Anesthesia management Archives - Page 11 of 20 - Xenon Health

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.

The Sedasys computer-assisted personalized sedation (CAPS) system is an anesthesiology machine that aims to automate anesthesia delivery(2). If successful, this machine would greatly reduce the need for anesthesiologists. This four-piece system includes a Bedside Monitoring Unit (BMU) that stays with the patient from before the procedure through post-procedure recovery, a Procedure Room Unit (PRU) that contains the propofol infusion pump controller, the display monitors, and disposable devices for single-patient use (3). With a push of a button, the Sedasys machine sends a measured dose of sedation drug to a patient via<a href=”https://xenonhealth.com/patients/”> intravenous IV infusion</a> (2, 3). The machine monitors the patient’s breathing, blood oxygen levels, and heart rate. The machine’s computerized voice instructs the patient to squeeze a controller, aiming to keep the patient in a period of moderate sedation. The machine uses an algorithm for propofol dosing that attempts to maximize patient comfort and safety (7). If any problem is detected, the machine is programmed to slow or cut off the drug’s infusion (2). Medical professionals such as nurses are still needed for monitoring, but this machine hopes to replace the job of an anesthesiologist in certain procedures such as routine endoscopies.

Critics have indicated several disadvantages associated with the machine. The Sedasys machine was only approved to administer sedation for healthy patients undergoing colonoscopy and esophagogastroduodenoscopy (EGD) procedures, thus many patients and procedures requiring anesthesia will not be able to safely utilize Sedasys (3, 7). In an emergency situation, a physician anesthesiologist would be able to intervene and save the patient whereas a Sedasys machine would not have the capability to do so. “While the Sedasys System can safely administer sedation for healthy patients undergoing the procedures mentioned, emergencies can and do occur, even during the simplest procedures and with the healthiest patients,” Jeffrey Apfelbaum, co-chair of the American Society of Anesthesiologists (ASA) states (6). Additionally, those opposed to the use of Sedasys are wary of whether medical professionals will remain strictly compliant with the limitations imposed by the Food and Drug Administration (FDA). Mistakes in complying with FDA guidelines such as patient selection, fulfillment and maintenance requirements, and immediate availability of an anesthesia professional could have fatal consequences.

<a href=”https://xenonhealth.com/anesthesia-professionals/”>Anesthesiologists</a> lobbied against the Sedasys machine for years, arguing that machines could not replicate the skillset of an anesthesiologist (2). They claimed that the Sedasys machine would be especially dangerous in emergency situations because any error in anesthesia delivery being potentially fatal to the patient. After initially being denied twice, the Sedasys device was approved by the FDA under the condition that it was limited to simple screenings and an anesthesiology doctor or nurse was on-call in case of emergency (2, 5). However, in March 2016, Johnson &amp; Johnson reported that it will discontinue its Sedasys computerized anesthesia system (5). The machine was pulled from the market after poor sales (4). According to news reports, only a handful of providers adopted the device (5). In hopes of more successful products, the company is now focusing on developing technology that assists doctors rather than replacing them. While the Sedasys machine seemed like a promising way to cut costs and reduce human errors, further study has indicated that no machine can replace physician anesthesiologists.

<img class=”size-medium wp-image-3867 aligncenter” src=”https://xenonhealth.com/wp-content/uploads/2016/07/XH-73-300×200.jpg” alt=”XH 73″ width=”300″ height=”200″ />

Sources:

1. https://www.washingtonpost.com/news/the-switch/wp/2016/03/28/its-game-over-for-the-robot-intended-to-replace-anesthesiologists/
2. https://www.washingtonpost.com/business/economy/new-machine-could-one-day-replace-anesthesiologists/2015/05/11/92e8a42c-f424-11e4-b2f3-af5479e6bbdd_story.html
3.http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm353950.htm
4. https://www.technologyreview.com/s/601141/automated-anesthesiologist-suffers-a-painful-defeat/
5. http://www.massdevice.com/johnson-johnson-bails-sedasys-automated-anesthesia-device/
6. http://www.newsweek.com/plug-pulled-robot-doctor-after-humans-complain-442036
7. http://www.medscape.com/viewarticle/851173

Medical sequestration is the two percent payment reduction for the Medicare Fee-for-Service (FFS) program that affects claims with dates-of-service or dates-of-discharge on or after April 1, 2013 until further notice (1, 3). This two percent reduction also includes “claims for durable medical equipment (DME), prosthetics, orthotics, supplies” and all claims under the DME Competitive Bidding Program. Beneficiary payments for deductibles and coinsurance, however, are not subject to the two percent payment reduction. For those working in anesthesia services, note that drugs or any other health care item or service provided under the fee-for-service program are not excluded from the two percent reduction (1). The implementation of medical sequestration was a result of the Budget Control Act of 2011 and a sequestration order issued in March 2013 requiring reductions in Federal spending. Medical Sequestration alone is slated for a $11 billion cut (4).

According to a joint statement by the American Hospital Association (AHA), American Medical Association (AMA), and American Nurses Association (ANA), as many as 766,000 healthcare-related jobs could be lost by 2021 if these Medicare cuts remain (4). They also predict a “ripple effect” that will reduce the spending of goods and services by health care providers and organizations affected by sequestration. In regards to patient care, the AMA President Dr. Jeremy A. Lazarus states that “[c]oupled with the looming 27% Medicare physician payment cut, this 2% sequester will hurt patient access to care” and “[w]e need stability in Medicare physician payment […] to promote high-quality, high-value, better-coordinated care to our patients,” emphasizing that medical sequestration will harm both physicians and patients (4).

In September 2012, the American Society of Anesthesiologists (ASA) and 72 other medical organizations joined in to oppose the cuts in Medicare spending and advocated for Congress to repeal the Medicare Sustainable Growth Rate payment cuts (2). According to the ASA President, Dr. Jerry Cohen, largely hospital-based anesthesiologists will have significant implications because hospitals will be cut under sequestration. To best work within the new parameters, Dr. Cohen suggests that anesthesiologists lead coordinated care efforts in the surgical setting such as ASA’s Perioperative Surgical Home model of care in order to improve quality, ensure patient safety, and assist in cost containment. He emphasizes the importance of continuing ASA’s new models of coordinated care in order to continue improving quality and safety despite these reductions. The ASA has reached out to Congressional leaders to state their opposition to medical sequestration and advocate against these cuts, stating in a joint letter that “adequate and stable investments are necessary so that physicians can modernize their practices to support the coordinated care that will improve health and prevent costly complications, and enable the participation in new payment and delivery models” (2).

Those working in anesthesia services should note that the Center for Medicare & Medicaid Services (CMS) suggests Medicare physicians to continue reviewing the impact of this payment reduction on Medicare reimbursements (3). CMS also encourages healthcare providers to discuss the affects of sequestration with their patients (1). For more information on reimbursements, physicians can contact their Medicare Administrative Contractor (3, 6). Congress enacted medical sequestration in order to help reduce federal spending, but many in the medical community fear that sequestration will have negative impacts on patients, medical research, and the economy (5).

Sources:

1. http://www.wpsmedicare.com/j8macpartb/fees/cms-sequestration-qandas.shtml
2. http://www.beckersasc.com/anesthesia/how-will-medicare-sequestration-impact-anesthesiology-qaa-with-asa-president-dr-jerry-cohen.html
3. https://med.noridianmedicare.com/web/jeb/fees-news/fee-schedules/mpfs/sequestration
4. http://www.gihepnews.com/news/what-s-news/single-article/sequestration-will-hit-pay-but-spare-incentives/297b05abb6028d88f37f0356a5d9f8ef.html
5. http://www.aacn.nche.edu/government-affairs/12Nov.pdf
6. http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/index.html

The value-based modifier (VM) program was created under the Affordable Care Act and requires that the Centers of Medicare & Medicaid Services (CMS) apply VMs in determining physician pay for services performed under Medicare Part B-a process that has already begun its rollout in early 2015 (see below for important dates and deadlines).¹ Yet with the VM rollout scheduled to be completed in 2018, many are left to wonder what affect VMs will have on eligible professional (that includes physicians, CRNAs, PAs, NPs, and CNSs) pay? Herein we aim to dive into some of the common questions surrounding VMs and predict what affect VMs will have on healthcare providers.

The most important aspect of the VM program is to note is that it is a departure from the traditional fee-for-service model (a volume centric model) employed by CMS in determining physician pay². In other words, provider pay will not be determined solely by the number of patients seen in a given time period. Instead the VM program aims to incentivize providers to improve the quality of their care in order to receive higher levels of compensation. Simply put, the value modifier acts to increase/decrease a provider’s compensation based on the quality of service, rather then the number of patients seen. This implies, for example, that an anesthesia services provider, or anesthesia management provider that traditionally sees 400 patients/day would focus on improving the quality of care for those patients rather than trying to scramble and see extra patients(the rationale stemming from the idea that physicians and other healthcare professionals can deliver higher quality care if they are not pressured to see more patients).

This shift from a volume-centric model toward a quality-based model raises a couple of natural questions: how are physicians and other eligible providers evaluated for the quality of care? What quality metrics would be employed? Are payments based solely on the quality of care? These questions address many of the common misconceptions about VMs. For example, VMs take into account the cost and quality of rendering a service in determining payment-not just the quality of care. To measure quality, CMS relies on a system known as the PQRS (Physician Quality Reporting System). The PQRS program is a quality reporting program that encourages individual eligible professionals (EPs) and group practices to report information on the quality of care to Medicare.³ This means that physicians and other eligible professionals may elect to report on certain aspects of care delivered (i.e. the use of Post Anesthesia Care Unit-PACU- guidelines). Based on the relationship of the quality of care delivered with respect to other providers the provider may be eligible for an upgrade/downgrade in pay. One final factor to note is that the quality metrics reported in a given calendar year affect VM adjustment in the following two years, as noted in the table. Thus PQRS reports in 2016 will affect VM adjustment in 2018.

In the context of our earlier example, of an anesthesia services provider, or anesthesia management provider, this group could choose to report on self-selected measures of quality. For example, the group could report on the use of PACU guidelines, the percentage of smokers who abstain from smoking prior to anesthesia, and perioperative temperature management in assessing the quality of care delivered. These quality metrics are then compared to similar anesthesia services providers and the providers are ranked on the basis of quality of care delivered and the cost of care delivered. This combined cost-quality of care metric is then used to determine the VM. Groups with high cost of care and low quality of care are penalized by up to -4% (a 4% downgrade in pay), while groups that deliver high quality care at lower cost are rewarded with a +4% boost in pay. The use of penalties in VMs brings an important note about the VMs to the surface. The CMS designed the VM system is designed to be globally budget-neutral so that the national incentive pool equals the size of the penalty pool. Hence, high-performing professionals are in essence rewarded with dollars taken from low-performing professionals.²

This financial penalty/reward system brings about many concerns about the future quality of care and the overall makeup of healthcare providers. We predict the increased use of CRNAs and PAs to decrease the cost of service while maintaining a similar level of care (the idea being that physicians may command higher levels of pay for similar services). In addition, we predict two broad changes in healthcare delivery. The first is consolidation of healthcare provider groups in order to achieve higher quality of care while reducing fixed costs of healthcare delivery; the second is the increased deviation of high performing physicians/physician groups from performing services under Medicare Part B. Nonetheless, as the VM program takes full effect in early 2018, the quality of healthcare will be closely monitored and the advantages/disadvantages of the VM system will be evaluated.

References:

1. http://www.aana.com/resources2/quality-reimbursement/Pages/Value-Based-Modifier.aspx
2. http://www.saignite.com/resources/10-faqs-about-pqrs-and-the-value-based-payment-modifier
3. https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeedbackprogram/valuebasedpaymentmodifier.html

A co-management agreement is an increasingly popular integration model under which hospitals and physicians jointly manage a health service. Driven in large part by a shift to payment models that emphasize better clinical outcomes, co-management agreements are thought to incentivize physicians to work with hospitals to improve overall efficiency and quality.  Under a co-management agreement, physicians and hospitals contract to have the physicians co-manage an entire hospital service line, such as anesthesia services. As part of this type of management structure, physicians have a financial incentive to meet quality outcomes ; a portion of physician payment is “performance-based” which requires the physician group to meet certain standards to receive full compensation.  Because of the growing popularity of this type of practice agreement, it is important for physicians to know more about these co-management agreements.

1. Co-management agreements reflect the trend toward pay-for-performance (P4P) reimbursement models.

Annually, the United States spends far more on healthcare than any other developed country.  As health care costs have risen, lawmakers, healthcare administrators, and healthcare providers have looked at ways of improving our health while lowering the cost of healthcare. One approach is to focus on reimbursement and payment structures for healthcare services.  Traditionally, medicine in America has been practiced under a fee-for-service model, under which, physicians are generally reimbursed per service (hospital admission, lab work, diagnostic tests).  In recent years, however, this model has been criticized for its potential to incentivize providers to order and produce higher volumes of health care services without any assessment of the effect on cost or outcome.  As a result, healthcare providers are increasingly being compensated under a pay-for-performance model, which includes the co-management agreement.

2. How does a Co-Management Agreement work

 Under a typical co-management agreement, a hospital will contract with specialty physicians, such as anesthesiologists, to oversee and manage an entire hospital service line.  There are typically two parts to the co-management agreement. There is a “base fee,” which is a fixed payment that is made at regular intervals, that compensates the physician group for the basic day-to-day effort of managing, overseeing, and improving the service line. In addition to the base fee, there is an incentive fee.  This fee is not guaranteed, but is only given if the pre-determined quality objectives for that particular service line are met. This is where the performance incentive for the physician group lies. If the physician group meets outcome objectives, they receive the incentive fee in addition to the base fee.  In this way, the co-management agreement encourages physicians to meet quality standards and patient outcome markers, rather than encourage a volume-based practice.

An important issue that comes up with this type of P4P payment scheme involves determining how the standards are defined and measured. Quality metrics should be developed cooperatively between the hospital and physician group. This will ensure consideration of both the needs of the patient population as well as the operational needs of the hospital. Performance measures should use objective methodology, be verifiable, and be based on credible medical evidence.

3. Do physicians benefit under these agreements?

 A co-management agreement can be a beneficial change to the practice of specialists such as anesthesiologists. A well-written co-management agreement will clearly outline the rights and responsibilities of both the physicians and the hospital so that all parties are informed, up front, about their role in the integrated model.  Anesthesiologists are an integral part of a hospital’s operation. By being part of a well-articulated co-management agreement, anesthesiologists can benefit from having an impact on the operational and strategic effects of the hospital.  In many ways, such ventures allow the anesthesiologist to integrate with the hospital and to be a part of improving operations, without requiring the physician to become a hospital employee.

4. Beware of Legal Pitfalls

A bad co-management agreement can run afoul of federal and state laws that prohibit kickbacks and other types of rewards between hospitals and physicians.  One  key thing to remember in a co-management agreement is the need for both the base fee and incentive fee to be based on “fair market value.” Moreover, the compensation cannot vary based on the number or volume of patients seen by the physician group or the number of referrals made from the group to the hospital for services.  Rather, the goal of the co-management agreement must clearly be to enhance quality. Finally, these agreements are often of limited duration out of necessity.  Quality goals and benchmarks continuously change and develop; thus, there needs to be constant revision and of the measures and outcomes.  Many organizations refer to the HHS Office of Inspector General’s Advisory Opinion No. 12-22 as a template for developing a legally compliant agreement.

Co-management agreements are likely to continue being used as hospitals look for ways to improve quality of care while reducing costs.  And, as physicians look toward changes in the way insurance pays for health care, they are also interested in looking at new ways to improve their practices. Value-based health care cannot succeed without physician involvement because physicians are the leaders in designing and redesigning clinical care.