The Center for Medicare and Medicaid Services (CMS) is constantly progressing its policies, particularly concerning its value-based care programs. Of these programs, MACRA, the Medicare Access and CHIP Reauthorization Act, represents a highly innovative legislative measure to encourage quality care among CMS-reimbursed physicians. Signed into law in 2016, MACRA created distinct payment pathways for physicians such as the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs) program. The following article will discuss 2018 updates to MACRA and MIPS specifically, with an emphasis on how such updates will affect providers and practices at-large.

For individual clinicians, reporting requirements under MACRA will dramatically increase in 2018. To begin, a physician or practice’s score is calculated utilizing various quantitative measures for quality. In order to have a score included in the total score, CMS requires physicians to satisfy specific data submission requirements by utilizing a data completeness measure. Data completeness is defined as the percentage of potential data that the physician submits to CMS upon reimbursement request. In 2017, the threshold for data completeness was set at 50%, however in 2018 CMS has increased this threshold to 60%. This increase reflects the shift at CMS to integrate claims data from a variety of healthcare institutions.

In addition to more rigorous data reporting requirements, CMS will begin to assess cost measures for CMS institutions, a dramatic shift from the previous policy. Initially, the inclusion of cost measures in MACRA/MIPS evaluations was set to occur in 2019, however CMS accelerated this timeline by including it in 2018. For MIPS scoring purposes, cost will account for 10% of the total score. Furthermore, points for cost will be calculated by measuring Medicare Spending Per Beneficiary (MSPB) and cost per capita. Once the data is submitted, CMS will perform cost calculations in order to minimize potential institution biases. CMS is setting the level of contribution of cost to the total score at a conservative 10%, with the aim to double this contribution by 2019. In essence, 2018 will serve as a pilot year of sorts for CMS to test the methodologies and processes around measuring, evaluating, and applying cost to scoring.

Lastly, CMS has made a concerted effort to account for the wave of natural disasters that plagued the United States in 2017 (Hurricane Irma, Hurricane Harvey, Hurricane Maria). Physicians and practices that are located in those areas that are MIPS-affiliated may submit a hardship exception application to account for a dearth of data or reporting requirements. Moreover, these physicians and practices will not be subject to late penalties.

In sum, the MACRA and MIPS changes for 2018 are significant in progressing the cost and quality agenda of CMS, while also remaining cognizant of the influential impact of the environment on healthcare over the past year. Future updates will continue to streamline evaluation processes, ensuring that value is at the center of the U.S. healthcare system.

Sources:

1. https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/QPP-Year-2-Executive-Summary.pdf
2. https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/QPP-Year-2-Final-Rule-Fact-Sheet.pdf
3. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/QPP-MIPS-Quality-and-Cost-Slides.pdf

The association between epidural labor analgesia and maternal fever remains somewhat controversial despite being supported by evidence in randomized controlled trials, observation and retrospective studies. Perhaps this is because maternal fever during labor itself is a complex and multi-factorial phenomenon, and many criticisms of the studies demonstrating the above association include selection bias, bias in obstetric practice, and faulty study design. Anesthesiologists are often tasked to explain the potential complications of epidural analgesia, and it behooves us to better acquaint ourselves with this often overlooked topic.

Randomized controlled trials comparing intravenous opioid or unmedicated labor to epidural analgesia show that the epidural arm is more likely to experience hyperthermia and overt clinical fever. The increase in temperature is gradual, with women who receive epidural analgesia earlier in labor experiencing greater increases. There is some degree of selection bias in observational studies, as those women who are more at risk for fever (e.g. longer labor, longer duration of ruptured membranes, more frequent cervical examinations) are also more likely to elect for epidural analgesia. However, the randomized controlled trials give stronger support to a causal relationship.

The mechanism is incompletely understood, as not all women who receive an epidural exhibit an increase in core body temperature – only about 20% do. The most consistently supported mechanism is that of noninfectious inflammation mediated by pro-inflammatory cytokines. Less popular theories include altered thermoregulation and avoidance of opioids, which may suppress fever.

The maternal consequences of fever during labor include elevation of heart rate, cardiac output, oxygen consumption and catecholamine production. Shivering and antibiotic exposure are more common in febrile women. Frequently obstetric management is altered, with a higher associated incidence of operative vaginal and cesarean delivery. It is unclear whether the labor pattern is altered by the fever, or it simply influences obstetric decision making in respect to fears of maternal or fetal complications of delaying delivery.

Maternal fever also has fetal effects as well, including fetal hyperthermia. This in turn may be associated with low fetal tone, lower Apgar scores, advanced airway management, cardiopulmonary resuscitation, and neonatal seizure.

Treatment of maternal fever, whether or not associated with epidural analgesia, is therefore important. However, treatment options are limited given the unclear etiology of the fever. Acetaminophen is not effective in suppressing epidural-related maternal fever. High dose methylprednisolone, is effective, however it is impractical given the risk of increased neonatal bacteremia. Therapeutic effects of systemic opioids have also been weak, and carry the complication of possible neonatal respiratory depression.

There is a need for further research into the etiology, prevention and treatment of epidural related maternal fever. In the meantime, anesthesia providers can provide patients with what is known on the topic to help them make an informed decision.

References

Arendt KW, Segal BS. The association between epidural labor analgesia and maternal fever. Clin Perinatol. 2013 Sep;40(3):385-98. doi: 10.1016/j.clp.2013.06.002. Epub 2013 Jul 19.

Segal, S. Labor epidural analgesia and maternal fever. Anesth Analg. 2010 Dec;111(6):1467-75. doi: 10.1213/ANE.0b013e3181f713d4. Epub 2010 Sep 22.

The Centers for Medicare and Medicaid Services (CMS) has released two rule updates that will heavily impact anesthesiology providers in 2018. As previously discussed, CMS is a government agency that administers governmental health programs, providing guidelines for pricing and reimbursement at the state level for Medicare Centers of Excellence and other Medicare/Medicaid-serving providers. Anesthesiology providers, including anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) are subject to such guidelines. Furthermore, CMS as an agency is trending towards providing more specific diagnosis and reimbursement codes for surgical procedures, highlighting the specific anesthesia procedures. The most recent round of Rule Updates supports the trend.

As of Jan 1, 2018, CMS has pronounced that anesthesia for endoscopies are to be affected by a new reimbursement scheme. The decision was driven by a meeting of key stakeholders, that included the Medicare Payment Advisory Commission, the American Society of Anesthesiologists (ASA), and the American Medical Association.

In sum, the rule changes will change services rendered as follows:
1. Endoscopic retrograde cholangio-pancreatography (ECRP) is now a unique code. As such, ECRPs will be reimbursed at a greater base unit as compared to prior to this ruling, at a rate of 6 units versus 5 units. For reference, one unit is roughly 8 minutes to 22 minutes of provider time.
2. Colonoscopies and screening for colonoscopies has been reduced. These procedures will now receive 3-4 units per procedure.

The American Society of Anesthesiologists is particularly active in the CMS space and has advocated heavily for appropriate and equal reimbursement of anesthesiology services. In response to the above Rule Updates, the ASA has released a public statement criticizing the undervaluation of endoscopies. The ASA, after conducting market research among its membership, is assured that these procedures should achieve at least 4 units. While the difference in one unit may seem negligible, in terms of reimbursement it can have grave implications. Sum reimbursement is dependent on the CMS-determined conversion factor; for 2018, CMS has concluded that the anesthesia conversion factor will be 22.1887 USD (a rise from 2017’s 22.0454 USD value), in comparison to an overall resource-based conversion factor of 35.9996 USD. Therefore, to conduct a simple thought exercise, one could imagine 1000 endoscopy procedures occurring per year in an endoscopy suite. At a rate of 5 units per procedure, the net annual reimbursement would equate to 1000 procedures * 5 units per procedure * 22.1887 conversion factor = 110,943.50 USD. However, at the updated CMS rate, this net annual reimbursement would change to 1000 procedures * 3 units per procedure * 22.1887 conversion factor = 66, 566.10 USD, a dramatic decrease. In combination with the fact that many physicians will continue to devote the same amount of time to the procedure, the decreased unit allocation could lead to a severe undervaluing of the physician’s time. Conversely, if the physician or physician’s office aims to achieve reimbursement parity, they must require that physicians minimize the number of minutes they spend per procedure per patient, which can lead to medical error and lapses in safety. From the perspective of the ASA, rule changes which decrease unit allocation for routine procedures is dangerous for the provider, the patient, and the healthcare system as a whole.

The anesthesia space will continue to be impacted by rapid changes in CMS governance. Anesthesiologists, CRNAs, and healthcare administrators must be kept knowledgeable of such changes to keep pace with the rapid innovation present in the American healthcare system.

Sources:
https://www.asahq.org/advocacy/fda-and-washington-alerts/washington-alerts/2017/11/cms-releases-final-rule-for-2018-medicare-physician-fee-schedule
https://www.federalregister.gov/documents/2017/11/15/2017-23953/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-02.html

There is considerable flexibility in decisions made by healthcare facilities concerning anesthesia services, specifically with respect to the employment of physician anesthesiologists and the use of non-physician anesthesia providers. While there are a variety of providers involved with the delivery of anesthesia care, as well as diversity among anesthesia delivery models, anesthesiologists and certified registered nurse anesthetists (CRNAs) are the primary anesthesia provider types. Non-physician providers are increasingly being utilized in today’s anesthesia workforce, and there is a growing influx of women and younger providers into the workforce. Concerns about a provider shortage are also escalating, and regional differences exist throughout the workforce. Understanding these recent trends necessitates examining changes in demography and today’s healthcare sector, specifically in the aging population, the rise of value-based care, and new provider models.

Current demographic changes are influencing the anesthesia workforce and causing shifts in demand, as the growing number of baby boomers retiring as well as an aging U.S. population are causing an increase in the demand for healthcare services, including anesthesia and perioperative care. Additionally, many older, predominantly male anesthesiologists are retiring. There is an influx of younger anesthesiologists, including an increasing number of women, into the field. This trend is expected to continue as older providers retire [1]. The overall number of anesthesia providers continues to shrink, however. These demographic trends, including the  retiring physician population, may increase the shortage of anesthesia providers. Studies on the anesthesia labor market in the U.S. have predicted that the shortage will continue to grow through at least 2025 [2]. This trend is not unique to the U.S., however, as there is currently a global shortage in the surgical and anesthesia workforce leaving five billion people around the world without access to safe, affordable anesthesia and surgical care, according to a WFSA global workforce survey [3].

As concerns about the cost of health care and the physician shortage persist, restructuring the anesthesia workforce to reduce the total pe