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Spring 2009

Avoiding Pitfalls as Practices Move Toward Care Team Model

Jackie Popiela
Vice President of Client Services, ABC

Much like the average American consumer, many anesthesia practices are finding ways to survive in today’s tough economic market. There are any number of external forces influencing many anesthesia groups to join the growing trend of practices that have decided to consider the Anesthesia Care Team model for the first time. These practices are currently feeling the pinch due to decline in hospital based cases, payor mix increasingly shifting toward higher governmental payors or self-pay. In many cases there are added pressures due to increased hospital subsidy, improved OR efficiencies and addition of service lines as hospitals struggle to maintain their ground.

Before a practice actually makes the transition to the Anesthesia Care Team model, it is imperative that the first step be communication with the hospital. Some groups have actually remained in the physician-only model simply because hospital by-laws did not allow for other qualified anesthesia personnel to practice within the hospital. Many of these same groups are finding it increasingly difficult, if not impossible, to retain and recruit physicians given the current market climate. There is the general sentiment that the surgeons would balk and take their cases elsewhere or that the hospital simply does not understand what CRNAs are. If the group is presenting the concept of adding CRNAs into the practice, approaching the hospital first to make changes to their current by-laws may be presented in such a manner that it is viewed as fostering a true partnership with the Group. Initially, the onus of educating the hospital will be placed on the Group. The Group should be prepared to provide information on CRNA education, scope of practice and medical direction guidelines and it is important that the Group have access to the latest information regarding Medicare regulations governing medical direction. Often, the hospitals will make revisions to the existing by-laws to include other qualified anesthesia personnel (CRNAs, AAs) but may limit the medical direction to a 1:3 ratio.

For Groups that are receiving a subsidy from the hospital, this is the perfect segue into discussions of the overall impact of opening additional ORs or adding additional lines of service such as OB or cardiac coverage. One can argue that the anesthesia care team model is not only more cost-effective but will also allow the Group to meet the increased coverage demands. There are various staffing models that can meet the needs of the hospital, surgeons and anesthesia providers. Having OR utilization information based on anesthesia productivity as well as the hospital figures can provide a more complete picture of overall staffing needs. After the CRNAs have been integrated into the schedule, is also important to revisit utilization reports to ensure that the proper ratios are maintained to maximize staffing either within the anesthesia department guidelines or per hospital by-laws.

Certainly the choice to migrate toward a new model of practice comes after much consideration and with its own set of philosophical and cultural challenges. One of the greatest cultural challenges after the hospital agrees to accept the addition of CRNAs is convincing surgeons that their patients will still be adequately cared for. This is also another opportunity for communicating with the hospital and partnering with the medical staff. Through education and proper planning, this may develop into a win-win situation for the surgeons as well.

Glenn Malmberg, Practice Administrator for Toms River Anesthesia Associates in Toms River, NJ recently addressed this issue when his primary facility agreed to include CRNAs into their medical staff for the first time in the hospital’s history. Mr. Malmberg states, “A surprising success was acceptance by the surgeons. We anticipated acceptance by surgeons would take a period of time and (had) developed strategies to address the potential problem. However, acceptance by many surgeons occurred rapidly and the problem we anticipated has not occurred”. One of the strategies that may be taken is to initially place CRNAs in ORs which are staffed by surgeons who may be more accepting of the care-team model approach. Once there are established successes and surgeons are comfortable with the CRNAs, this will lead to further acceptance from the surgical staff.

The surgeons are not the only medical staff who may need to be convinced of the benefits of adding CRNAs to a practice. On more than one occasion, there may be some members of the anesthesia group who need to be won over. A similar strategy may be employed within the group. There may be anesthesiologists who were accustomed to working with and medically directing CRNAs either in a previous practice or during training. These are the physicians who should initially be charged with medical direction of the new CRNAs. These physicians can also be key in running interference between the CRNAs and medical staff. If the information and support is coming directly from a colleague, this may help to allay misconceptions and misinformation.

Once the anesthesia group has identified and addressed the possible philosophical differences, cultural and clinical impacts of including CRNAs in practice, the next steps are where and how to start recruiting for these CRNAs. When Mr. Malmberg began recruiting for CRNAs on behalf of the group, he was able to use the fact that this was a new position as a selling point. According to Mr. Malmberg, “We learned to emphasize the advantages of getting in on the ground floor such as helping to develop the program and the opportunity for leadership positions as the program grew.” It was important that the group find the right individual and they focused on experienced CRNAs with strong leadership skills. These first pioneers need to be more than clinically skilled; they must also be astute enough to address concerns that surgeons may have and handle these issues with finesse and in a spirit of education and partnership. This particular group chose to hire CRNAs as employees, while there are other groups who choose to work with staffing agencies initially.

Dr. Jennifer Baxter is the CFO of Surgical Anesthesia Associates in Washington D.C., a practice that successfully integrated CRNAs within the past year. Her group chose not to hire the CRNAs initially, but instead they used agencies to assist in meeting their staffing needs. Whether groups choose to use agencies or hire the CRNAs as employees, Dr. Baxter warns that the provider enrollment for CRNAs needs to be a priority and the impact of possible delays in collections needs to be monitored closely. As with hiring a new physician, it is important to obtain as much of the provider enrollment information as soon as the group has offered a position to the CRNA. When utilizing an agency, many times the agency is able to provide this information prior to the CRNA’s provision of services.

Another area where changes will need to be made is with documentation. The physical record will need to be revised to meet the documentation requirements for medical direction. For groups that are currently utilizing an Electronic Medical Record (EMR), programming changes may be necessary to include such criteria as the seven steps of medical direction and to account for additional hand-offs. If the group is using a paper record, it is important to factor in the time necessary to obtain approvals from Records Committees.

Education for anesthesiologists and CRNAs on proper documentation will ensure not only that all billable procedures are captured, but also that the group meets compliance requirements. Mr. Malmberg and his Group had access to several anesthesia industry experts through his group’s partnership with Anesthesia Business Consultants who not only assisted in providing revenue-impact analyses but also held physician and CRNA education in-services. If possible, informing the hospital that there are in-services to ensure documentation and medical direction compliance also serves to illustrate that the group strives to maintain top-quality standards in all aspects of anesthesia services. The emphasis should be on the anesthesia care TEAM.

The groups who have included CRNAs into practice successfully did not do so overnight. There was certainly lengthy planning, many hospital meetings to attend and often, the most difficult hurdles to overcome were internal to the anesthesia groups. The key to success was both communication and information. It is important to anticipate the difficulties and to plan accordingly. Being able to provide relevant and valuable information quickly also speaks to the commitment of the group toward achieving a seamless assimilation into the group and evolution from physician-only to anesthesia care team.