1. Anesthesia is not reimbursed for many GI procedures. ASCs should be aware that payors are increasingly unwilling to separately reimburse for anesthesia services provided during GI procedures. According to William Hoffman, MD, corporate medical director of Anesthesia Healthcare Partners, some commercial payors refuse to pay professional fees to anesthesiologists for certain GI procedures. This refusal restricts the type of pain control that can be provided to patients undergoing GI procedures and also potentially slows the throughput of cases, he says. For example, the use of propofol during colonoscopy provides greater pain relief and quickly wears off, allowing GI patients to get out of the center quicker. Narcotics, such as Demerol, may not provide complete pain relief and take longer to wear off, says Dr. Hoffman.
Although GI physicians can direct the use of propofol, some anesthesiology groups argue that the practice is safer when directed by anesthesiologists. As a result, a number of anesthesiologists, including Dr. Hoffman, are working with payors to try to explain the benefit of reimbursing anesthesia services during these procedures. If an ASC contracts with a carrier that currently does not provide separate reimbursement for anesthesia, it is important that the gastroenterologists on staff are competent at offering various types of pain relief during these procedures.
2. Inefficient ASCs risk difficulties in securing anesthesia services. ASCs that do not employ or have anesthesiologists as investors will likely have to compete with other facilities, including hospitals, for the service of anesthesia groups. If the anesthesia group is compensated based on anesthesia unit production, and the market is experiencing anesthesia provider shortages, facilities with gaps between cases could risk increased costs in securing anesthesia services, including possible requests for anesthesia stipends to make up for down time, warns Robert Welti, MD, corporate medical director and COO, Western region, for Regent Surgical Health. ASCs with strong volumes and little downtime remain an attractive location for anesthesiologists.
3. Anesthesia reimbursement varies greatly between public and private payors. Professional fees for anesthesia services are determined by adding the time units required (one time unit typically equals 15 minutes) for a procedure with the procedure's base units, which vary according to the complexity of the anesthesia service, and then multiplying by a conversion factor, which is determined by the payor. The current average Medicare conversion factor for anesthesia nationwide is $20.92, which is about one-third the rate of managed-care contracts, according to Sharon Merrick, coding and reimbursement manager for the American Society of Anesthesiologists. For example, from Oct. 2006-Feb. 2007, conversion factors for managed care contracts ranged between $52.16 and $65.06, on average, according to the ASA's 2007 national survey of anesthesia conversion factors. At the time of the ASA's 2007 study, the average conversion factor for Medicare was $16.19. Additionally, some private payors allow coding for a qualifying circumstance or modifying factor, such as for varying degrees of comorbidity, which increase payments because of increased complexity, while CMS does not reimburse for these modifying factors, says Ms. Merrick.
4. ASCs with high levels of Medicare patients may be more at risk for subsidy requests. Medicare reimburses at a very low rate, compared to most managed care providers, for anesthesia services, says Thomas Wherry, MD, a practicing anesthesiologist and principal of Total Anesthesia Solutions. Thus, ASCs with a large percentage of Medicare patients could be less attractive to anesthesia groups. As a result, these ASCs should be prepared for anesthesia subsidy requests and should begin to analyze if meeting the request is worth maintaining the relationship with the anesthesia group.
However, at present, the majority of facilities paying anesthesia subsidies or at risk for these requests are hospitals, says board-certified anesthesiologist Sterling "Chip" Wood, MD, partner at Atlantic Ambulatory Anesthesia Associates. "Hospitals have a much higher Medicare population, and Medicare reimbursements for anesthesia are low. In order for most ASCs to be profitable, they aren't able to do large volumes of Medicare cases. However, some ASCs, such as maybe an eye center with a huge Medicare population, could be asked for subsidies," he says.
5. Knowing anesthesia providers' needs can reduce the risk of subsidy requests. If an anesthesia group does bring up the idea of a subsidy request, ASC leaders should discuss what exactly the anesthesia provider needs to cover costs. Dr. Wherry recommends that ASCs know exactly the number of anesthesia units that the group requires to remain profitable, and work with them to determine if scheduling or other efforts, besides subsidies, could help them meet this goal.
6. Anesthesiologists also play an important role in the efficiency of an ASC. Therefore, it is important that an ASC bring in anesthesiologists that are committed to efficiency. "Our anesthesia groups to help us make our centers more efficient by being committed to helping us get rooms turnover, and they are willing to do this in order to remain the provider of anesthesia services to our patients," says Brent Lambert, MD, president and a founder of Ambulatory Surgical Centers of America.
Additionally, the use of certain anesthetics, such as propofol for sedation, reduce the time needed to perform cases, which allows an ASC to schedule more cases and schedule more efficiently, according to Stanford Plavin, MD, an anesthesiologist and managing partner of Ambulatory Anesthesia of Atlanta. The use of generic antemetics, to reduce post-op nausea, rather than name-brand medications, can also save ASCs up to $15-$20 per case, says Dr. Plavin.
Mark Schoenfeld, MD, a board-certified anesthesiologist with Columbia Anesthesia Associates who practices at Ambulatory Surgery Center of Union County (N.J.).says that he often forgoes using the "designer drugs of the day" and uses less expensive drug options in order to increase ASC efficiencies.
7. Advances in anesthesia have allowed more patients to be safely treated at ASCs. Traditionally, older and sicker patients were treated in the hospital as opposed to ASCs, but advances in anesthesia have allowed patients that once would have been turned away from the ASC an opportunity for treatment. According to Irvin Thomas, MD, medical director of Safe Sedation, Thomas, an ambulatory surgery anesthesia group, newer medications with shorter half-lives and a shorter duration of action give ASCs the opportunity to treat patients who were once designated to the hospital in the outpatient setting.
However, treating older and sicker patients at the ASC has created more of a challenge for anesthesia providers in the outpatient setting. Traditionally, ASC-based anesthesiologists and CRNAs could take comfort in the fact that they were treating the healthiest patients. Although ASC patients still tend to be healthier than hospital patients, anesthesiologists in the ASC-setting are now seeing more complicated anesthesia cases. As a result, anesthesiologists should be especially careful in determining which patients can safely be treated in the ASC as surgeons are now referring more patients to these facilities, according to Dr. Wood.
8. Offering the latest in anesthesia services may improve volume. ASCs whose anesthesiologists are willing to use innovative techniques with regard for excellent patient safety are attractive to prospective patients who may hear about the facility from other satisfied customers. According to Dr. Thomas the use of peripheral regional anesthesia alone, or in combination with general anesthesia, may provide some of these advantages, which include higher patient satisfaction scores due to excellent post-operative pain control and a lower incidence of post-operative nausea and vomiting.
The improved post-operative pain control provided by regional pain blocks is a result of their effects extending after the surgery. If a patient had undergone general anesthesia, he or she would not have that additional pain control, says Dr. Schoenfeld. Most patients also report less post-operative nausea and vomiting from regional blocks than with general anesthesia, he says. Less nausea and vomiting reduces recovery times, which allows the ASC to see more patients in a day and potentially lowers case costs.
9. Complications from anesthesia have declined dramatically despite more patients undergoing ambulatory procedures. The number of deaths attributed to anesthesia was approximately 1 in 1,500 fifty years ago. Today that number has improved nearly tenfold, despite more patients being treated in operating rooms nationwide. Currently, the chance of a healthy patient suffering an intraoperative death attributable to anesthesia is less than 1 in 200,000 when an anesthesiologist is involved in patient care, according to the American Society of Anesthesiologists.
Dr. Schoenfeld says that anesthesiologists have successfully reduced these complications in the outpatient setting by taking an active role in determining which patients can and cannot be seen at ASCs. He recommends that anesthesiology staff review patient charts and evaluate in person any questionable cases before the day of surgery. Decisions about treating patients should be made before the day of surgery so that patients do not take off work and take up time on the schedule if there is a possibility that they cannot be treated at the ASC. These situations upset patients and are costly to ASC who could have scheduled other cases during those times, he says.
10. Innovative anesthesia services may require investments in technology. ASCs that wish to offer more innovative anesthesia options, such as regional nerve blocks for orthopedic patients, may need to purchase new technology in order to make these techniques available to patients. Although many anesthesiologists use nerve stimulators to detect nerves for administrating regional blocks, new monitoring devices that use ultrasound waves to visualize nerves could grow in popularity, says Dr. Schoenfeld.
However, Dr. Wherry warns that these devices may require a significant investment — the monitors can cost around $30,000.
11. ASCs can benefit from treating anesthesia providers as true team members. According to Dr. Wherry and consulting medical director for Health Inventures, ASC staff members sometimes fail to appreciate contracted anesthesia providers as true members of the ASC team. However, ASCs that treat anesthesia providers as true team members and include them in the ASC decision-making may find financial benefits from doing so. Anesthesia providers may be more efficient when they feel truly a part of the ASC's success and may be able to offer ideas to cut costs and improve efficiencies.
As a result, if an ASC is outsourcing its services, they should consider using an anesthesia group that provides anesthesiologists and CRNAs that are dedicated only to serving that center, says Dr. Hoffman.
Read an additional 12 things to know about anesthesia and anesthesia in ASCs.