7 Priorities for Anesthesiologists & ASCs in 2013
1. The rise of accountable care organizations. Accountable care organizations are expected to play a greater role in healthcare over the next few years, as President Obama's administration continues implementation of the healthcare reform law. While there is no standard model for ACOs as of yet, the general idea is that the model would tie provider reimbursements to quality metrics and reductions in cost of care for an assigned patient population.
The facilities best-positioned for this change are probably large health systems, which can track a patient's care over a larger continuum than a practice or surgery center — and work with payors to negotiate rewards for improving outcomes. But Dr. Desai says surgery center providers need to think about their place in ACOs as well. "The bigger the hospital system you are associated with, the more likely you are to be incorporated into the ACO, "she says. "If you're part of a very small physician group, you might be left out in the middle of nowhere."
Though they may not have the clout to enter ACOs without hospital partnership, surgery centers are uniquely positioned to succeed in an accountable care organization. Small practices and ASCs are used to operating on a tight budget while providing high-quality outcomes; because their volume depends so heavily on referrals and reputation, they can't afford to make mistakes or waste money. This may prove useful as hospitals look for partners that can keep costs down while boosting quality metrics.
2. Measurement of quality outcomes. "The measurement of quality metrics and outcomes is going to be crucial, and anybody who is not doing that well needs to focus on it," Dr. Desai says. "I don't mean the 'mom and pop' measurements. You need to have a computer system that can provide sophisticated measures." She says measuring quality outcomes is very different for surgery centers and hospitals. Instead of looking at mortality and forms of morbidity such as heart attack and stroke, surgery centers are more concerned with patient satisfaction, speed of return to normal function and post-operative nausea and vomiting.
So far, there are only a few measures that Medicare requires surgery centers to track — in 2013, ASCs will be required to report instances of patient burn, falls, wrong site/side/patient/procedure/impact, hospital admission/transfer, antibiotic timing, safe surgery checklist use and volume of certain procedures.
Dr. Desai says surgery center should not stop with the Medicare requirements, since there are other benchmarks that can tell a lot about quality and patient satisfaction. "We are looking into what we can do about nausea and vomiting rates," she says. "Some surgery centers have rates as high as 30 percent, and others as low as 5. There is talk of putting a nausea score on everyone who comes into the center, so you know if you should do multi-modal pain management." She says the Society of Ambulatory Anesthesia has developed a database called SCOR that contains many different metrics against which anesthesiologists can benchmark their outcomes.
3. The disappearance of hospital stipends. Anesthesia practices that currently run on a hospital stipend may face the disappearance of those dollars, Dr. Desai says. "Generally the rule is, the more inefficient the hospital, the more the stipend," she says. "The stipend can range from 2 percent to 30 percent of hospital income, which means millions of dollars at some of these larger institutions." She says anesthesia practices should prepare for those stipends to be reduced or go away, meaning practices will have to run more efficiently in order to survive.
She says the easiest area to target for cost reduction is anesthesia staffing inefficiencies. "If your OR utilization of staff is not greater than 70-75 percent, you're not going to make it based on your own professional billing in most payor mixes," she says. She says practices should be looking at any "downtime" in the facility: What time are people arriving in the morning, what time are they leaving, and how quickly are they moving patients through the practice? "Every minute adds up to a lot of minutes over the year," she says.
4. Becoming indispensible as anesthesiologists. Dr. Desai says in 2013, anesthesiologists are going to have to become indispensible by integrating themselves into the organizations they work for. She says it's critical for anesthesiologists to become valuable as facilities move towards more integrated physician models and collaborative care. "We are the physicians on site every day, so we have to assume a leadership role," she says. "Even when surgeons are owners, they come and go. Hospital administrators come and go. Whether or not we want to go to committee meetings, we have to."
She calls anesthesiologists the "invisible provider" — the physician that is there for every case but that no one notices. She says anesthesiologists must work on becoming service-oriented, offering ideas and projects to the institution to make sure patient care is as high-quality as possible.
5. Drug shortages. Drug shortages are still plaguing facilities across the country, with up to 98 percent of participants in an American Society of Anesthesiologist survey reporting drug shortages in their facilities. Dr. Desai says despite efforts by the ASA and the federal government to relieve shortages, no easy answer is in sight. This means anesthesiologists must take initiative to set par levels and make sure necessary drugs are on hand for surgery.
She says anesthesiologists are also essential in a facility to designate substitutes for drugs the facility cannot attain. "These all need to be outlined ahead of time, since they might not be the drugs we typically use," she says. She adds that pre-op and post-op staff must be educated on the differences in side effects, since patients must be warned about the recovery experience.
6. Reducing anesthesia variability. Dr. Desai says it's important for anesthesia providers to work to reduce variability in their practice. This means that if a practice includes several different physicians, they may have different processes, recommendations and policies. For example, they may disagree on which patients are appropriate for treatment in an outpatient facility — how obese they can be, how many comorbidities they can have, etc. "You need to have a consensus among your providers," she says.
7. Peer review. A lot of anesthesia groups aren't willing to be involved in peer review, Dr. Desai says. "It's simply work, and they don't want to review the charts or set up their parameters," she says. She says anesthesiologists have to be willing to do peer review, since asking another specialty to monitor anesthesia performance is dangerous and ineffective. She says getting involved in peer review will also engage anesthesiologists in the metrics used by their facilities and the government.
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