ASA Recommendations on No Surprises Act Implementation

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On January 1st, 2022, the Biden administration’s “No Surprises Act” will be implemented in medical practices throughout America. The bill intends to protect patients from additional unanticipated medical bills following treatment while also establishing an independent dispute resolution for physicians to demand fair payment from health insurers. While the legislation is a promising step towards greater clarity on the financial component of healthcare, there remain some uncertainties about how this change will alter the ever-complicated relationship between physicians and health insurers. To this end, the American Society of Anesthesiologists (ASA) generated a list of recommendations for the implementation of the No Surprises Act.

The recommendations are included in an 11-page document addressed to the U.S. Department of Health and Human services, the U.S. Department of Labor, and the U.S. Department of Treasury, and are organized into five key categories: independent dispute resolution, qualifying payment amount and initial payment, patient engagement, interaction with state laws, and auditing. The ASA requests in particular that the process for independent dispute resolution be transparent by weighing all factors equally in the determination of payment and explicitly stating an intention to do so. According to the document, these factors include:

 

“the QPA, any additional information requested, the provider or facility’s level of training and experience, and the parties’ market shares, among other factors…We believe it is necessary for the Departments to be specific as to these considerations so the IDR process is standardized and does not vary significantly from one entity to the next. Even in the best of circumstances, these factors are subjective and will be assessed differently by each arbiter.”[1]

 

The list of recommendations also includes a demand for active commitment towards the reduction of biases in the settlement of payment disputes.

Moreover, the ASA requests that calculations of insurer’s median in-network amounts are done both accurately and fairly. The letter mentions the number of variables that can affect the cost of healthcare dramatically, including zip code, specialty, physician’s level of training, the frequency of payments, and several other factors. According to the ASA, the No Surprises Act does not specify its plans to determine median in-network amounts, and to not consider these factors would result in inaccurate payments and provide ample opportunity for healthcare insurers to underpay physicians.

One of the final notable components of the ASA’s requests is the demand that physicians be able to access the federal independent dispute resolution process. The ASA argues that in states where similar legislation to the No Surprises Act is already being implemented, the interaction between state and federal law would place too much strain on physicians. The letter states:

 

“We are concerned that the interaction of these federal and state frameworks will result in a patchwork scheme that creates tremendous uncertainty about which laws apply, placing the burden on parties to analyze which regulatory scheme they fall under. We believe this is asking too much of providers and patients. Providers’ primary concern is patient care and patients’ primary concern is obtaining the care needed to promote good health. We urge the Department to never lose sight of these important objectives.”1

 

While the No Surprises Act has the potential to change the landscape of healthcare payment for both patient and physician alike, there remains the need for increased clarity. The ASA’s recommendations offer an actionable template for equitable implementation.

References

[1] ASA Makes Recommendations to Biden Admin: Implement ‘No Surprises Act’ Equitably Without Improper Advantage to Health Insurers. (2021). Retrieved from https://www.asahq.org/about-asa/newsroom/news-releases/2021/06/asa-makes-recommendations-to-implement-no-surprises-act-equitably

 

Mosquito Modification to Control Mosquito-Borne Disease

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Mosquitos are a common vector for deadly diseases in humans, including malaria and dengue fever. Their capacity for disease transmission makes them dangerous to human populations, resulting in mosquitoes being responsible for millions of deaths per year (Ito et al. 2002). There have been substantial efforts to reduce mosquitos’ populations, from insecticide to removing pools of still water (Ito et al 2002). However, mosquito populations have persisted, and they have continued to spread disease. Insecticide resistance in mosquitoes makes controlling mosquito populations difficult, causing a need for alternative methods to reduce mosquito-borne disease transmission. Recent advances have led scientists to research the effectiveness of a modification that limits the ability of mosquito populations to get infected themselves, rather than limiting the spread of mosquitoes themselves.

 

Viral disease spread was significantly reduced in mosquito populations that were infected with Wolbachia pipientis (wMel), an inherited intracellular bacterium which infects many insects (Utarini et al. 2021). The wMel bacteria causes the mosquito to be less susceptible to dengue virus than non-modified mosquitoes. A previous study in 2013 showed wMel infected mosquitos were less likely to transmit dengue, however, the impact on human disease transmission was still unknown. In an Indonesian study, areas with wMel mosquito populations had reduced 77% of viral dengue cases, compared to areas with control populations (Utarini et al. 2021).

 

This study showed that modified mosquitoes can compete in natural environments. Additionally, the reduced vector capacity had tangible impacts on communities. The wMel versus non-modified population disparity in dengue cases shows how effective targeted infection of mosquitoes can be in controlling mosquito-borne diseases in human populations.

 

Similarly, control of parasitic diseases spread by mosquitoes have been hindered by an inability to control mosquito populations. Malaria, a disease caused by infection by Plasmodium parasites, has evaded many tools designed to limit its spread. New understanding of the gut’s role in the immune system has provided a new method to limit the transmission of malaria (Pike et al. 2017).

 

Researchers genetically modified mosquitoes create a peptide to inhibit Plasmodium development, specifically in the midgut. This genetic modification reduced the vector capacity of mosquitoes; however, it did not affect the overall fitness (Pike et al. 2017). Another study of genetically modified mosquitoes revealed the genetic modification is inheritable in mosquitoes and the resistance to the malaria parasite persisted through at least ten generations (Ito et al. 2002).

 

Genetic modification of mosquitoes can reduce transmission for diseases caused by mosquito-borne pathogens. This is important because genetic transmission can be effective in addressing a wide array of mosquito-borne diseases. While each situation would require specific knowledge of what genetic modification to create in the mosquitoes to limit disease control, this research is providing a new standard in how to control vector disease spread.

 

Genetic modification is a new method to address the significant issue of mosquito-borne diseases. It directly targets the vector capacity of mosquitoes, allowing for disease control at the source. Additionally, existing genetic modifications have been proven to be inheritable. This would allow the mosquito populations to naturally maintain resistance to known diseases. If genetic modification of mosquitoes becomes common practice, this would significantly lower the efforts needed to maintain a genetically modified mosquito population.

 

References

 

Ito, J., Ghosh, A., Moreira, L., et al. Transgenic anopheline mosquitoes impaired in transmission of a malaria parasite. Nature 417, 452–455 (2002). https://doi.org/10.1038/417452a

Pike, A., et al. “Changes in the Microbiota Cause Genetically Modified Anopheles to Spread in a Population.” Science, vol. 357, no. 6358, Sept. 2017, p. 1396, doi:10.1126/science.aak9691.

Utarini, A., et al. “Efficacy of Wolbachia-Infected Mosquito Deployments for the Control of Dengue.” New England Journal of Medicine, vol. 384, no. 23, Massachusetts Medical Society, June 2021, pp. 2177–86. doi:10.1056/NEJMoa2030243.

Quantitative Neuromuscular Monitoring in Anesthesia

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Residual paralysis is a prevalent yet under-recognized issue in perioperative medicine. Residual paralysis occurs when the effects of a neuromuscular blocking agent persist into the surgical recovery period. This complication has been associated with increased risk of critical respiratory events, postoperative pulmonary complications, coma, and patient death [1,2]. Additionally, certain populations are more susceptible to residual paralysis, particularly the elderly. A recent American study reported that up to 57.7 percent of older patients experience residual paralysis following surgery [3]. In order to mitigate associated risks, it is recommended that physicians perform perioperative quantitative neuromuscular monitoring on patients who are more susceptible to residual paralysis.

 

Quantitative neuromuscular monitoring involves transcutaneous stimulation using the train-of-four (TOF) or post-tetanic count (PTC) pattern, depending on the depth of the neuromuscular block. Following TOF stimulation, one can measure the number of elicited muscular contractions as well as the ratio of the fourth to the first twitch response. Quantitative measurements of twitch force, acceleration, velocity, or compound muscle action potential can be taken using mechanomyography, acceleromyography (AMG), kinemyography, and electromyography (EMG), respectively. Today, most clinics have access to an AMG monitoring device [4]. Importantly, AMGs require additional normalization to the control TOF ratio for increased accuracy, which can be achieved by measuring a baseline value before administration of a neuromuscular blocking drug [5]. Though EMG devices are less common, they are not affected by changes in muscle contractility nor temperature, making them the gold standard of quantitative neuromuscular monitoring according to Manfred et al. [4].

 

Once the patient has been subjected to quantitative neuromuscular measurements, physicians may use the resulting data to make pertinent clinical decisions. If the measurements indicate residual neuromuscular paralysis, then reversal of the neuromuscular block may be necessary. This can be accomplished by either waiting for the patient’s neuromuscular function to return spontaneously (which often involves prolonged recovery times and continuous monitoring) or through pharmacological intervention. Some of the most common neuromuscular block reversal agents are acetylcholinesterase inhibitors, which inhibit the breakdown of the muscle-stimulating neurotransmitter acetylcholine. Since this methodology requires a minimal threshold of acetylcholine already in the synaptic cleft to be effective, this option is only optimal in cases where minimal residual paralysis remains. If the persistent neuromuscular block is severe, more rigorous intervention may be needed: for example, the modified cyclodexterine sugammadex has been shown to sequester and encapsulate steroidal muscle relaxants for renal excretion, thus reducing their presence in muscle tissue and reversing paralytic effects [6,7]. Sugammadex is therefore useful in both moderate and extreme cases of residual neuromuscular paralysis.

 

In sum, quantitative neuromuscular measurements can be used to effectively identify postoperative residual paralysis, thus allowing physicians to make informed clinical decisions and improving patient outcomes. It is therefore of great clinical interest for anesthesia providers to perform quantitative neuromuscular monitoring following intensive surgical procedures, particularly in patients that are at a high-risk for persistent paralysis. Moreover, it is anticipated that this type of post-surgical monitoring will become increasingly integrated into standard care in the years to come.

 

References

 

  1. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS. Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Anesth Analg 2008;107:130-7. doi: 10.1213/ane.0b013e31816d1268
  2. Berg H, Roed J, Viby-Mogensen J, Mortensen CR, Engbaek J, Skovgaard LT, Krintel JJ. Residual neuromuscular block is a risk factor for postoperative pulmonary complications: A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand 1997;41:1095-103. doi: 10.1111/j.1399-6576.1997.tb04851.x
  3. Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Shear TD, Vender JS, Parikh KN, Patel SS, Patel A. Residual Neuromuscular Block in the Elderly: Incidence and Clinical Implications. Anesthesiology 2015;123:1322-36. doi: 10.1097/ALN.0000000000000865
  4. Manfred B, Matthias E, Heidrun Lewald. Safe and Efficient Anesthesia: The Role of Quantitative Neuromuscular Monitoring. Advances in Patient Safety. 2020. http://advancesinpatientsafety.org/assets/ge_article-new.pdf
  5. Suzuki T, Fukano N, Kitajima O, Saeki S, Ogawa S. Normalization of acceleromyographic train-of-four ratio by baseline value for detecting residual neuromuscular block. Br J Anaesth 2006;96:44-7. doi: 10.1093/bja/aei273
  6. Kaufhold N, Schaller SJ, Stauble CG, Baumuller E, Ulm K, Blobner M, Fink H. Sugammadex and neostigmine dose-finding study for reversal of residual neuromuscular block at a train-of-four ratio of 0.2 (SUNDRO20). Br J Anaesth 2016;116:233-40. doi: 10.1093/bja/aev437
  7. Schaller SJ, Fink H, Ulm K, Blobner M. Sugammadex and neostigmine dose-finding study for reversal of shallow residual neuromuscular block. Anesthesiology 2010;113:1054-60. doi: 10.1097/ALN.0b013e3181f4182a

Residency Caps and Their Influence on Anesthesiology

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In 1997, the U.S. Congress passed the Balanced Budget Act, which was meant to limit Medicare-based funding to residency programs and cap the number of residency spots available to medical school graduates [1]. As a result of these residency caps — and in spite of the adjustments made by the Balanced Budget Refinement Act of 1999, which marginally increased residency funding — federal funding for medical residencies has not kept pace with the number of residents needed to care for a growing and aging population.

 

Between 2001 to 2010, funding for medical residencies increased just 0.9% [2]. One survey, intending to track changes in residency numbers across specialties before and after the 1997 BBA, used the annual National GME Census as its data source. The census, a joint project of the Association of American Medical Colleges and the American Medical Association, tracks the numbers and specialties of U.S. medical residents, as well as those residents’ demographic information. The study found that, following a temporary halt in residency-program growth after 1997, programs began expanding again between 2002 and 2007, with an 8% net increase between 1997 and 2007 [3].

 

Indeed, in the aforementioned survey, anesthesiology residencies grew faster than almost any other specialty, with an increase of 9.1% between 2002 and 2007 [3]. The data on growth in anesthesia residency programs proved unexpected, after a number of analyses in the late 1990’s and early 2000’s predicted shortages in anesthesiologists: for instance, one study estimated a shortfall of between 1,100 and 3,800 anesthesiologists in 2002 [4]. Meanwhile, specialties like primary care saw marked decreases in the number of residency positions available following the passage of the Balanced Budget Act. According to one analysis, the decade between 1998 and 2008 saw a net loss of 390 positions for first-year family medicine residents [5]. However, these changes did not follow the passage of the Balanced Budget Act immediately, and thus cannot necessarily be linked directly to its passage: a survey of 478 family medicine practices found that, in the two years following the act’s passage and the subsequent changes to residency funding, there was a relatively minor net reduction of 82 residents [6].

 

While the Balanced Budget Act caps funding for residencies, researchers have predicted that certain subspecialties may actually see a shortage of residents in the coming years, and in some cases may be unable to fill open residency slots. This discrepancy is predicted even in spite of growing enrollment numbers at existing U.S. medical schools—the number of U.S. medical school applicants increased 18% between the 2020 and 2021 academic years, perhaps in part due to the COVID-19 pandemic [7]. Still, one study has predicted that 22,280 individuals will graduate from American medical schools in 2026, matching into a predicted 29,880 residency positions (given the yearly growth rate of 2.55% in U.S. residency slots from 2006 to 2015). If trends continue as calculated in this study, there will not be a shortage of residency positions overall, though highly competitive specialties may encounter a different situation [8].

 

While the Balanced Budget Act and subsequent Balanced Budget Refinement Act limited government funding for medical residencies, these residency caps control neither the number of medical school graduates per year, nor the chosen specialties and subspecialties of those graduates when matching into residency programs. As a result, certain specialties may encounter a shortage of residents to fill funded residency positions, while others may encounter a lack of available positions for qualified medical school graduates.

 

References 

 

[1] Havidich, Jeana E., et al. “The Effect of Lengthening Anesthesiology Residency on Subspecialty Education.” Anesthesia & Analgesia, vol. 99, no. 3, 2004, pp. 844–856., doi:10.1213/01.ane.0000130258.38402.2e.  

[2] Iglehart, John K. “The Residency Mismatch.” New England Journal of Medicine, vol. 369, no. 4, 2013, pp. 297–299., doi:10.1056/nejmp1306445.  

[3] Salsberg, Edward. “US Residency Training Before and After the 1997 Balanced Budget Act.” JAMA, vol. 300, no. 10, 2008, p. 1174., doi:10.1001/jama.300.10.1174.  

[4] Schubert, Armin et al. “An updated view of the national anesthesia personnel shortfall.” Anesthesia & Analgesia, vol. 96,1 (2003): 207-14, table of contents. doi:10.1097/00000539-200301000-00043 

[5] Weida, Nicholas A, et al. “Loss of Primary Care Residency Positions Amidst Growth in Other Specialties.” American Academy of Family Physicians, vol. 82, no. 2, 15 July 2010, p. 121. 

[6] Schneeweiss, Ronald et al. “The effects of the 1997 Balanced Budget Act on family practice residency training programs.” Family Medicine, vol. 35,2 (2003): 93-9. 

[7] “Enrollment Up at U.S. Medical Schools.” AAMC, Association of American Medical Colleges, 16 Dec. 2020. https://www.aamc.org/news-insights/press-releases/enrollment-us-medical-schools

[8] Hayek, Sarah, et al. “Ten Year Projections for US Residency Positions: Will There Be Enough Positions to Accommodate the Growing Number of U.S. Medical School Graduates?” Journal of Surgical Education, vol. 75, no. 3, 2018, pp. 546–551., doi:10.1016/j.jsurg.2017.08.021.  

Intraoperative Management of Hypertension

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Hypertension can dramatically increase surgical patients’ rates of morbidity and mortality. Preoperative hypertension increases a patient’s probability of experiencing cardiovascular complications during surgery by 35% [1]. Perioperative and postoperative hypertension can result in bleeding, myocardial infarctions, and adverse cerebrovascular events [2]. To manage intraoperative hypertension, clinicians must monitor patients’ blood pressure, while implementing regimens that account for the risk of cardiovascular events, possible blood pressure fluctuations, and preexisting medications [1].

 

Clinicians treating hypertensive surgical patients must avoid exacerbating preexisting hypertension, which requires a comprehensive understanding of high-risk events. Perioperatively, hypertension can occur or be worsened due to insufficient analgesia administration, anesthesia induction, extubation, volume overload, and clonidine withdrawal syndrome [1]. Patients undergoing intraperitoneal, abdominal aortic, peripheral vascular, or carotid surgery are most likely to experience hypertensive events [1]. Some studies have reported that anesthesia information management systems (AIMSs) are effective in managing hypertension intraoperatively, but this is not always true due to current technological limitations [3].

 

While lifestyle modifications may be preferable to pharmacology in driving long-term improvements, little can be done in that regard once surgery has begun [4]. Consequently, pharmacology is an essential aspect of perioperative hypertension management. Patients already taking antihypertensive medication should continue doing so, including on the day of surgery, if such drugs do not lead to negative interactions with drugs needed for surgery and anesthesia [1]. During surgery, clinicians should choose pharmacologic agents according to a patient’s comorbidities [5]. For example, patients with coronary artery disease may benefit most from beta-blockers, combined with diuretics or angiotensin-converting enzyme inhibitors [5]. Intraoperative use of beta-blockers can reduce patients’ 30-day and 1-year mortality [5]. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are not associated with higher mortality rates or complications following noncardiac surgery, suggesting that they are safe to continue administering in the surgical setting [5]. The goal of pharmacology therapy is to stabilize blood pressure at <130/80 mm Hg [5].

 

Depending on the anesthetic agents present during surgery, designing a safe and appropriate perioperative pharmacological regimen may become more difficult. Anesthesiologists should be aware of the anesthetic implications of each class of antihypertensive medication [6]. For instance, diuretics can promote dehydration, hypokalemia (if they are not potassium-sparing), and hyperkalemia (if they are potassium-sparing) [6]. Angiotensin II receptor antagonists can lead to refractory hypotension during induction and rebound hypertension once use has been discontinued [6]. Angiotensin-converting enzyme inhibitors (ACEIs) are more safely administered on the day of surgery if deep sedation is planned [6]. ACEIs may cause angioedema, but the risk is low [6].

 

If a patient experiences a hypertensive event during surgery, physicians should choose a fast-acting, safe, easily titrated, inexpensive, and predictable antihypertensive agent [2]. Clinicians should seek to gradually reduce blood pressure by 10 to 15% within the first hour [2]. Following that initial period, blood pressure should continue to decrease, the goal being to reach 160/100 mm Hg within the next two to six hours [2]. In these events, esmolol, nicardipine, fenoldopam, and labetalol are the most commonly used medications [2]. Parenteral agents can also be used, but newer medications appear safer during hypertensive emergencies [2]. While clonidine and ACE inhibitors are not easily titratable and have long-lasting effects, they may also be appropriate in urgent situations [2].

 

Ultimately, intraoperative hypertension requires clinicians to strike a delicate balance between various pharmacological considerations. Because hypertension increases mortality and morbidity, physicians should aim to design the optimal plan for each individual patient.

 

References 

 

[1] M. Koutsaki et al., “Evaluation, risk stratification and management of hypertensive patients in the perioperative period,” European Journal of Internal Medicine, vol. 69, p. 1-7, November 2019. [Online]. Available: https://doi.org/10.1016/j.ejim.2019.09.012.  

 

[2] J. Varon and P. E. Marik, “Perioperative hypertension management,” Vascular Health and Risk Management, vol. 4, no. 3, p. 615-627, June 2008. [Online]. Available: https://doi.org/10.2147/vhrm.s2471.  

 

[3] B. G. Nair et al., “Anesthesia Information Management System-Based Near Real-Time Decision Support to Manage Intraoperative Hypotension and Hypertension,” Anesthesia & Analgesia, vol. 118, no. 1, p. 206-214, January 2014. [Online]. Available: https://doi.org/10.1213/ANE.0000000000000027.  

 

[4] R. Oza and M. Garcellano, “Nonpharmacologic Management of Hypertension: What Works?,” American Family Physician, vol. 91, no. 11, p. 772-776, June 2015. [Online]. Available: https://www.aafp.org/afp/2015/0601/afp20150601p772.pdf.  

 

[5] W. S. Aronow, “Management of hypertension in patients undergoing surgery,” Annals of Translational Medicine, vol. 5, no. 10, p. 227, May 2017. [Online]. Available: https://doi.org/10.21037/atm.2017.03.54. 

 

[6] R. Yancey, “Anesthetic Management of the Hypertensive Patient: Part 1,” Anesthesia Progress, vol. 65, no. 2, p. 131-138, Summer 2018. [Online]. Available: https://doi.org/10.2344/anpr-65-02-12.