Truven Health Analytics has chosen anesthesia services as the culprit in their White Paper Can New Payment Models Stop the “Insidious Creep?” The Case of Colonoscopies (You can download the pdf directly from Truven by clicking on this red lettered title).
This White Paper references New York Times articles, selective research and (my favorite) the author’s personal experience, to highlight the cost, increasing popularity, potential danger and questionable necessity of having anesthesia for a colonoscopy.
Selecting a study “from the Industry” where it is hypothesized that deep sedation, “because of impairment in patient response, this technique also has the potential for greater likelihood of adverse events.” The author ending the paragraph with the conjecture, ” This finding suggests that this trend not only results in a significant increase in costs with no real benefit to the patient, but a possible increase in the risk of complication.” How in the course of one paragraph does a hypothesis become a finding ?
The next paragraph,
“In the current Fee For Service market, this creeping patient expectation for deep sedation cannot be stopped. The patient readily defers to the physician’s insistence that the deep sedation is necessary, since it is covered by insurance and, ‘I deserve the best care available.’ This patient tells all of his friends that the experience was not nearly as bad as he feared and that it was certainly due to the effects of anesthesia. Word spreads and patients insist that their physician follow this ‘best practice’. “
Truven Health Analysis
” I speak from personal experience when I say that a screening colonoscopy is not a pleasant experience. But it’s really not that bad. Its ‘bark is worse than its bite’. The preparation is actually much more unpleasant and the insertion of the IV is more painful than the procedure under conscious sedation.”
Impact of New Payment Models
“Will either of the proposed new payment models, bundled payment or the accountable care organization (ACO), impact this insidious trend represented here as the rapid increase in anesthesiologist participation for simple colonoscopy procedures ??
The concluding sentence in the White Paper,
“The role of the Accountable Care Organization in assuring that utilization rates are appropriate and consistent with the population’s needs requires that the organization establish and manage compliance with evidence based guidelines.”
Although newspaper sensationalism, hypothesis and personal experience make for a compelling storyline, ignoring the numerous “industry” studies describing the benefits of anesthesia, neglecting patient satisfaction, improved compliance etc, illustrates the bias of the White Paper and fails to measure up to criteria necessary to establish evidence based guidelines.
It is up to the anesthesia professions to respond to these biased reports masquerading as “findings” and “evidence based guidelines”. We must make sure the rest of the story is told by us, our patients and the physicans that value the services we provide for the gastroenterology procedures.
Dennis Gundersen, CRNA
As a subcontractor of CRNA service to companies that contract anesthesia services to GI practices, I am gaining first hand experience in anesthesia bundling . Recently one of the new GI practices terminated a contract after only four months of service. The primary motivation behind this questionably ethical move was a prominent payors negotiation, which enhanced the GI practice’s facility fee in exchange for the bundling of anesthesia services.
Some Back Story – This particular Payor has spent the past year refusing to pay for anesthesia services without pre-authorization, delaying or denying payments and in general discouraging the administration of propofol by qualified anesthesia professionals. Bundling is the next hoop to be added by this Payor.
Bundling occurs when a Payor negotiates an all inclusive fee to cover expenses related to a particular procedure, known as a facility fee. This negotiated bundle shifts the propofol decision directly to the GI practice. Now the GI practice determines which of their patients (or physicians) warrants the use of an anesthesia provider and propofol.
Some may argue this removes the “middle man” anesthesia services companies and improves efficiency. Or does it simply shift the “middle man” to the GI practice? This particular practice believes they will avoid any “company model” issues because they will not be charging separately for anesthesia services, and therefore not profiting from the anesthesia provider’s services.
Really ? – Lets drill down a bit at this argument. I don’t have access to any actual numbers so I will invent some to illustrate my point. Lets assign a facility fee of $350 before the bundling negotiation. After negotiations the bundling results in a $150 increase for a total of $500. in the practices facility fee. This particular practice often does 45 procedures a day. Under the old facility their fee was $350×45=$15,750. The bundled fee $500×45=$22,500 results in a gain of $6,750 per day in facility fees. $6750x 5days= $33,750 week, 33750x 52weeks = $1,755,000.00 annual increase in facility fees.
Obviously this does not take into account the additional cost of a CRNA. This practice was never an anesthesia provider in every room practice. Only one of the four rooms had a CRNA or MDA. The remainder were the conscious sedation model where the GI physician directed nurses to administer a concoction of drugs to get the patient through the procedure.
With bundling this practice intends to employ a CRNA(s) and offer one room with propofol. If we use a CRNA market rate of $1000 a day for a 10 hour day – $1000 x 5days x 52 weeks = $260,000.00 $1,755,000 – $260,000 = $1,495,00 difference to the GI practice. Now who is the “middle man” ?
Although anesthesia bundling will probably not go away in the near future, there are ways to prepare for a bundling proposal.
Dennis Gundersen, CRNA
Next time – Anesthesia, the Insidious Creep ?
Perspective: Are We in a Medical Education Bubble Market?
David A. Asch, M.D., M.B.A., Sean Nicholson, Ph.D., and Marko Vujicic, Ph.D.
N Engl J Med 2013; 369:1973-1975November 21, 2013DOI: 10.1056/NEJMp1310778
“…Are we in a bubble market in medical education? In medicine, students buy their education from medical schools and residency programs (which pay wages that are lower than the value of the work that residents provide in return). This education is transformed into skills and credentials that are then sold to patients in the form of services. So long as it is believed that patients, or whoever purchases health care on their behalf, will keep paying more and more for physicians’ services, students and trainees should be willing to pay more and more for the education that enables them to sell those services.
A simple measure of this market economy is the ratio of the average debt of a graduating student to the average annual income in the profession on entry into the workforce. There are more precise ways to measure the return on investment in medical education — for example, the net present value of the stream of cash flows out (for education) and in (for services). But that value isn’t very intuitive for most prospective students. In contrast, debt-to-income ratios reflect what students must borrow rather than what they must pay and, given whatever other assets they may have, how much in the hole they have to go. Thus, these ratios may better reflect how students actually feel about buying education…”
“…So, the amount that schools are able to charge students is inextricably linked to how much we pay doctors now and how much we plan to pay them in the future. Medical students can take on enormous debt only because the costs of that debt can be easily passed along to others down the road…”
“Some animals are more equal than others.”—Napoleon, Head Pig
in George Orwell’s Animal Farm
The Orwellian Inner Workings of American Anesthesia
Roosters and Ostriches, lying lions,
Dung heaps, mountains and molehills,
Sharks, snakes, pimps and other lowlife,
Worker bees and one mute hound who tells all
Anesthesiologists claim that the dramatic rise in anesthesia safety over the last half century is the direct result of larger numbers of doctors trained in anesthesia. Sounds sensible … at first.
Remember the classic banty rooster who crowed and crowed atop his fencepost until at last … up the sun rose in the eastern sky. Then he puffed out his tiny chest and strutted around the henhouse, declaring, “See there?! I did that! Me! Yeah, I made that sun come up!”
That little banty rooster demonstrated the logical fallacy Post hoc, ergo propter hoc, and so do the cockamamie doctors’ unscientific claims. One thing occurring after another in time does not prove causality.
Clearly, space age monitors are one major reason anesthesia is so much safer now, and the doctors know that. But they wish to fool the public, to pull the wool over our eyes. Their claim is typical self-serving cockadoodle bull puckey, runaway rampant hyperbole. I made that sun come up! Yeah, me!
Sadly, hogwash hollow boasts and blatant self-serving exaggeration have become the characteristic behaviors of certain anesthesiologists. Their claims do not stand up.
A president of the anesthesiologists’ association (A$A) once bragged to Congress — under oath — that he had personally performed over 300,000 anesthetics. Think about it — 30 anesthetics a day for 40 years? Poppycock! Patently ridiculous. Why this puffery, this transparent braggadocio? Why is the leadership of the A$A so threatened by the 44,000 CRNAs who are their professional competitors? Why are the foxes in charge of the henhouse?
Because “Some animals are more equal than others.”
THE DUNG HEAP
When Napoleon the Head Pig in George Orwell’s AnimalFarm lectured to his underlings in the barnyard, he did so from atop the dung heap. It made him look bigger, taller, more important. Perhaps to impress the politicians and hospital administrators is why American anesthesiologists construct these mountains of bovine excreta. They crow, “I’m better than a ‘anesthesia nurse’; I’m a doctor, so you should take my word for it. Honest!” Then, when confronted with the facts behind their overblown distortions, they stick their heads in the … sand.
Anesthesia is anesthesia: one specialty with a single standard of care but two classes of competing providers.
It’s scandalous, really. Ostriches, roosters, pigs — beyond the barnyard, the American anesthesia menagerie comprises a veritable zoo. (As Marge Simpson would say, “This witch hunt is becoming a circus!”) And the driving force that animates this menagerie is politics — politics beyond intramural competition — internecine warfare, a bitter battle for the bucks, pure and simple, waged on a distinctly un-level playing field. Why unlevel?
Why, because some animals are more equal than others, of course. If you trust the pig Napoleon’s word.
Really now, consider. Do you need a Rolls-Royce to drive to the market? No, a Ford will suffice. Do we rush to the Mayo Clinic each time we catch a cold? No, we don’t. We certainly don’t run to a doctor when we are perfectly HEALTHY! Most patients undergoing anesthesia are quite healthy. For healthy people to pay Rolls-Royce prices for routine anesthesia … this is waste, exorbitant waste that borders on fraud. And it’s widespread.
Lacking insight to the unique nature of anesthesia, patients, lawmakers, judges — even ostensibly well-informed hospital administrators — all too often these experts accept the doctors’ unsupported claims and are duped by this one simplistic unfounded presupposition: nurse good, doctor better. Not in anesthesia, not necessarily. Anesthesia is anesthesia. Of course we are safer, the doctors claim — we are more highly educated — it just makes sense. Really? Where’s the proof that the doctors are safer providers? Medical decisions should be made based on science, i.e. evidence, not on unfounded, unwarranted presuppositions. In fact CRNAs are proven to be just as safe.
A State Supreme court recently opined: “[It is] fundamentally reasonable that additional education and training would enable anesthesiologists administering or overseeing anesthesia to better protect patients….” Reasonable? Not really. They’ve had the wool pulled over their eyes. Those are wolves wearing sheepskins, your Honor!
Forget presumptions, where’s their proof?
Safer? Half the anesthesiologists in America are NOT board certified. Anesthesiologists are sued for negligence at SEVEN times the frequency of CRNAs. Seven times. That figure alone would suggest the doctors are in fact LESS safe than CRNAs. Nevertheless, monopolistic control of anesthesia departments is often handed to the doctors. They are given their perch from which to crow and crow and crow. Once the foxes are in charge of the henhouse, what do they do? — severely restrict practice privileges of CRNAs: no regional anesthesia, no central lines, etc. They don’t want CRNAs to appear to be what they are: clinically interchangeable gaspassers.
How do the doctors get away with this fraud? Because we let them. They have been given a monopoly, the power to make themselves look taller, more special, because some pigs are more equal than others.
MILKING THE SYSTEM
Competition is short-circuited by monopolies. Anesthesiologists cost 11 times more than CRNAs to train, and are paid at least 3 or 4 times as much as CRNAs. Anesthesia is anesthesia. Two types of provider, one high standard of care.
Yet, the A$A refuses to even open discussions of peaceful coexistence with the AANA unless nurse anesthetists first acknowledge that anesthesia is solely and exclusively the practice of medicine. You must first kiss my … ring, then we talk. And they then add, with a wink, “You don’t let the stewardess fly the airplane.” [An actual honest-to-goodness quote from A$A leadership. You can't make this stuff up.]
Where does one start? So much bovine excrement, so few shovels.
A little history. At the end of W.W.II there were fewer than 300 board certified anesthesiologists in America. In the 1950s health insurance companies like Blue Cross began to reimburse for anesthesia, and — Eureka! — a gold rush. Healthy patients! Nurses’ work! Big bucks! Doctors flocked to anesthesia, theretofore predominately a nursing specialty since the 1880s.
Eventually a new class of entrepreneurial American millionaire arose: the ‘supervising’ anesthesiologists. Less work, more lucrative and far safer than standing out on a night-time curbstone in the redlight district, soliciting passersby. A ‘stable’ of CRNAs perform the actual hands-on patient care; the superfluous so-called ‘supervising’ doc hogs the lion’s share of the bucks.
Some anesthesiologists ‘supervise’ from the golf course. Some, home in bed. They’re perfectly comfortable doing so because they know in their hearts, despite their loud public claims to the contrary, that CRNAs are just as capable as themselves clinically, and that patients are quite safe in their absence. Many ‘supervise’ in the surgery lounge all the day long, surfing the ‘net or snoozing with their feet up. (I worked with one who rarely even put on a scrub suit, sometimes for weeks at a stretch, so unneeded was he. Another ‘supervised’ from out of state.)
Why is so-called ‘supervision’ so popular among anesthesiologists? Unearned income of course. In a word, featherbedding. The drone collects, the worker bees work. It’s fraud all over again. And again, widespread.
While many valid comparisons can be drawn between anesthesia and aviation, that one above — ‘You don’t let the stewardess fly the airplane’ — that ain’t one of them. CRNAs do the same job, every bit as well as anesthesiologists, due to the unique nature of the specialty we share.
So, what is the anesthesiologists’ place? (Not just hidden in the lounge with the donuts, coffee and CNBC on TV.) As perioperative specialists, anesthesiologists can contribute expert advice in the management of the rare complicated patient — perhaps one in a thousand cases. Or, more realistically, one in ten thousand.
I’m reminded of a true life encounter between high level representatives of the A$A, the AANA, and a US Senator: [An actual encounter, paraphrased from first person reports.]
“What are you there for?” the Senator asked the doc. “The CRNAs appear to do the actual work.”
She said, “…Well, I’m there for when the shit hits the fan.” [Her exact words, verbatim. You cannot make this stuff up.]
Taken aback, the Senator asked her to elaborate.
The doctor said that when a problem arises, an anesthesiologist can help a nurse anesthetist to rescue the patient, whether it be managing a difficult airway, whatever.
“How often does this come up?” the Senator asked.
The doctor was vague.
The Senator persisted. “Every day?”
“Oh, no. Modern anesthesia is quite safe. Mortality’s only one in a quarter million.”
“Well? Every week? Once a month?”
The doctor admitted that at her own institution such a situation was likely to occur perhaps once every six months.
“So you are telling me,” the Senator concluded, “that we pay you three times as much as a CRNA so you can hang around and ‘be available’ twice a year? Incredible!”
MUTE HOUND SPEAKS VOLUMES
If doctors were in fact overall superior anesthetists, as they claim, would not someone over the last one hundred and twenty years been able to document that fact? Could it not be easily proven? Forget presumptions, where’s the proof?
The British medical system holds the key to refuting the American anesthesiologists’ characteristically overblown claims. Bear with me. The proof itself is the very lack of evidence.
In The Hound of the Baskervilles Sir Arthur Conan Doyle (himself a Scottish physician) had Sherlock Holmes catch the murderer because the man’s own dog did not bark, at the supposed intruder who committed the murder. No barking, therefore the hound knew the killer, and his silence indicted his master. Elementary, my dear Watson.
Now … Britain uses only physician anesthesia providers. Half the hospitals in America use only nurse anesthetists. So if the A$A argument of superiority held water, British anesthesia should be clearly and demonstrably better than America’s.
Does such a difference exist?
No. Nothing of the sort. There is no significant difference between American and British morbidity and mortality statistics in anesthesia. Anesthesia is extremely safe in both countries.
Anesthesiologists do not by mere virtue of any scholastic degree do safer anesthesia than CRNAs. That ole banty rooster never once made the sun come up. Hollow boasts, all that hogwash.
Anesthesia is Anesthesia
Two classes of provider in America, one uniformly high standard of care. CRNA or anesthesiologist, rich suburbs or poor boondocks, quality of care is high nationwide. No scientific study of anesthesia outcome has ever distinguished a significant difference in quality between the two types of providers.
Still, the doctors’ lies and distortions and poppycock go on.
And meanwhile, down in the depths of the American anesthesia workplace, hidden behind O.R. doors you will find those true beasts of burden, the worker bees the CRNAs. We CRNAs endure and prosper, delivering Cadillac anesthesia care at Chevrolet prices, doing the best job possible for our patients, while our stupervisors drive their Mercedes and lobby the gullible. CRNAs steadfastly fight the political battles we must fight, when you make your living by swimming with sharks.
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