The AANA Candidate Forum, an elusive but continually improving venue for Candidates and Members to interact, is up and running. Questions and Responses are coming in and you might be surprised with some of the Questions and Responses.
A glimpse at some of the questions:
What does the Vice President actually do ?
What happens if NBCRNA is replaced ?
What will you do if you lose ?
What sets you apart ?
Whom do you represent ?
Although you’ll catch glimpses of profiles and sound bites on Face Book or Listservers, the AANA Candidate Forum is the only “neutral site” sponsored by AANA that encourages direct interaction. Don’t let your questions remain unasked, become an informed voting member. You just might find it empowering !
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 ?