Anesthesia Bundling and the CRNA

facts about bundlingAs 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 ?

2 thoughts on “Anesthesia Bundling and the CRNA

  1. I personally believe it’s more important to see bundling as a means to increase efficiency and accountability where before, there was little incentive to do so. This is especially in true for in-patient facilities.

    We know the ACA was just one of the many influences that set this model of reimbursement in motion, but consider this. Hospitals have always thrived on inefficiency, you could theorize that anesthesia has as well.

    When we look at the model that outpatient surgical facilities employ to minimize waste while increasing utilization and efficiencies in order to generate profits. From a shareholder perspective we begin to see a sustainable model of cost effective care provision.

    Inpatient facilities bill for operative room (time average rate in the US is 66/ min.) Anesthesia bills per unit of time. I understand this is an over simplification of those other important factors that must be considered, but there was never a real push to increase efficiency in those inpatient facilities, despite the committees.

    Payments are based on billed units of time and inpatient facility occupancies. I am aware of the different ways that payers (second and third parties) give a premium for minimal stays and such, but as we move forward reimbursements will depend on performance and better patient outcomes.

    Hospitals will now truly begin to look for the value of those services and products that increase safety, efficiencies, and staff utilization in ways they never did before. Everyone will be expected to perform to the most optimal level of competency. Surgeons, anesthesia providers, nurses, and all other important professionals and non professionals.

    Those of us that form the chain of great care we have come to expect in this nation will now be expected to perform in order for our employers to receive full reimbursements.

    We must find ways to increase the value and importance of our services to meet these goals. Your facilities will appreciate them.

    Providers and staff will now determine profitability and viability for those facilities in the very near future.

    I don’t see this as a threat to my profession. In fact I see this as an opportunity for our profession to prove its worth as we know it, cost effective provision of safe care. If receiving a fair “bundled” compensation while providing safe and efficient care is what we must do, then we must use it to improve our status. We don’t perform this job with the same expectations of pay our esteemed counterparts do. This is not a lifestyle salaried profession for us. For the most part we are fairly compensated. I truly believe pay will only improve during this cost effective value driven care initiative.

    Having a seat at the table on private bundling (out patient facilities) and one with our physician owned groups for those inpatient settings will keep us informed. Always stay informed!

    This fight will take place between providers of many different disciplines, but it only hurts our patients and our professions. It hurts those fragile working relationships . It hurts the trust we have in each other.

    As a capitalist I believe we will prevail. This will take time and commitment. Being informed is your only guarantee of being a part of the big picture moving forward. This is my two cents, and I am aware of the over simplification I have portrayed, but it should be considered.

    Best Regards,

  2. David,
    I believe “Having a seat at the table on private bundling ” is going to prove difficult. I believe the “capitalist” days for healthcare providers is quickly disappearing. Although I agree that staying informed is crucial, staying involved is vital. AANA and our State Associations can be excellent resources, assuming we members step up and become actively involved. Shared experiences, shared strategy and shared resources will be key as the Affordable Care Act unfolds.

    Dennis Gundersen, CRNA

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