The Centers for Medicare and Medicaid Services (CMS) have released their final payment rule for Medicare programs, which will affect care and coverage for patients insured through Medicare. These rulings will go into effect in 2019, impacting practices for the year to come. With regards to anesthesia practice management, the final payment rule will institute policies that may impact pricing, reimbursement, and case management.

Medicare management of outpatient treatment is set to experience many changes in 2019. The Outpatient Prospective Payment System (OPPS), the central pricing mechanism for all outpatient procedures, is scheduled to undergo a rate increase of approximately 1.25%, as calculated by annual inflation, productivity, and service value additions. This new rate will extend to all CMS “Centers of Excellence”, as well as all Medicare providers that oversee outpatient surgical treatments. The updated rules are also provisioned to decrease the percent reimbursement allocated for out-of-network providers. Per this update, outpatient surgeries performed by out-of-network providers will be reimbursed at 40% of the national Medicare rate, creating a significant financial disadvantage for choosing out-of-network providers. Such an action can be attributed to the push for a more segmented healthcare market where patients select providers based on their coverage.

Beyond changes in reimbursement related to outpatient procedures, the new payment rule also expands coverage. In 2019, specific cardiology procedures will be added to the coverage list, including cardiac catheterization. Anesthesiologists that work closely with cardiologists, interventional cardiologists, and cardiac surgeons should take note of such coverage expansions. In the orthopedic sector, the Current Procedural Terminology (CPT) code designation for anesthesia on open procedures such as knee joint replacement and total joint arthroplasty was removed from the inpatient-only designation. This change in designation means that certain open procedures can now be reimbursed in both inpatient or outpatient settings. This change also aligns with technological advances in musculoskeletal care, such as image-guided surgery, which have rendered feasible procedures that were previously only accessible in inpatient settings. Anesthesia providers that focus on orthopedics should be aware of this change when considering the transition to including flexible setting procedures in their practice.

For anesthesia and pain practices that are also involved in the management of drug supply and disbursal, the final payments rule has distinguished payments between opioid and non-opioid pain medications in an initiative to more closely monitor the opioid landscape in the United States. By making this distinction, the use of opioid-based anesthetics will become separated from the general supply of anesthetics, encouraging anesthesiologists and pain management physicians to conduct a thorough assessment of the costs and benefits of each before administering or prescribing them to patients.

In summary, the CMS final payment rule for Medicare programs in 2019 instates new policies that may influence anesthesiologists, certified registered nurse anesthetists (CRNAs), and anesthesia practice managers through changes in pricing, reimbursement, access, and coverage. By maintaining a comprehensive understanding of these new Medicare policies, anesthesia practices can ensure that they are continually improving the quality of healthcare delivery by more thoughtfully serving patients.

References:

1. Stewart A. “What ASC anesthesia groups should know about the 2019 final payment rule: 6 insights.” Becker’s ASC Review. 2018 Nov. https://www.beckersasc.com /anesthesia/what-asc-anesthesia-groups-should-know-about-the-2019-final-payment-rule-6-insights.html
2. Ellison A. “CMS’ proposed outpatient payment rule for 2019: 10 things to know.” Becker’s ASC Review. 2018 July. https://www.beckershospitalreview.com /finance/cms-proposed-outpatient-payment-rule-for-2019-10-things-to-know.html
3. CMS. “Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019.” Centers for Medicare & Medicaid Services. 2018 Nov. https://www.cms.gov/newsroom/fact-sheets.

Professional societies provide a host of benefits for anesthesiologists and other healthcare professionals. Societies give healthcare professionals a significant competitive advantage over their peers by providing opportunities for personal and professional growth. One of the most notable perks of joining a professional society is the opportunity for networking with other doctors, nurses, and healthcare managers. When an anesthesiologist partakes as an active member of an extensive society network, they are able to collaborate and expand their knowledge by interacting with other like-minded and innovative individuals. Immersion into the culture of a professional society keeps members up to date with the latest discoveries and opportunities in their field, including the latest in healthcare management and anesthesia services.

Another benefit of joining a professional society is the opportunity for continued education and mentoring. Professionals can stay informed about new breakthroughs by accessing the society’s seminars, journals, studies, and continued medical education courses.¹ Many professional societies offer certification courses to their members, allowing them to expand their educational credentials. Mentoring services are also an invaluable resource to healthcare providers. Mentors can provide support for developing professionals by focusing on any areas that may be lacking. Both parties in a mentoring relationship serve to benefit as many find mentoring to be a rewarding experience that renews their enthusiasm for the medical field and their desire to help others. The intrinsic value of being invested in one’s profession leads to unparalleled opportunities for growth. By showing such dedication to the field, healthcare professionals demonstrate that medicine is not only a job, but a lifestyle. When professionals exude a strong enthusiasm and commitment to excellent healthcare, they create a magnet for colleagues and patients who will come to view them as an industry leader. As a result, healthcare practitioners can feel more satisfied and confident in their role, allowing them to conduct their practices with more positive energy.

Lastly, professional societies provide various forms of monetary support. These supports may include discounts to certification programs and conferences, access to scholarships and grants; and may sometimes even include group rates on medical insurance.² Professional societies also give monetary backing to support legislation that may benefit their members. The American Society of Anesthesiologists (ASA) advocates for “fair payment and lessened administrative burden by leading discussions about proposed and final rules from the Centers for Medicare & Medicaid Services (CMS) to ensure that the interests of ASA members and their patients are represented,” allowing members an opportunity to make their voices heard.³ Professional Societies also protect their members by defending them against regulation changes and company acquisitions that may be costly to individual healthcare providers, including doctors, nurses, and anesthesiologists. The American Medical Association (AMA) reported in 2017 that “blocking the proposed Anthem-Cigna merger alone saved physicians at least $500 million in payments annually.”⁴

Joining a professional society has many advantages. These advantages include opportunities for networking, furthering education, renewing passion for the practice, receiving and giving individualized mentorship, and monetary and legal support. The many benefits afforded to a healthcare professional by joining a professional society are more than likely to outweigh the cost of membership, making it an overall worthwhile investment.

References:

1. eCareers, Health. “4 Benefits of Joining Your Professional Healthcare Association.” Health ECareers, 9 Feb. 2018, www.healthecareers.com/article/career/the-benefits-of-joining-your-professional-healthcare-association.
2. “6 Ways Professional Healthcare Associations Advance Your Career.” Top Personality Traits for Physical Therapists, www.jobs.net/Article/CB-4-Talent-Network-Healthcare-6-Ways-Professional-Healthcare-Associations-Advance-Your-Career.
3. “​Member Benefit” American Society of Anesthesiologists, asahq.org/member-center/member-benefit.
4. “2017 AMA Annual Report.” American Medical Association, 2017, www.ama-assn.org/sites/default/files/media-browser/2017-ama-annual-report.pdf

Anesthesiologists serve as the cornerstone of the perioperative arena. The current role of the anesthesiologist goes beyond that of anesthetic delivery; anesthesiologists must also have expertise in pre-operative planning, pain management, and patient population analyses in order to execute their functions effectively. Like other physicians and healthcare providers (HCPs), anesthesiologists are subject to healthcare policies, specifically with regards to reimbursement mechanisms and utilization. As the United States healthcare system broadens its scope of practice, anesthesiologists should heed developments in care models, utilization, and payment mechanisms, each of which have the ability to significantly impact the future role of the anesthesiologist.

We have written previously on collaborative care delivery. Most notably, we examined the perioperative surgical home (PSH), which is a care delivery model that moves from a disease-centered approach to care to a patient-centered approach to care. In the PSH model, anesthesiologists comprise the care team for a patient alongside primary care physicians, nurses, surgeons, and social workers.¹ In this way, the treatment plan is arrived at collaboratively, allowing for a decision to be made that is optimal for the patient. The PSH model has faced polarizing support and criticism from physician leaders as it becomes increasingly recognized in the medical literature. In order to measure anesthesiologist attitudes, researchers conducted a longitudinal, quantitative, survey-driven study to gauge provider attitudes toward changes in care delivery, including PSH.² Multiple iterations of the survey were administered over two years in order to capture several data points. Study participants (n=6000) were all board certified anesthesiologists and active members of the American Society of Anesthesiologists. At the end of  two years, the researchers concluded that knowledge of the PSH model had increased among all participants, notably across a range of geographies and care center modalities. Moreover, anesthesiologists were more likely to express support for the implementation of a multidisciplinary approach to PSH, as opposed to a strictly physician or medical care-based team. These findings suggest a potential opportunity for anesthesiologists to serve as leaders in the PSH movement, especially given the systems approach to medicine that many anesthesiologists employ in their practices already. Therefore, as care centers begin to transition to PSH care delivery models, anesthesiologists may find value in leading the movement.

In addition to changes in care delivery models, anesthesiologists will encounter changes to payment mechanisms that may influence their future practicing regimens. While the majority of healthcare financing in the United States is currently fee-for-service (FFS), changes in workforce allocation, such as adoption of the PSH, may also render a difference in billing and healthcare financing.³ Bundled payments are one potential payment mechanism that may pick up traction in the United States healthcare system in the coming years. Since anesthesiologists are often employed in shift work, bundled payments may not seem like the most compatible model at first; however, a salaried workforce may be better equipped to combat the complicated world of co-payments, deductibles, and holistic payments. Hence, until healthcare policies can provide a clearer picture of how healthcare is financed in the United States, anesthesiologists should stay informed on how payment mechanisms can impact their own remuneration.

As a result of shifts toward collaborative care and per-patient compensation models, the role of anesthesiologists continues to move away from isolated practices towards integrated developments in the field. Healthcare in the United States is changing rapidly and anesthesiologists are well-equipped with the background and skills to serve at the helm.

References:

1. Kain ZN et al. “The Perioperative Surgical Home as a Future Perioperative Practice Model.” Anesthesia & Analgesia. 2014 May. 118(5):1126–1130,
2. Raphael DR et al. “Two-Year Follow-up Survey: Views of US Anesthesiologists About Health Care Costs and Future Practice Roles.” Anesthesia & Analgesia. 2018 Feb;126(2):611-614.
3. Scott BC and Eminger TL. “Bundled Payments: Value-Based Care Implications for Providers, Payers, and Patients.” American Health and Drug Benefits. 2016 Dec. 9(9): 493-496

Today, medical care involves more than just one doctor: it involves a synergized team of doctors who come together to treat one patient. In order to achieve the highest quality patient care, there must be a significant amount of teamwork in the operating room. While much literature is focused on the relationship between an anesthesiologist and a patient, it is also imperative to examine the relationship between a surgeon and an anesthesiologist. Studies show that effective communication between surgeons and anesthesiologists can significantly improve patient outcomes and mitigate patient safety risks, leading to healthier relationships for all parties involved. An article published in Current Opinion in Anesthesiology names communication as the “most important tool in solving professional, legal and ethical questions.”[1] All parties who play a role in patient care must be able to interact in a responsible and professional manner that allows them to reach a consensus of actions based on their diverse medical expertise and experience. Collaboration can serve as a safeguard against dangerous, ethically ambiguous decisions made by individuals by creating an environment where courses of action must be discussed and agreed upon before they are taken. Active listening and clear expression of opinion are aspects of good communication. These are skills that must be practiced, as they are entirely different from the technical skills needed to treat patient illness and injury.

Strong relationships between surgeons and anesthesiologists extend beyond simple professional courtesy; quality relationships between doctors are essential to the health and safety of the patient. Dysfunctional relationships between care providers can lead to errors that can jeopardize the wellness of the patient. A paper published in The American Journal of Surgery found that communication failure among health care providers was a causal factor in 82% of adverse event or close-call reports.^[2] Another study conducted by Sutcliffe et al. confirmed this finding, showing that 91% of reported errors could be attributed to a lack of proper communication.^[3] It is vital for hospitals to commit to decreasing the prevalence of mistakes that lead to bad patient outcomes and low satisfaction. Preventing medical errors is among the highest priorities at every medical facility, especially when considering the importance of good operational outcomes as well as the ethics of providing exemplary care. Lowering the frequency of miscommunication can be achieved with the help of training programs.

Strengthening relationships between healthcare providers leads to a slew of benefits, the most important of these being increased patient safety. When surgeons and anesthesiologists have effectual relationships, we can expect faster turnaround at the health facility in addition to improved patient satisfaction. A recent study conducted by the University of Colorado Medical Center analyzed the impact of provider communication strategy on patient safety and found that “interventions and implementation methods become instrumental in preventing negative patient outcomes.”^[4] Initiating a communication strategy for use by all health care team members at the Denver Health Medical Center led to decreased time needed for communication about patient concerns and increased patient issue resolution. When care is administered quickly and easily due to good, strong relationships, medical professionals can find more happiness and fulfillment in their work. This dynamic ultimately results in safer treatments and the increased likelihood that patients live longer, healthier lives.

References:

Booij, Leo HDJ, and Evert van Leeuwen. “Teamwork and the legal and ethical responsibility of the anaesthetist.” Current Opinion in Anesthesiology2 (2008): 178-182.

Awad, Samir S., et al. “Bridging the communication gap in the operating room with medical team training.” The American Journal of Surgery5 (2005): 770-774.

Sutcliffe KM, Lewtorz E, Rosenthal MM, et al. Communication failures: an insidious contributor to medical mishaps. Acad Med 2004;79:186–94.

Dingley, Catherine, et al. “Improving patient safety through provider communication strategy enhancements.” (2008).

The primary objective of an anesthesiologist is to ensure that the patient undergoes a safe, effective procedure with an optimized post-operative recovery time. In order to effectively deliver on this, it is essential for anesthesia providers to be cognizant of changes in the field, whether that be in the form of new iterations of delivery methods or novel medications used in the operating room (OR). Randomized controlled trials (RCTs) are utilized to compare the efficacy of medical technologies and to assess their practical applications in the clinical setting. In the field of anesthesia management, administrators and physicians alike should remain informed about relevant research developments.

At the Joint World Congress on Regional Anesthesia held in April 2018, a team of anesthesiologist-researchers presented an analysis of the field’s scientific literature spanning over a century^[1]. Utilizing a series of standardized metrics, the research team sought to measure bias, reliability, and access in anesthesiology-related RCT literature over time. They found that the summarized risk of bias decreased over time while the sample size of patients included in these trials effectively remained the same. These findings suggest that while the strategic underpinnings of anesthesia trials are becoming quantitatively less biased, the access to patient participants has remained the same despite the recent increase in clinical trials conducted globally^[2]. This is an important consideration for healthcare management, particularly those in the service delivery lines as they consider introducing novel medications and delivery mechanisms to the existing hospital framework. Healthcare administrators should further explore the implications of research on new technologies and assess whether existing RCTs offer strong enough support for adopting these technologies in clinical settings.

In addition to assessing the applicability of RCTs, anesthesia providers should also analyze trial results for the presence and frequency of adverse events in their patient populations^[3]. As providers, anesthesiologists and certified registered nurse anesthetists (CRNAs) are directly implicated in the patient’s pain management, both during and immediately following surgery. Knowing the possible side effects and adverse events of any novel agent is thus critical for understanding its application in the context of individual patients. Certain subpopulations, such as young children and the elderly population may also be more susceptible to adverse events compared to the overall population^[4]. By performing a thorough analysis of trial results, including side effects and adverse events, anesthesia providers can better determine which novel technologies and agents are most suited to their practice.

Anesthesia management can benefit from increased exposure to and knowledge of clinical trials. This extra awareness can help equip providers with the relevant information for forecasting future medical management for their patients. As lifelong learners, anesthesia clinicians should also utilize research resources to understand how their field is evolving by staying up-to-date on new medications, innovations in the OR, and interventions for pain management and patient recovery. As new medications and technologies enter hospitals and the OR, anesthesiologists and certified registered nurse anesthetists (CRNAs) can serve as leaders in progressing anesthesia healthcare delivery.

^[1] Karlsen, A. P. H., et al. “Evolution of Bias and Sample Size in Postoperative Pain Management Trials after Hip and Knee Arthroplasty.” Acta Anaesthesiologica Scandinavica, vol. 62, no. 5, 2018, pp. 666–676., doi:10.1111/aas.13072.

^[2] Pagel, P. S., & Hudetz, J. A. (2012). Recent trends in publication of basic science and clinical research by United States investigators in anesthesia journals. BMC Anesthesiology, 12, 5. doi:10.1186/1471-2253-12-5

^[3] Michael M. Todd; Clinical Research Manuscripts in Anesthesiology. Anesthesiology. 2001;95(5):1051-1053.

^[4] Luo, J., Eldredge, C., Cho, C. C., & Cisler, R. A. (2016). Population Analysis of Adverse Events in Different Age Groups Using Big Clinical Trials Data. JMIR medical informatics, 4(4), e30. doi:10.2196/medinform.6437