Physicians want the anesthesia reimbursement model changed now — here's how

Four anesthesiologists joined Becker's to discuss why the anesthesia reimbursement model needs to be changed. 

Editor's note: These responses were edited lightly for brevity and clarity. 

Thomas Durick, MD. Anesthesiologist at the Ohio State University Wexner Medical Center (Columbus): Anesthesia reimbursements continue to be misunderstood by CMS, insurers and even our own colleagues. We allow the government and insurance companies to dictate what our services are worth (such as the recent bundling of ultrasound services into the most commonly performed regional anesthesia procedures for a reduced total reimbursement). We do the same (or more) work each year for less reimbursement and more challenges to get paid. Until we fight to be seen as more than nameless, faceless plunger pushers with opposable thumbs, we will remain in the shadows. Anesthesia providers as a whole need to come together as one to make it clear that we need to be paid fairly and that without us medicine grinds to a halt. We should stop the infighting between anesthesia provider factions and unify our voices, resources and intelligence to rally against the reimbursement gods that we have allowed to dictate policy and payment. Make anesthesia billing simpler: You perform a nerve block that benefits the patient intraoperatively and postoperatively? You should get paid for the nerve block independently of the course of the anesthetic. You helped reduce postoperative pain, which might result in fewer opioids administered and a faster recovery, better patient satisfaction, less postoperative nausea and vomiting ... but if I can't get paid for it, what is the likelihood I will be compelled to take that medicolegal risk for no financial benefit? We should never have to ask ourselves that question, yet we do based on declining reimbursement for seemingly everything we do.

William Joseph Martin, DO. Medical Director of Anesthesiology at Hugh Chatham Health (Elkin, N.C.): Most third-party payers base their payment model on Medicare and a multiplier. However, in anesthesia specifically the model is a disaster. Most of your physicians who use Medicare are based on relative value units and procedure codes. For example, you do a gallbladder procedure, Medicare pays a certain amount, and the third-party payer says, "Well, Medicare doesn't pay very much, so we'll pay you a certain percent times whatever Medicare pays you when we negotiate your contract." But it's different for anesthesiologists because we're time-based. You can have one surgeon do a procedure in 40 minutes and another take 2.5 hours — if you're paid on a global fee, nobody wants to provide service to that other physician because you could do two procedures while the other is doing one. With anesthesia, you can't control that; that's why it's time-based. 

This is especially true if the group employs the certified registered nurse anesthetists. They don't have to worry about billing and collecting, so as they want more salary increases, reimbursements don't match and eventually those lines cross and you can't afford to employ them. 

That's why a lot of hospitals and practices are looking to employ everyone — the physicians and the CRNAs — so when they go to negotiate with third-party payers, they have control over the costs. That's why you're seeing more being employed because they can't afford to negotiate costs unless they're in a multistate anesthesia group. You're seeing payers have to choose between employed anesthesiologists or those large anesthesia groups. 

Scott McGraw, MD. Chief Medical Officer and Anesthesiologist at Baylor Scott & White Surgical Hospital Las Colinas (Texas): Primary concern is annual decreases in Medicare rates for anesthesia. This is especially difficult considering Medicare pays 20% to 40% of what commercial payers do.

Tariq Naseem, MD. Anesthesiologist and Interventionist at Cedars-Sinai Smidt Heart Institute (Los Angeles): So the most important thing would be that at a federal level, especially with the Medicaid office, they have to reevaluate the anesthesia reimbursements. It is so bad, something like $0.33 on a dollar, and it's impractical to do that. If institutions were paying anesthesiologists like that, every operating room would just shut down. And the way that is now being dealt with, fortunately or unfortunately, is that they're being paid for value. And while that makes sense, it does not align with what the federal and insurance standards are. This is where CMS really needs to get its act together. This has been going on for a while, and still every year we see cuts in physician reimbursements. The reimbursements absolutely make no sense with reality. It's just not practical. 

And it has already become a value-based thing because it was always true that you needed an anesthesiologist to run the perioperative machine of any institution, but because they were always available, it was never a problem. For the first time we're realizing that without anesthesiologist, the entire perioperative machinery comes to a halt. And for most institutions — by that I mean hospitals and medical centers — I wouldn't be wrong if I said 30% to 40% of revenue comes from the perioperative production line — operating rooms, catheterization labs, gastrointestinal suite, interventional radiology, interventional neuroradiology, anywhere procedures are being placed. 

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