Anesthesia management Archives - Page 14 of 20 - Xenon Health

Healthcare insurance is financial protection that reduces the risk of debt due to healthcare expenses. Americans have historically sought coverage through private health insurance companies, and most rely on employers for coverage (3, 2). In 2010, the Affordable Care Act was passed by Congress and signed into law, which allows Americans to choose insurance based “in a new open, competitive insurance market” that “keeps insurance companies honest by setting clear rules” (4). According to Medicaid, this new law will “expand coverage, hold insurance accountable, lower health care costs, guarantee more choice, and enhance the quality of care” (3).

As of February 2016, 12.7 million Americans have exceeded the Obama administration’s sign-up goals and gotten insurance under the federal health-care law (1). Of the 12.7 million signed up, 4 million are new users of HealthCare.gov, suggesting that the federal healthcare law has done well in getting healthcare coverage for those previously uninsured. While Top Administration Officials are optimistic about the federal healthcare law’s current successes, some remain skeptical of the new law’s potential for continued growth. Millions of people are still uninsured, and the new law has faced backlash from insurers who now must offer healthcare coverage at the same price regardless of medical history. Additionally, many people see the federal healthcare law’s promise for cost transparency and affordable care as lacking in implementation (7).

While the government has recently made many changes to healthcare in America, there is also a private group seeking to change how employers provide healthcare. Many major companies who offer healthcare for their employees now plan to work together to research employee health spending and outcomes through the Health Transformation Alliance (2). With 20 large companies so far, this group is piloting a project in 2017 that aims to pinpoint which healthcare providers had the best outcomes and value for patients with various illnesses. Using this data, they hope to steer workers to certain providers. Amidst rising healthcare costs, they hope to find ways to curb costs to insure that companies are able to keep providing healthcare benefits for employees. Since the majority of Americans rely on employers for insurance, with 4 million people among the 20 participating companies, the Health Transformation Alliance is in a position to have a large influence on the healthcare system in coming years.

In the field of anesthesiology, the Affordable Care Act supports coverage of anesthesia services by a CRNA. The law itself includes a pilot project for Graduate Nursing Education (GNE) to support Advanced Practice Registered Nurses (APRNs).  The American Association of Nurse Anesthetists (AANA) states that CRNAs play an important role in providing cost-effective care for the implementation of the Affordable Care Act (5). Medicare Part A, Medicare Part B, and Original Medicare all cover the costs of some or all of certain anesthesia services (6). While there are many speculations as to how the recent changes to the healthcare system will affect Anesthesiologists and CRNAs, much is still unknown.

Overall, there is a general desire for transparency within the healthcare system, especially in regards to the costs of it. As the federal healthcare law continues to be carried out and new projects such as the Health Transformation Alliance are implemented, it is important to all those working in healthcare to be aware of their effects.

Sources:

1. http://www.wsj.com/articles/federal-health-care-enrollees-exceed-goals-1454627826
2. http://www.wsj.com/articles/companies-form-health-insurance-alliance-1454633281
3. https://www.medicaid.gov/affordablecareact/affordable-care-act.html
4. http://www.hhs.gov/healthcare/about-the-law/read-the-law/index.html
5. http://www.future-of-anesthesia-care-today.com/cost-effective.php
6. https://www.medicare.gov/coverage/anesthesia.html
7. http://oig.hhs.gov/reports-and-publications/top-challenges/2012/issue01.asp

Because endoscopic procedures, such as colonoscopy and esophagogastroduodenoscopy (EGD) tend to be uncomfortable and invasive, procedural sedation plays a crucial role in such procedures by managing the fear, pain, and anxiety of patients. Computer-assisted personalized sedation (CAPS) devices are an emerging technology that seek to improve the safety, efficiency, and precision of surgeries performed under sedation.

Traditional methods of sedation—the most common of which have been the administration of an anxiolytic agent and an opioid agent—are limited by the extensive time to achieve sedation, a long recovery time after the procedure, and difficulty in titration. In recent years, these methods have increasingly been replaced by the use of propofol, a sedative-hypnotic agent that acts and wears off quickly, shortens recovery time, and facilitates titration. However, because propofol is labeled as an anesthetic, only anesthesia professionals are allowed to administer the drug. Meanwhile, qualified anesthesiologists and CRNAs may not be available—an issue that may intensify as both the number of endoscopic procedures and propofol use in these procedures is predicted to rise in the coming years. By using a computer interface to facilitate drug titration for cases of minimal to moderate sedation, the SEDASYS CAPS system may lessen the burden on anesthesiologists and manage professional allocation.

This novel method of sedation, designed and created by Ethicon Endo-Surgery Inc., “is a computer-assisted device that administers the prescription drug propofol into the blood stream via intravenous IV infusion.” The system noninvasively monitors the patient’s physiological data (oxygen saturation, capnometry, respiratory rate, heart rate, blood pressure, electrocardiography, and patient responsiveness) and then uses this data to titrate sedation and adjust propofol infusion. It allows the physician to select and adjust the initial maintenance rate and to periodically administer rapid bolus doses in the case of patient discomfort. Most importantly, the CAPS system empowers the endoscopist-nurse team to administer propofol without an anesthesiologist present during the procedure.

The new technology is intended for low-risk patients above the age of 18 undergoing colonoscopy or EGD with minimal or moderate sedation. Although an anesthesia professional does not need to be directly on site, one does need to be “immediately available” for assistance or consultation in case of an emergency. Propofol does not have a reversal agent and so, if misused, can result in an unintentionally deep level of sedation and potential airway compromise that must immediately be attended to a by a trained anesthesiologist. Endoscopists who wish to use the system will need to undergo extensive device-specific training.

Many measures have been taken to ensure that the necessary safety mechanisms are present within the SEDASYS CAPS system. Propofol dosing is limited through a cap on the initial infusion rate, a restriction on infusion rate surges, and a mandatory three minute loading dose whenever infusion is increased. Infusion is not allowed unless oxygen is being delivered simultaneously. The oxygen delivery rate is adjusted based on oxygen saturation. Throughout the procedure, the system uses verbal and tactile simulation to check the patient’s level of sedation. In the case of any distressing physiological parameters, endoscopists are alerted through visual and audible alarms and propofol infusion may be halted.

The FDA officially granted Premarket Approval for the SEDASYS System on May 3, 2013. Test trials have found that the average recovery time for patients undergoing endoscopy and colonoscopy with CAPS was 27 minutes, compared with 33 minutes for patients who were given traditional sedation drugs (nearly a 20% reduction in recovery time). Patients in the CAPS group were reportedly more satisfied with their experience and felt less pain during the procedure, while endoscopists likewise expressed a greater satisfaction with this method, crediting the deeper and more stable level of sedation.

CAPS has the potential to not only improve the efficiency and outcomes of these endoscopy procedures, but also better allocate anesthesia professionals. A 2012 RAND study found that from 2003 to 2009, the number of colonoscopies and upper gastroenterology (GI) procedures increased by 26 percent, a rate that is only expected to continue accelerating. Meanwhile, SEDASYS estimates that there are currently 15 million patients in the US who are candidates for procedures using the new technology. With the computerized sedation system capable of precisely tending to these routine procedures, trained anesthesia professionals, who are in relatively limited supply, will be free to direct their skills towards greater risk patients.

Following the passage of the Health Information Technology for Economic and Clinical Health Act (HITECH) in 2009, the healthcare industry and all anesthesia services have been jolted farther into the digital age. A law that highly incentivizes the usage of electronic health record systems, HITECH, requires that healthcare providers, including anesthesiologists, leave behind paper records and adopt a digital system that is intended to streamline a physician’s access to medical records, ease the process of prescribing medication, and reduce the amount of unnecessary paperwork. Despite the many possible benefits that could arise from a digital system, electronic records have created an extremely pressing problem for the healthcare industry.

Privacy and the confidentiality of sensitive personal information are the backbone of the doctor patient relationship; however, the adoption of an electronic record system leaves private information that is being transmitted, stored, or recorded vulnerable to the attack of hackers who can penetrate these online systems. The only way to prevent these malicious attacks, which can result in identity theft and the loss of billions, is by encrypting this private medical information. Encryption makes use of a complex algorithm that transforms the information into unreadable ciphertext that can only be deciphered when the authorized party enters the correct key. When this key is stored properly, on a separate device that is not being used to read or store encrypted information, it becomes almost impossible for a hacker to steal the information and cause a severe data breach.

Despite encryption’s critical role in securing private and confidential information, the amount of healthcare providers who use encryption software is surprisingly low—only 44% of organizations in the United States reported that they made “extensive use” of encryption technology and only 29% encrypted tablets or smartphones. Encryption is particularly critical to anesthesia services where information can include not only names and social security numbers, but also insurance information and medical histories that can be manipulated by the uninsured or those with pre-existing conditions in order to gain coverage. The market for such information is quickly growing, with a 600% increase in cyberattacks on healthcare centers in 2014 alone. If such a cyberattack occurred at a center for anesthesia services it could put thousands of patients in jeopardy and result in millions in fines.

The lackluster usage of this important technology can be traced back to the fact that there are no definitive legal requirements that healthcare information must be encrypted. HIPAA Security Rule considers encryption an “addressable” issue, meaning that it cannot be ignored by an organization, but the organization has significant flexibility in determining what level of secure encryption they will use, or if encryption is even appropriate for their devices. The abstract wording of this law has allowed many leaders in healthcare and anesthesia management to forego essential, high-end encryption software, either using minimal or no encryption techniques. Believing that their data is being properly protected and that there is minimal risk of a security breach, management groups avoid extensive encryption software that is deemed expensive, confusing, and cumbersome. Indeed, many physicians have adamantly fought against using encryption because they feel as if the complicated keys could waste time when every second counts and that encrypting the information in diagnostic and monitoring equipment could compromise function. Thus a very significant conflict arises between the need to efficiently deliver patient care and thoroughly protect private healthcare information.

Despite reservations from physicians, encryption is the best means of protecting information and preventing potentially devastating data breaches. In February 2015, Anthem Blue Cross had a breach of security that put the healthcare information of 80 million people in jeopardy because Anthem had not encrypted this confidential stored data. This is not an isolated incident: in 2013 alone 60% of healthcare institutions reported data breaches due to lack of security, resulting in over $1.5 billion in fines. Technology is working to prevent these types of breaches by making encryption software easier to use and the keys less complex—one startup is even testing using fingerprints to safely access medical records. In the mean time, anesthesia management groups and all healthcare providers need to recognize the extreme importance of encryption in protecting patients and hospitals from destructive consequences.

Sources:

1. https://www.healthit.gov/policy-researchers-implementers/health-it-legislation
2. https://www.healthit.gov/sites/default/files/pdf/privacy/privacy-and-security-guide.pdf
3. http://healthitsecurity.com/news/too-few-organizations-implement-data-encryption-survey-says
4. https://www.technologyreview.com/s/530411/hackers-are-homing-in-on-hospitals/
5. https://hipaacentral.com/Documents/Perspectives/HIPAA-Encryption-Requirements-Perspective.aspx
6. https://www.virtru.com/blog/why-isnt-everyone-using-encryption-in-health-care/
7. http://www.healthcareitnews.com/news/why-does-healthcare-resist-encryption
8. http://www.pbs.org/newshour/rundown/lack-health-care-cyber-security-standards-raises-questions/
9. http://www.mobilecomputingtoday.co.uk/1551/ensuring-healthcare-compliance-protecting-securing-patient-data/
10. https://www.technologyreview.com/s/545566/using-patient-fingerprints-to-break-down-medical-record-silos/

Anesthesia can be administered in a variety of settings. Office-based anesthesia has become increasingly more common (1). Between 1995 and 2005, the number of elective procedures performed in offices doubled to approximately 10 million procedures per year. This increase in office-based anesthesia is due largely to newer surgical and anesthetic techniques and perceived economic advantage for office-based procedures. For some patients, office-based procedures may require less paperwork, provide greater privacy, and feel less imposing than hospital procedures (5). While there are advantages to office-based anesthesia, special considerations are needed to provide safe and effective care.

Compared to a hospital setting, an office-based setting would not be able to provide as much backup resources and support. Therefore, specific regulations must be taken into account to ensure patient safety (1). The American Society of Anesthesiologists (ASA) has a set of guidelines concerning the implementation of office-based anesthesia and the special considerations it requires (2). The American Association of Nurse Anesthetists (AANA) also has set standards for office-based anesthesia practice (3). These guidelines parallel many of the same fundamental standards for the ASA and AANA. Based on these guidelines, some special considerations include determining whether an office-based procedure is best for the patient, facility accreditation, and building and equipment safety.

Depending on the health of the patient and the type of procedure planned, office-based anesthesia may or may not be the best option. Reliable statistics on the morbidity and mortality of office-based anesthesia still remains difficult to analyze because of limited sample size and lack of uniform criteria for morbidity and mortality (1). However, there are some studies that find that office-based anesthesia is less safe than ambulatory surgical centers, with higher rates of adverse events and death associated with office-based anesthesia procedures (1). There is still some consideration as to whether these findings are valid. Nonetheless, patient safety remains to be a top concern for those advising patients considering procedures in an office setting versus a surgical center. Appropriate preoperative testing must be considered, and those with specific conditions, such as morbidly obese patients or those with sleep apnea, will likely be counseled to consider procedures in a hospital setting (5).

Another special consideration is that anesthesiologists and nurse anesthetists are responsible for ensuring that the facility and equipment are routinely inspected (1). This is especially important in office-based settings where a problem during a procedure may be more dangerous for patients. The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) and other accrediting institutions offers certification and accreditation to facilities that meet their standards (5). According to ASA’s guidelines, at a minimum, facilities “should have a reliable source of oxygen, suction, resuscitation equipment and emergency drugs” (6). Routine inspection is expected, and a back-up power supply should be available in case of emergency. Additionally, all personnel should be comfortable working in an office setting and regularly trained in the facility’s emergency protocols.

As office-based anesthesia has become more common, considerations for maintaining a safe office anesthesia environment has become a priority for many researchers and organizations. The ASA has even compiled an informal manual to supplement their formal guidelines (4). Interested readers can also find several textbook references regarding office-based anesthesia (1). Office-based anesthesia and surgery can provide proper conditions for procedures, and is seen by many to be a better option for some patients.

Sources:

1. http://www.sciencedirect.com/science/article/pii/S1932227510000194
2. https://www.openanesthesia.org/office-based-anesthesia-guidelines/
3. http://www.aana.com/resources2/professionalpractice/Pages/Standards-for-Office-Based-Anesthesia-Practice.aspx
4. https://www.asahq.org/shop-asa/detail?productId=133693
5. https://www.thieme-connect.com/products/ejournals/html/10.1055/s-2007-979210
6. http://www.asahq.org/~/media/Sites/ASAHQ/Files/Public/Resources/standards-guidelines/guidelines-for-office-based-anesthesia.pdf

Due to the complexity of the third-party medical payment system, insurance companies sometimes overpay or underpay anesthesia practices. If an insurance company overpays a practice, the payer might later ask the practice for a refund. It’s important that anesthesiologists and their staff know how to respond to requests for refunds.

The American Medical Association has created a guide for practitioners, called the Overpayment Recovery Toolkit, which lays out the procedure for responding to a request for a refund. The first thing that it is important to know is when or why a request for refund might be submitted. Sometimes an insurance company simply makes duplicate payments by mistake. Other times, two different insurers pay for a procedure when only one was actually responsible. This results from a failure to coordinate between payers. It could be that an insurance company pays for a patient whose plan doesn’t actually cover the procedure or service that was billed, or that the service was performed without the necessary preauthorization. In still other scenarios, an insurance company could end up paying for a procedure later deemed medically unnecessary. There are many factors that could lead to an overpayment. Any of these scenarios might prompt an insurance company to request a refund.

In especially vigilant practices, accountants may notice that insurance companies have overpaid and immediately call the company to ask them to send a refund request. This proactive approach allows anesthesia practices to maintain control over the timing of the refund request and to keep the “books clean,” as one participant in the Billing Office Issues discussion group on the Medical Group Management Association website notes.

In most instances, the practice does not reach out to the insurance company about an overpayment, but rather first learns that the payment has been botched when an insurance company submits a request for a refund for a certain amount of money. It’s important that anesthesiologists respond promptly to these requests: within a week or two, if no specific deadline is given. Even if no answer can be given immediately, practices should communicate with the insurance company and take steps towards resolving the issue.

It’s also imperative that the anesthesia practice checks to make sure that the request for refund was made within the appropriate time window. State statutes mandate the window of time in which a request for refund may be made. The time frames vary by state but could be within 6, 12, 18, 24, or 30 months of the date the original overpayment was received. If it is determined that the request for refund is invalid, the practice should appeal and submit a letter that fully explains the reason for appealing.

On the other hand, if it is determined that the request for refund is valid, managed care contracts permit the insurance companies to regain overpayment amount by paying less for future services. In other words, the insurance company can offset the amount by underpaying by the same amount as they overpaid. This system means that the anesthesia practice doesn’t have to cut a check to the insurance company, but rather receives less money for services rendered until the debt has been settled.

Without the knowledge of how to respond quickly and painlessly to insurance companies’ inevitable requests for refunds, anesthesia practices can end up wasting undue quantities of time and resources on resolving these issues of payment.

References:

http://www.tdi.texas.gov/hprovider/ppsb418faq.html

http://www.beckersasc.com/anesthesia/what-should-anesthesia-practices-do-with-unclaimed-funds-belonging-to-patients.html

http://www.anesthesiallc.com/publications/blog/entry/when-payers-ask-anesthesiologists-to-refund-overpayments

http://www.ama-assn.org/ama/pub/advocacy/topics/administrative-simplification-initiatives/appeal-your-claim/overpayment-recovery-toolkit.page