makes his money performing complex surgical interventions, but the cardiologist makes his money managing patients over time. I have personal experience with a Long Island heart center that brought in an anesthesiologist to manage the ICU. In that case, it was a very profitable service, but the politics ultimately made it so challenging that the doctor left the facility.
There is also a curious chicken and egg phenomenon at work here, as indicated by the following abstract for an article in Anesthesia and Analgesia: The number of anesthesiology residents pursuing critical care medicine (CCM) fellowship training has been decreasing in recent years. A significant number of training positions remain unfilled each year. Possible causes of this decline were evaluated by surveying residents regarding their attitudes toward practice and training in CCM. All 38 anesthesiology programs having accredited CCM fellowships were surveyed. Four of these and one program without CCM fellowships were used to develop the survey instrument. Four programs without CCM fellowships and 34 programs with CCM fellowships make up the survey group. Returned were 640 surveys from 37 (97 percent) programs accounting for over 30 percent of the possible residents. Resident interest in pursuing CCM training decreased as year of residency increased (P < 0.0001). Residents in programs with little patient care responsibility during intensive care unit (ICU) rotations expressed less interest in CCM training (P < 0.012). The administrative role of the anesthesiology department in the ICU also influenced resident interest (P < 0.014). Written responses to open-ended questions suggested resident concerns with the following: stress of chronic care, financial consequences of additional year of training, ICU call frequency and load, ICU role ambiguity, and shared decision-making in the ICU. A recurring question was, “Are there jobs (outside of academics) for anesthesiologist intensivists?” Most residents knew a CCM anesthesiologist they admired and knew that there were unfilled fellowship positions available. Defining the job market, improving curriculum and teaching, supporting deferment of student loans, and introducing residents and medical students to the ICU earlier may increase the interest in CCM practice among anesthesiology residents (Anesthesia and Analgesia 1993).
With the changing focus of healthcare, is the ICU a clinical opportunity that anesthesia practices should be pursuing? Three factors would appear to support a revision of traditional thinking. If we assume that other opportunities for practice expansion are slowly drying up it might be time to revisit the potential of the ICU. As an increasing number of anesthesia practices receive stipends and other forms of financial support from facilities, there is a growing concern about justifying financial support. If anesthesia can expand its scope of services this could have distinct strategic advantages. An active role in the ICU is also logically indicated by the current focus on the Perioperative Surgical Home. In an era of customer service, hospitals love the concept of accountability for quality of care. Clearly a comprehensive service that includes co-management of the ICU with surgery has great potential to accomplish this.
As is true of so many other developments in healthcare, the real challenges to changing the practice model may be more educational and strategic than financial. Sometimes changing the culture of a facility is simply a matter of clearly delineating the advantages of a new approach. Some serious stakeholder analysis might reveal significant opportunities. It is all in the packaging.
Jody Locke, MA serves as Vice President of Pain and Anesthesia Management for ABC. Mr. Locke is responsible for the scope and focus of services provided to ABC’s largest clients. He is also responsible for oversight and management of the company’s pain management billing team. He will be a key executive contact for the group should it enter into a contract for services with ABC. He can be reached at Jody.Locke@AnesthesiaLLC.com.