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The Employee Retirement Income Security Act (ERISA) of 1974 is a federal law that sets strict guidelines and minimum standards for pensions, health plans, and eventually all welfare benefit plans that were designed by employers in the private sector. The specificity and broad scope of the ERISA’s standards quickly allowed the act to become the trusted backbone of private retirement plans and eventually the basis of the employer-based healthcare system. Ultimately the ERISA provided much needed transparency, accountability, and reliability for participants and greatly decreased the ability of the plan sponsor/employer to take advantage of or discriminate against any employee. By first analyzing the different facets of the ERISA and how it impacted pensions, then scrutinizing its unique impact on health plans, we will see the importance of the ERISA to the well-being of all private sector employees, especially those of anesthesia management companies. Not only should such private employees understand their personal rights and protections, but as members of the healthcare industry it is critical to understand the rights that are afforded to one’s patients and how holding an ERISA qualified health plan may even affect their coverage.

Title I of the ERISA, entitled “Protection of Employee Benefit Rights”, is by far the most comprehensive and important section of the act, carefully delineating all of the requirements that plans must now meet and establishing the crucial fiduciary responsibility for employers. In order to provide transparency, ERISA mandates that all of the aforementioned welfare benefit plans be placed in writing and given to participants, with participants also having the right to be notified promptly of the pension’s worth upon request. ERISA also establishes specific timelines regarding when an employee will become a participant in a benefit plan, when portions of the plan become nonforfeitable, and how long a participant can be away from their job before they lose active benefits. These minimum standards have immensely benefitted employees, allowing them to receive benefits even after job termination and leave a job with a set amount of retirement benefits intact.

However, the fiduciary responsibilities that are established in the ERISA are perhaps the act’s most important feature, as they are critical in ensuring that the plan managers are only operating with the best interest of the participants in mind. The fiduciary standard requires that all risk be minimized, that the best possible coverage be provided, and most importantly, that there is no conflict of interest between the principal (participant) and the agent (employer/plan manager). While holding the employer to the fiduciary standard is critical to preserving accountability, it can be a large, complex burden for the employer, leaving every financial decision open to scrutiny, as even major corporations such as Fidelity Management Trust Co. have very recently been named in a class action suit that claims that the fiduciary responsibilities had not been properly upheld.

If the employer is not making sufficient payments, protecting funds in a separate trust, or if any other part of the EIRSA is breached by the employer, all plan participants have the right to hold employers accountable, as the ERISA gives employees the ability to sue for monetary damages without any fear of retribution. This has allowed employees to be treated fairly and to view retirement plans as a reliable and defensible source of income. ERISA even further strengthened the reliability of these plans by establishing the Pension Benefit Guaranty Corporation in Title IV of the Act that is able to insure participants whose pensions were lost due to the closing of the company. Finally, it is important for all members in anesthesia management companies to note that the ERISA never requires a private employer to create a benefit plan or details what benefits the plan should include, but rather works to regulate the plans that are already in existence.

While the ERISA was originally created to address retirement plans, its broad interpretation has extended to health plans, and because ERISA is a federal law, it preempts any state law that would otherwise regulate the health plan, allowing the plan to face all of the specific ERISA guidelines and federal regulation, but be completely exempt from the content requirements that are usually set by states. Nonetheless, amendments to ERISA in regards to covered health plans have allowed for crucial reform that healthcare providers and anesthesiologists should be aware of. The Consolidated Omnibus Budget Reconciliation Act (COBRA) allowed families to receive healthcare even after a job had been lost, and the first part of HIPAA was passed in order to prevent discrimination or coverage refusal based on a disability or preexisting condition. Thus despite operating primarily as a means to protect retirement funds, ERISA has also become a crucial tool in ensuring fair and comprehensive health coverage from private employers.

Sources:

1. https://www.dol.gov/general/topic/health-plans/erisa
2. http://www.nccmp.org/resources/pdfs/other/Summary%20of%20ERISA.pdf
3. http://www.bankrate.com/finance/retirement/how-erisa-impacts-retirement.aspx
4. http://webapps.dol.gov/dolfaq/go-dol-faq.asp?faqid=225
5. http://www.bna.com/fidelity-faces-erisa-n57982072865/
6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449155/

Medicare Spending Per Beneficiary (MSPB) is a measure of hospitals’ average spending compared to the national median after adjusting for factors such as age, sex, race, and severity of illness (1). MSPB includes all Medicare Part A and Part B costs starting 3 days prior to hospital admission through 30 days after discharge (3). MSPB is reported as a ratio, and a score of 1 means that the hospital’s spending is the same as the national median (1). Medicare releases each hospital’s MSPB-1 Performance Rate online along with other scores such as the MSPB-1 Achievement Points, Improvement Points, and Measure Score (4). These additional measures give patients a quantitative summary of how the hospital measures up against other hospitals and whether it has improved over time. People can then take these measures into account when choosing an appropriate physician.

MSPB is used as a measure of efficiency by the Hospital Value-based Purchasing (VBP) Program, which strives to improve healthcare quality by linking Medicare’s payment system to a value-based system (1, 2). According to Medicare, they use MSPB to “increase the transparency of care for consumers by recognizing hospitals that provide high quality care at lower costs to Medicare” (5). The Centers for Medicare & Medicaid Services’ (CMS’) use of MSPB ratings and the implementation of a value-based system encourages hospitals to provide the highest quality of care. Hospitals are compensated based on quality of care, not quantity of services (4). MSPB is the first pay-for-efficiency measure to penalize or reward hospitals (1). It accounts for 25% of a hospital’s Fiscal year (FY) 2016 VBP Report, which is an increase from 20% the year before (6). This report provides hospitals with a Total Performance Score (TPS), which is a factor in how funds are distributed.

Care providers must stay up to date on how their services will be evaluated. In 2014, more than 1,400 hospitals received reductions in their Medicare payment rates due partly to the implementation of a value-based system that evaluates efficiency (6). According to The Journal of the American Medical Association, most of the opportunity for increasing a hospital’s MSPB rating is during the post-acute care period, which is the period following an inpatient acute hospital stay. Hospitals are encouraged to “reevaluate their patterns of discharge timing, destination, and execution” (6). While shorter hospital stays may initially reduce costs, they may also result in more expensive post-acute care and a higher chance of readmission. Optimal healthcare decisions vary depending on each patient’s unique circumstance and environment. In order to obtain a good MSPB rating, physicians must balance providing adequate inpatient care with reducing unnecessarily costly care.

For anesthesia providers, it will be increasingly important to stay up to date with the various aspects of anesthesia management to ensure highest quality of care. As more anesthesiology research is conducted, physicians will be able to have a greater understanding of what procedure will be best for patients. In the future, it is likely that Medicare will tie more money to healthcare efficiency and continue to penalize high readmission rates (6). Physicians should reconsider the most appropriate care setting when discharging patients in an effort to reduce readmission. As MSPB ratings become increasingly more important, healthcare providers must emphasize studying the cost and outcomes of their patients to continually improve their services.

Sources:

1. https://www.aamc.org/download/363786/data/mspbwebinarslides.pdf
2. https://www.cms.gov/Medicare/Quality-initiatives-patient-assessment-instruments/hospital-value-based-purchasing/index.html
3. https://www.medicare.gov/hospitalcompare/data/spending-per-hospital-patient.html
4. https://www.medicare.gov/hospitalcompare/data/hospital-vbp.html
5. https://www.medicare.gov/HospitalCompare/data/efficiency-domain.html
6. http://jama.jamanetwork.com/article.aspx?articleid=1830000

In this day and age, any information that is online is susceptible to attack. Medical information, unfortunately, is no exception, and according to the Verizon 2015 Protected Health Information (PHI) Data Breach Report, which analyzes 80,000 of such incidents (including data breaches), stolen medical information affects 18 out of 20 industries examined (1, 2). Due to this threat, many people are actually withholding their medical information from their healthcare providers, which has a negative ripple effect—healthcare companies and providers need this information in order to perform most effectively.

Data breaches also occur in several other areas of industry. However, PHI breaches have several distinguishing characteristics, particularly in who is conducting the breach, how the breach occurs, and the consequences of the data breaches. For example, the number of internal and external actors in breaches is fairly similar, meaning that much of this data is stolen by people who have insider access (2). The data that is stolen tends to be vulnerable and valuable personal information that can easily be used to facilitate financial crimes and tax fraud (2).

86% of all breaches of PHI data fall into three categories: lost portable devices (that, in this day and age, often contain private health information via mobile applications and or access to communications via email), errors in sending medical reports to the wrong recipient, and misuse from an employee that has access to the information (insider abuse). However, there are several new opportunities and techniques that can be used to phish data away from the physical machine that holds the database. According to the Verizon PHI Data Breach Report, around 23% of recipients who receive any kind of phishing messages will open the messages and the attachments—and each of these attachments will have malware and malicious codes that can get through and compromise systems (3). These consequences often have long-term effects: after this data is stolen, because the effects are often not evident, it can take up to years for users to discover that there has been a breach (2).

The US Department of Health and Human Services (HSS), in light of the number of increasing PHI breaches, has required that HIPAA (Health Insurance Portability and Accountability Act) covered entities give both speedy individual and media notices of the occurrence of the breach, and what kinds of information might have been exposed (3). In addition to these notifications, the Secretary of the HHS must be notified based on the magnitude of the breach (4).

These breaches are no exception to anesthesia providers, who often also carry PHI for the multitude of surgical procedures that must occur under anesthesia. To prevent against these breaches, there can be simple measures taken to protect user’s personal data. According to the Healthcare IT News, five steps to boosting against vulnerabilities include conducting an annual HIPAA security risk analysis, encrypting data-at-rest, conducting more frequent vulnerability assessments and penetration testing, investing in the security awareness of your employees, and engaging with your business associates (5). The protection of user’s personal data is important to the entire healthcare industry as it builds trust between the public and various types of healthcare providers—businesses should take care to ensure that their PHI databases are secure by taking steps forward for security in an ever-changing information technology-based world.

1. http://www.verizonenterprise.com/phi?_ga=1.244046022.2139379989.1461258579
2. http://news.verizonenterprise.com/2015/12/2015-protected-health-information-report/
3. http://www.verizonenterprise.com/DBIR/2015/
4. http://www.hhs.gov/hipaa/for-professionals/breach-notification/index.html
5. http://www.healthcareitnews.com/news/5-ways-avoid-health-data-breaches

Malignant Hyperthermia (MH) is a rare, life-threatening condition that poses unique challenges to both anesthesia teams and affected families. Patients suffering from malignant hyperthermia show no outward symptoms and usually lead perfectly normal lives; however, once they come in contact with specific volatile anesthetic gases or muscle relaxants used as general anesthesia, they soon find themselves in a life or death situation. Specific drugs used in general anesthesia such as halothane, desflurane, or succinylcholine have been shown to trigger Malignant Hyperthermia and cause patients to enter a dangerous hypermetabolic state. An overabundance of calcium ions floods the muscle cells, leading to muscle rigidity, while an increase in metabolism results in a skyrocketing heart rate, rapid breathing, and a characteristic high temperature. This precarious state could easily lead to organ failure and death; however with proper medical training and the successful application of muscle relaxants like Dantrolene, the vast majority of those who experience a Malignant Hyperthermia episode are able to make a full recovery.

Thankfully this dangerous condition is by no means common and is predicted to occur in roughly 1 in 5,000 to 1 in 50,000 procedures where anesthesia is delivered. However, those that are at risk for malignant hyperthermia are connected by a genetic link, as the condition is indeed an autosomal dominant inherited disease. Autosomal dominant means that a patient would only need one copy of the gene to be at risk and that if a parent is known to have MH, then there is a 50% chance that their child will be at risk as well. Due to this extraordinarily strong inheritance pattern, those who have a close relative with malignant hyperthermia are automatically considered at risk for MH and are treated accordingly. In fact, because MH does not show any symptoms other than the episode that occurs when under anesthesia, it is almost impossible to diagnose the condition or identify who’s at risk without some connection to the disorder in the family history. When a patient has a family history of MH, their risk can be verified by either doing genetic tests and looking for a mutation in the ryanodine receptor gene, RYR1, that is associated with the majority of MH cases, or by performing the only diagnostic test presently available for MH, the caffeine-halothane contracture test. Nonetheless, researchers have found that these tests are not perfect, and a negative result does not always mean that a patient is not at risk for MH. Furthermore, it has been found that those that are at risk for MH do not necessarily always react to the volatile anesthetic gases, and a patient can have several normal anesthesia experiences before having an episode of Malignant Hyperthermia. Thus due to the inherent difficulty in determining who will get MH and when, all of those who are at risk due to a family connection need to inform their anesthesia and medical team immediately.

An at-risk patient who has notified their physician should be prepared for a heightened level of monitoring, both by medical and anesthesia staff and through diagnostic tests, to ensure their own safety and prepare for any type of emergency situation. Because malignant hyperthermia is uncommon and usually unanticipated, it is essential that every member of the anesthesia team be knowledgeable of the condition, be skilled in following the treatment protocol, and be prepared to move fast, as the probability of complications resulting in cardiac arrest, kidney failure, or brain injury increases dramatically as time progresses.

In in the pre-operative stage, the team will be careful to gather an accurate family history, begin monitoring the patient’s temperature, and prepare anesthesia that is safe for one who is at risk for MH. During surgery, temperature will continue to be monitored and all resources needed to treat MH should be prepared. It is critical that the anesthesiologist know the early signs of MH—as the heightened temperature usually comes later—and is able to act fast and effectively to stop the triggering anesthesia and decrease temperature. Dantrolene is presently the only drug approved to treat Malignant Hyperthermia, making it imperative that the anesthesia team has access to the drug and can use it effectively if an emergency occurs. While the majority of cases occur during the procedure, there are rare instances of MH that do occur post-operatively and 25% of those who experience MH during surgery will have the syndrome reoccur in the next 24-36 hours. Thus those at risk for/suffering from MH will be closely monitored during post-op, as the anesthesia team watches the patient’s temperature, assesses any muscle damage, and possibly arranges a genetic consultation. Although there is no cure for this genetic disorder, with the proper communication between an informed patient and a prepared anesthesia team, this rare condition can be effectively and efficiently managed.

Sources

1. https://ghr.nlm.nih.gov/condition/malignant-hyperthermia
2. http://www.mhaus.org/healthcare-professionals/be-prepared/safe-and-unsafe-anesthetics
3. http://www.aana.com/resources2/professionalpractice/Pages/Malignant-Hyperthermia-Crisis-Preparedness-and-Treatment.aspx
4. http://www.ncbi.nlm.nih.gov/books/NBK1146/
5. http://www.mhaus.org/faqs/about-mh
6. http://www.sciencedirect.com/science/article/pii/S0001209206602366

Every fiscal year, the US Department of Health and Human Services (HHS) Office of Inspector General (OIG) releases a Work Plan that consists of reviews of various HSS programs and operations in order to ensure that HHS programs are functioning efficiently and with integrity. The HHS is a massive department that affects and manages everything from the nation’s food and drug supply, stockpiles of pharmaceuticals for emergency use, and the operation of health insurance, and so this Work Plan aims to keep these numerous programs accountable for their operations, as well as to assess the current plans of action.

The OIG states that the Work Plan allows for methods to combat waste, fraud, and abuse in these HHS programs. The OIG also reported that due to the Work Plan and reviews implemented during the fiscal year of 2015, they expected astounding recoveries of funding—more than $3 billion total, with about two-thirds coming from recoveries from investigative work, and the other third coming from recoveries in audit work (5).

While these reviews look to manage programs effectively across the multitude of departments within HHS, anesthesia services are also strongly impacted. Specifically, in the recent November 2015 publication of the 2016 Work Plan, two items were released in regards to anesthesia services. Both of these items were related to the Part B portion of the Medicare Plan, which covers medically necessary services (services needed to diagnose or treat one’s medical condition) and preventive services (services to prevent illnesses, or detect it at an early stage). Besides anesthesia services, Part B also provides coverage for clinical research, ambulance services, mental health, and durable medical equipment (DME).

The first item is a continuation of a review established by the HHS in the 2013 OIG Work Plan for anesthesia services. The review is two-pronged: the HHS would review Medicare Part B claims for “personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements”, and would also determine whether “Medicare payments for anesthesia services reported on a claim with the ‘AA’ service code” (1). This service code refers to who provided this service—AA corresponds to an Anesthesiologist’s Assistant, while there are also different service codes, like CRNA, which stands for Certified Registered Nurse Anesthetists (4). Essentially, this review ensures that the correct service code modifier on a Medicare claim will be reported. The consequences of an incorrect service code would lead to Medicare’s paying a higher amount, which is a form of governmental waste that the HHS would hope to avoid.

The second item is a new plan for a different review, introduced for the first time in the 2016 edition of the Work Plan. This new service confirms that a beneficiary who received anesthesia also underwent a related Medicare service that required such anesthesia (1). This also ensures that Medicare avoids paying for services that are not covered, those that are not “reasonable and necessary” (1).

In combination, these two new items indicate that the OIG continues to place strong emphasis in correct coding and billing of anesthesia services that are provided from various sources. According to the American Society of Anesthesiologists, in order to assure compliance, “anesthesia practices should conduct periodic reviews” and “confirm that there is appropriate documentation to support the claims filed to receive payment for services” (2).

Works cited:

1. US Department of Health and Human Services. 2016 OIG Work Plan. http://www.oig.hhs.gov/reports-and-publications/archives/workplan/2016/oig-work-plan-2016.pdf

2. American Society of Anesthesiologists, November 2015, Timely Topics. https://www.asahq.org/~/media/sites/asahq/files/public/resources/practice%20management/ttppm/2015-11-04-anesthesia-services-and-the-oig-work-plan.pdf?la=en

3. Centers for Medicare & Medicaid Services. What Part B Covers. https://www.medicare.gov/what-medicare-covers/part-b/what-medicare-part-b-covers.html

4. American Association of Nurse Anesthetists. Become a CRNA. http://www.aana.com/ceandeducation/becomeacrna/Pages/default.aspx

5. McKesson Business Performance Services. Office of Inspector General. http://www.mckesson.com/bps/blog/office-of-inspector-general-work-plan-for-anesthesia-and-pain-management/