Anesthesia management company Archives - Page 10 of 19 - Xenon Health

As the use of electronic personal health information (PHI) continues to rise and public concern mounts over privacy and security at healthcare centers, the US Department of Health & Human Services’ Office for Civil Rights (OCR) is finally implementing a formal audit process that will ensure that the privacy, security, and breach notification standards that were set forth in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) are upheld. All entities that are covered under HIPAA are now eligible for the audit process, including hospitals, health insurers, health care clearinghouses, and any health care providers that transmit PHI electronically. Additionally, phase two of the audit process, which will be completed at the end of 2016, includes auditing the entity’s business associates in order to ensure that all professional actions associated with the covered entity are HIPAA compliant. The implementation of such an audit process is long overdue, for the Health Information Technology for Economic and Clinical Health Act (HITECH) mandated in 2010 that audits must be completed at HIPAA-covered entities—however until now no formal process existed and the OCR would usually only investigate noncompliance cases following complaints, media attention, or a self-reported breach. Nonetheless the development of a standard audit protocol does indicate that the OCR is now taking the rise in non-compliance with HIPAA standards very seriously. Recent studies have found that about half of covered entities are noncompliant with at least one privacy standard, a shocking finding considering that a data breach of health information has the potential of putting millions of patients at risk.

The establishment of this audit process is of direct significance to all anesthesia management companies and anesthesia providers who are covered by HIPAA regulations, and it is thus critical to understand the specific process and the objectives of the audit in order to prepare for an inevitable review in the near future. While the HIPAA audit process may seem daunting, it is also a way for anesthesia management companies and providers to improve their security, identify any systemic flaws, and adopt a set of best practices that both honor and respect patients’ privacy.

During a given round of audits, OCR wishes to review a random sample of entities that is representative of the geographic, size, and structural diversity of all entities covered. When evaluating an entity, first a desk audit of the covered entity will occur, followed by a desk audit of the entity’s business associates, and finally there is the possibility of an onsite audit that will be even more rigorous and evaluate additional privacy requirements under HIPAA. A selected entity will be notified of the audit by email and will then have approximately two weeks to begin to deliver the appropriate documents to OCR through a secure online portal. Because the timeframe for submitting documents is so brief, one of the best ways to prepare for a potential audit is to gather all documented evidence of risk management plans, notices of privacy practices, and breach notification policies beforehand. All collected information will be analyzed, a draft of the findings will be presented to the audited entity, and the entity will have the ability to formally comment on any of the findings from the audit. Lastly the final report will be published, highlighting general issues and room for improvement in all audited entities, while not releasing individual entities’ names or specific violations. An individual entity will only be investigated further if a flagrant problem was found. Ultimately the OCR wishes to use this process not to financially punish those that are noncompliant but instead to identify systemic vulnerabilities and obstacles that entities face in order to equip them with better tools and practices to thus facilitate HIPAA compliance and reduce privacy breaches.

Operating room metrics are a part of evaluation and are important in measuring and comparing the quality of care and efficiency of operating rooms. These metrics are advantageous because they produce robust data that can be used to assess operating rooms and determine areas that require improvement. Operating room metrics that are essential to the efficient management of surgical services include On-Time Starts, Turnaround Times, Percent Block Utilization, Percent O.R. Utilization, Accuracy of Case Scheduling, and Case Time Variability. Many of these operating room metrics can benefit anesthesia services. According to The Journal of the American Society of Anesthesiologists, “[f]or anesthesiologists, efforts to increase anesthesia group productivity are the same as increasing the efficiency of use of OR time” .

In an effort to improve the quality of anesthesia care and reduce costs, healthcare providers have started to use operating room metrics. As a result of anesthesia’s tight integration within the surgical process, utilization of operating room metrics can have a significant impact on anesthesia services. The most commonly used metric for anesthesia managers is the evaluation of potential stipend requirements. Anesthesia managers use financial analysis to determine whether the revenue potential of each location matches the cost of providing care. Some practices also use other types of productivity metrics to evaluate the practicality of continued coverage. Assessment of these metrics can help in the sustainability of productive contracts and the elimination of less productive contracts.

Operating room metrics are also used to evaluate performance.  For example, percentage of cases cancelled or delayed by anesthesia are typical performance standards that are operating room metrics. These metrics can be linked to performance evaluations and stipend payments, which aim to incentivize high quality anesthesia care. With financial support of anesthesiology groups increasing, financial-based performance metrics in service contracts are also becoming increasingly more common.

Many anesthesiologists recognize the benefit of timely and accurate data in anesthesia management. Dr. Michael Simon, an anesthesiologist, states, “If you track complications of all types, such as nausea and vomiting, you can conclude why certain providers bring patients out who tend to be much more nauseous and need to spend much more time in the recovery room. […] This arms you for a discussion with those providers about how they do things a little differently in comparison to their colleagues with lower rates in that area,” highlighting one of the many ways operating room metrics can benefit anesthesia services and outcomes. Tracking each providers’ outcome can provide a better analysis of consistency of service and bring about improvement to certain metrics.

Improving operating room efficiency remains to be one of the top priorities for all hospital operating rooms. As an integral part of the operating room team, anesthesiologists also benefit from the efficient and effective use of operating room metrics. Incorporating operating room metrics not only allows anesthesia practices to effectively manage themselves, it also provides hospitals with productivity and performance indicators and metrics that emphasize the crucial role that anesthesia plays in improving operating room management.

With the Affordable Care Act’s increased emphasis on improving the quality of patient care, the American Society of Anesthesiologists has offered the ‘perioperative surgical home’(PSH) as a new model for perioperative care delivery in which the anesthesiologist serves as the coordinator of care from the preoperative through the postoperative phase. The idea behind this organization is not only to increase patient-centeredness, but also to find opportunities to cut healthcare costs and improve the delivery of healthcare resources.

The PSH model aims to reduce variability in perioperative care given that variability increases the likelihood for errors and complications. One way in which this variability can be reduced is through assuring the continuity of care and treating the entire perioperative episode of care as one continuum rather than discrete preoperative, intraoperative, postoperative, and post-discharge steps. The PSH achieves this continuity by having one team headed by anesthesiologists, to manage all aspects of this continuum from the time that the patient and the surgeon make the decision for surgery until 30 days after discharge (See the figure below for more details). During this perioperative episode, the goal of the PSH is to ensure that best evidence/best practices are applied in a consistent and standardized way to every patient undergoing surgery. At each step of this continuum patients are informed, educated, and involved in the decision-making and treatment planning. The point is to allow anesthesiologists to have a unique opportunity to improve outcomes, decrease length of stay and other metrics, and improve patient satisfaction.

Since the concept of PSH was conceived, different versions of the model have been implemented at institutions across the United States such as the University of Alabama Birmingham Health System. Elsewhere, the UC Irvine Health System implemented a PSH for primary joint replacement surgery (hip and knee) with the support of the Chairs of Orthopedics and Anesthesiology and Perioperative Care and the Chief Operating Officer of the hospital. There, multidisciplinary teams consisting of anesthesiologists, surgeons, nurses, pharmacists, physical therapists, case managers, social workers, and information technology experts meet weekly during the implementation phase, resulting in decreased readmission rates during the 30 days following surgery (down to 0.9% from 3.0%).

The early results of PSH initiatives have been encouraging (e.g. decreased readmission rates, lower healthcare costs, fewer mistakes, more efficient allocation of healthcare resources). The model has significant implications for policymakers, payers, administrators, clinicians, and patients, and may lead to policy-relevant cost savings and quality improvement across the perioperative continuum of care – especially with respect to integrated care organizations, bundled payment, and value-based purchasing.

As healthcare costs have come under increased scrutiny over the past several years, policymakers have increasingly realized that the reduction of the amount and kind of services used is an even more important cost-control measure than the simple reduction of prices. This reduction in the amount and kind of services ultimately implies that policymakers would like physicians (such as anesthesiologists, cardiologists, etc.) to reduce their utilization of healthcare resources by reducing the number of diagnostic tests they order, which drugs they prescribe, which surgical and other procedures they perform, and at what facilities they perform these procedures. However, since physicians ultimately dictate the utilization of healthcare resources implementation of these cost-control measures is quite difficult, and instead of direct control over physicians, policymakers must exert cost-control measures by altering incentives. To this end, the Affordable Care Act implemented many new policies aimed at changing payment incentives. Chief amongst these policies is changing payment away from a fee-for-service model through the creation of accountable care organizations (ACOs).

Simply put, ACOs are networks of physicians or physicians, hospitals, and other providers that take both clinical and financial responsibility for the care of patients. ACOs aim to breakdown barriers between primary care physicians, specialists, hospitals, home health care agencies, hospices, pharmacies, and other providers; the idea behind this organization is to coordinate patient care-particularly for patients suffering from chronic illnesses (who account for the majority of costs)-to focus on high-quality, lower-cost interventions and not just on what services are paid for. This organization would reduce wasteful duplication of tests and unnecessary interventions, while keeping patients healthy and reducing the need for treatments, specialist referrals, emergency room visits, and long-term hospitalizations.

While there are many conditions for a healthcare organization, such as an anesthesia management company, to qualify as an ACO (e.g. care for 5,000 Medicare beneficiaries, 3 year agreement with Medicare, CMS quality reporting, physician-led governance, etc.), ACOs aim to reduce healthcare costs by altering how payments for services are distributed. With the passing of the Affordable Care Act, the Medicare program was authorized to adopt the ACO model and with it three different types of ACO models were created. These types are summarized in Table 1.

While the most common ACO model is the shared savings, many worry that the initial reliance on fee-for-service payments may still encourage physicians to order more tests, visits, and treatments in order to increase payment. Furthermore, since ACOs entail significant start-up costs for integrated electronic health records, disease registries, effective care management programs, telemedicine, and other monitoring mechanisms. Since the deployment of these technologies and programs incur high costs, effective management others continue to worry that ACOs will ultimately fail due to lack of the appropriate financial and human resource management. The last major concern with ACOs are that through creation of large, comprehensive care delivery groups, Medicare may decrease competition among physicians and hospitals; ACOs, rather, than engage with Medicare, may negotiate better rates with private insurers and thus eliminate any savings for the overall healthcare system. Regardless of the concerns over ACOs, the ACO model has undoubtedly taken off-the first quarter of 2016 recorded a record 838 ACO organizations distributed across the three models and spurred use of the ACO model amongst private insurers.

Among the many factors that govern Medicare funding and expenditure, the Sustainable Growth Rate (more commonly referred to as SGR) formula has historically ranked amongst the most important. Simply put, SGR had been used to dictate the increase in physician compensation for services performed under Medicare, up until the implementation of the Medicare Access and CHIP Authorization Act (MACRA) of 2015-which now determines physician pay based on the merit/quality of service and/or alternative payment models (e.g. lump sum incentives or annual payments.). Originally, SGR was conceived as part of the Balanced Budget Act of 1997.[2] Its main focus was to control the yearly increase in spending on physician services.

Despite its recent replacement with MACRA, it is easy to see how important SGR was in light of the over $555 billion dollars spent on physicians services in the United States in 2010-for Medicare services alone this number is estimated to be about 110 billion dollars. But what exactly was SGR? As mentioned above, SGR was a formula that attempted to determine how much physician services should increase. Specifically, the SGR formula took into account three factors: the cost of physician services (based on a national level), Medicare enrollment, and the GDP. In 2003, the MMA (Medicare Prescription Drug, Improvement and Modernization Act) slightly modified the SGR by taking into account the estimated 10-year average annual percentage change in real GDP per capita. Increases in physicians costs (due to advanced technology, new regulation, or increased demand), increased Medicare enrollment, and increases to GDP all resulted in increases to the SGR.[1] Importantly, the SGR was designed to discourage overcompensation. In fact it included a clause specifically designed to discourage such behavior, which essentially stated that if spending for all physicians in Medicare in a given year exceeded the prior year’s SGR target, then the amount paid to physicians in the next year would be reduced in order to hit the SGR target. In a local context, anesthesiologists and anesthesia service providers performing services under Medicare would ideally be incentivized to keep costs under the SGR target. However, since physician costs were determined based on the total cost of physician services provided, local anesthesiologists and anesthesia service providers in reality had no incentive to lower costs.

As a result, this key feature of the SGR was not enforced throughout its history. As Figure 1 demonstrates, actual physician expenditures outpaced SGR targets starting in early 2005- in part because of special interest lobbying. The net result of this lobbying resulted in Congress enacting a series of temporary “SGR fixes” that delayed the required cuts to physician spending. After a series of “SGR fixes”, which further delayed the required physician spending cuts (while not altering the underlying SGR formula), the SGR formula required a 24% reduction to physician payments (an estimated $117 billion dollars in cuts implemented over a decade). In order to avoid this dramatic reduction in physician pay, Congress enacted MACRA in 2015 to shift physician compensation away from the SGR formula. Instead, physician compensation is now based on the merit(MIPS)/quality of service and/or alternative payment models(APM). Whether these programs fall victim to the same perils as SGR, however, is yet to be determined.