PPMIS Blog

ACO - Friend or Foe to Anesthesiology?

Deb Dietsch — Wed, 05 Oct 2011 18:59:00 GMT

ACO stands for Accountable Care Organization, but what does it really mean? According to a recent article in The Wall Street Journal (WSJ), The Model of the Future, “these entities propose to unite doctors and clinics or hospitals in groups that pool their resources with the goal of trimming spending while boosting the quality of care.”

On one hand the ACO seems like a friend

While in theory, the ACO seems like a helpful solution to healthcare reform. Many physicians remain skeptical--especially specialists. Many specialists including anesthesiology have concerns that the ACO model and its web of new regulations pose financial risks for providers. Although the intent of the formation of ACOs may be the unification of multiple healthcare providers around quality patient care delivery, the question of how the ACOs will truly function in the market remains unanswered. Pilot ACOs are up and running around the country to prove the concept.

In May 2011, the Center for Medicare and Medicaid Services (CMS) released a long-awaited rule that outlines the creation and operation of ACOs that will be eligible for potentially significant Medicare incentive payments in coming years. The Medicare ACO program, as defined by the Affordable Care Act (ACA), is slated to begin on January 1, 2012. For details, see our blog Medicare Proposes Accountable Care Organization ACO Guidelines.

But, on the other hand it could be a foe

What this new model means for anesthesia practices and the independent anesthesiologist remains to be seen. There were significant legal, financial, and risk concerns voiced during the comment period after the March 2011 issuance of the proposed rules. Many providers and medical groups saw significant financial risk in just starting up an ACO ($1.8MM estimate by CMS), in addition to the concerns over how they would capture the incentives for hitting the quality of care targets and measurements. What about the retrospective assignment of beneficiaries? Can hospitals clear the legal hurdles allowing them participation in the Shared Savings? Time is running out, and CMS has given no indication of the definitive answers to these questions.

What is the future for anesthesiologists?

It is now early 4^th quarter, and we are still waiting on the final ACO rules. Anesthesiologists have always been leaders (not late adopters) in process improvements and care coordination. Must they take a back seat or will they prevail as leaders once again? So, questions remain about the role of anesthesiologists with the pioneer model of ACOs suiting primary care-only. A multitude of events must take place NOW leading up to January 1, 2012.

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Bundled Payments of Joy for Anesthesia Services?

Steve Wirtz — Tue, 04 Oct 2011 16:52:00 GMT

In about two months the federal government's healthcare reform bill will celebrate its first birthday. The Patient Protection and Affordability Care Act has created a ripple effect of healthcare reform provisions that are dramatically affecting both the patients and healthcare provider. Anesthesiology practices are trying to figure out how they will have to change the way they deliver care, and how they will get paid. Both issues are still not settled.

Bundled Payments

Many reformers have believed that the solution to "fee for service" model that rewarded physicians for performing activities or services, would be to "bundle" payments around a particular health problem. This isn't new. Medicare proposed bundled payments for heart bypass surgery back in 1990. That demonstration project proved that bundled payments can work well. They were able to reduce costs, patients had better survival rates, and shorter hospital stays were part of the results. So, why hasn't there been a wider acceptance of these ideas, and adoption of the concept across a number of other specialties? There are a number of reasons, but the biggest one is---no one knows how to divide up the money in a fair and equitable manor. A second big issue is that there is no "standardized" patient, and hospitals are going to have those that blow their budgets with a peculiar health issue.

Enter the ACO

The Accountable Care Organization (ACO) is the latest rendition of the healthcare delivery team that will work cohesively to deliver great results at a lower cost. The rules around an ACO were announced in March 2011, and the final rule after a significant volume of questions were asked of CMS is due soon. The "Pioneer Model" of an ACO seems to have gained some traction for primary care providers, but many specialties and their associations (including anesthesiology) have voiced their concerns about the model.

From a story featured in Health Business Daily recently, a CMS official responded to feedback by health plans saying, "the Medicare Shared Savings Program (MSSP) needed some upgrades." He went on to state that the final rule would include the input and ideas from private health insurers. CMS administrator Dr. Donald Berwick has not given a specific date for release, but mentioned that release of a final rule to establish the ACO program for fee for service Medicare is "imminent." We will be covering this and other reimbursement issues in our upcoming issue of Vital Signs.

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5 Nightmare Issues for Anesthesia Practice Managers

Steve Wirtz — Wed, 28 Sep 2011 22:27:00 GMT

We are closing in quickly on the first anniversary of the passing of the Patient Protection & Affordability Care Act. Its effects on anesthesia practices are still unknown. Responding to tough economic times, new regulations, and an uncertain reimbursement future has left many practice managers and administrators wondering where they can legitimately cut more costs.

The fat is long gone, and their are no easy pickings left to cut-with more reimbursement cuts projected for 2012. If Medicare follows through with another 30 percent cut in physician payments, the ability to run a successful, innovative practice could become an elusive dream for many in practice today. Doing more with less is common, but how do practice managers continue to cut in light of increasing operating costs?

Juggling all of these high priority items every week does not add up to a restful night's sleep. In reality it may cause insomnia and a nightmare or two.

These are some of the sleep-disturbing issues that are top of mind:

Selecting a vendor and installing an EMR.
Determining eligibility for EMR meaningful use incentives.
Handling rising operating costs.
Finding and participating in an ACO (Accountable Care Organization).
Adapting to shared financial risk for the practice.

With the final rules on ACOs and the models for shared risk still unclear, there needs to be greater clarity to "produce better quality at a lower cost" mantra. The rules and guidelines are not clear. CMS is still saying that ACOs will be operational on January 1, 2012. Does that still hold?

And the previously listed concerns do not even include the compliance deadlines of ANSI 5010 and installation of new ICD-10 codes. IT infrastructures will need to accommodate and test for these vital issues to maintain the cash flow of the practice.

PPMIS is offering a compliance checklist and FAQ sheet to help you meet these goals. Download the ANSI 5010 fact sheet today!

Stay tuned in to our blog and our e-newsletter called Vital Signs.

Can Healthcare Providers Keep the Pace?

Deb Dietsch — Tue, 27 Sep 2011 19:53:00 GMT

With the threat of cost reductions and pay-for-performance initiatives looming, surveys indicate that many physicians are avoiding various tests and procedures. Is this wise? Aren’t physicians still liable for their patients care despite these financial incentives?

As the pressures mount, will physicians begin to undertreat patients by avoiding costly tests and procedures? Will the cost of malpractice insurance increase with more and more patients being undertreated and the threat of healthcare providers being sued?

Some medical professionals question whether patients should be more involved with the decision-making of their treatment. Would patients forego costly tests if they were well informed? Could physicians implement informed refusal? These are many of the questions behind controlling healthcare costs while maintaining quality patient care.

Like other disciplines, the anesthesia community is adopting quality of care standards to ensure patient safety. Putting patients to sleep ought to result in waking them up. Standards and checklists make this vital mission possible.

The Anesthesia Quality Institute provides anesthesiology with an unbiased, national and internal source of quality indicators and standards. The AQI was formed to lead the quality assurance initiative rather than having mandates for performance forces on its specialty by federal agencies, regulators, private payers, and surgical societies. Learn more by reading Why Is Quality of Care Vital in an Anesthesia Practice and 6 Key Measurements for AQI Reporting?

Will specialists be forced to join an Accountable Care Organization just to stay in practice? Physicians and hospitals are facing these challenges with impending payment threats and new payment models. Will healthcare providers sustain financial security in the days, weeks, and months ahead?

Medicare has already threatened to reduce payments in 2012 by 29.5%. While Center for Medicare and Medicaid Services (CMS) has proposed similar but smaller reductions in payment every year for the last nine years (as required by Medicare law), Congress has taken action each time to override the rate decrease. Fortunately, Medicare reimbursement rates for physicians have remained relatively static or actually increased in small increments from year to year.

Anesthesia practices beginning the 2012 budgeting process should not assume that "zero percent update" means that Medicare payment in 2012 will be equal to 2011 levels. Read more…Déjà vu: Medicare Payment Reductions Threaten Again.

Practice managers are also faced with meeting the federally mandated deadlines ANSI 5010, ICD-10 diagnostic codes, and EMR implementation. It seems the challenges just get bigger with each passing day. Bottom line healthcare providers are in business to make money. Can they maintain their practice while meeting the growing demands and obstacles?

Stay informed!

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Anticipating ANSI 5010: CMS Ramps Up!

Steve Wirtz — Tue, 27 Sep 2011 15:09:00 GMT

Many anesthesia practices are juggling resources and time lines getting ready for the HIPAA 5010 transaction set due to be implemented January 1, 2012. The Centers for Medicare and Medicaid Services (CMS), recently declared a 5010 Testing Week, and is also providing a series of "widgets" to help the industry prepare for the transition.

Almost right on the heels of this change, all medical practices will have to get ready for the changeover to the new ICD-10 diagnostic code set as well (2013). That change will move from the 13,000 codes being used today to a new set that will be over 140,000 separate codes for medical billing.

These are pretty compressed time frames, given the amount of work and testing needed to truly be ready. The federal government might be signaling that they won't be postponing their deadlines (which they did for ANSI 4010), and are lighting a fire under those entities that are behind in their testing. For a handy checklist for your practice, download our latest fact sheet. Failure to make the changes before the deadline exposes payers and providers to penalties.

What's a Practice Manager to do?

Is CMS also signaling that too many practices and the industry as a whole is not ready?

Will another delay be inevitable?

Are you willing to gamble?

That is a big gamble if your cash flow is interrupted, and your claim processing grinds to a halt. It would be a better move to keep on preparing, and keep a watchful eye on the CMS Web site (https://questions.cms.hhs.gov/app/answers/list/kw/5010).

Will your software vendor be ready?

For most providers who do not maintain their own IT systems, the work of writing the software code to support these changes is the responsibility of the software vendor.

PPMIS has been gearing up for ANSI 5010 since June 2010. We have included a list of questions to ask your software vendor in a previous blog post (http://info.ppmconnect.com).

Recent queries by MGMA and other organizations have found that as many as 50% of payers are not testing yet, and most of 2011 was to be spent testing their systems, with the software upgrades having been complete. The days of a system being partially driven by paper and software are drawing quickly to a close. Both electronic billing and electronic funds transfer mean that providers will have to have reliable software, and will be seeing fewer and fewer paper checks in the days ahead.

For more on this issue and others that affect your practice and revenue cycle management, subscribe to our new Vital Signs e-newsletter below.

To learn more about the Connect billing software, request a product demonstration.

6 Key Measurements for AQI Reporting

Deb Dietsch — Tue, 20 Sep 2011 15:55:00 GMT

In 1999, the Institute of Medicine declared medical errors were among the leading causes of death in the United States. In contrast, anesthesiology was cited as an area in which there have been impressive gains in safety and quality (as in the aviation industry). Our recently posted blog, 9 Ways the Anesthesia Practice Is Like Aviation, provides a great comparison.

The Anesthesia Quality Institute (AQI) was created to provide the specialty with an unbiased, national and internal source of quality indicators and standards. The AQI was formed to lead the quality assurance initiative rather than having mandates for performance forced on its specialty by federal agencies, regulators, private payers, and surgical societies. PQRI and P4P are two of these incentives.

The primary responsibility of the AQI is developing the National Anesthesia Clinical Outcomes Registry (NACOR). As defined by the AQI, “NACOR is a data warehouse that will eventually capture the 40 million anesthetics (a very rough estimate) and millions of pain clinic procedures performed each year by anesthesiologists in the United States. The growth of NACOR requires close collaboration between the AQI, individual providers, and healthcare information technology vendors. The focus of participation in the AQI is the ongoing contribution of case-specific data to the NACOR. AQI’s program recognizes the anesthesia practices, hospitals, and information technology vendors that have succeeded in this effort.”

Measurements

The main goal of AQI reporting is to aggregate the data from contributing anesthesia practices so that the practices can benchmark their care relative to peer groups. This data will be used for research into anesthesia risk factors, comparative effectiveness, and identification of best practices, which can then be used by ASA to develop quality measures, practice standards, and guidelines.

Quality management is vital in AQI reporting and ultimately provides the indicators for improving patient outcomes and business efficiency, and meeting regulatory requirements.

Administrative data
AIMS data
Hospital EHR data
Quality and outcome data – your group and other specialties
Patient satisfaction information
Anecdotes

Where can you pull the data you need? Your data is available from various sources:

The federal government (CMS – Medicare data and AHRQ – CAHPS data)
Private insurance companies
The Joint Commission
The ABA
Your IT vendors

Your IT vendor will play a major role is collecting your data. To participate as an AQI Preferred Vendor, the healthcare information technology company must have a product that actively meets AQI requirements for data transfer. The requirements in meeting the criteria include breadth and depth of data submitted, data formatted in accordance with the AQI-defined schema, data transfer to AQI in a safe and secure fashion, timeliness of data submission, and staying up to date with AQI changes.

AQI Preferred Vendor Status

PPMIS has met criteria deeming it a preferred vendor with the Anesthesia Quality Institute (AQI). This status is vital to PPMIS’ commitment to providing its clients with the tools for ensuring the best possible service to their patients. PPMIS clients can use the AQI reporting feature in our PPM: Connect and PPM Plus billing software for benchmarking the quality of care they provide.

With the Preferred Vendor status, PPMIS is posted on the AQI Preferred Vendor page at www.aqihq.org/AQIVendors.aspx.

PPMIS is a medical billing software and services company, specializing in anesthesia. Founded by anesthesiologist for the anesthesia community, PPMIS delivers a streamlined claim processing system.

Get paid faster because of fewer claim rejections and our comprehensive error checking and concurrency validations.

Contact PPMIS for a product demonstration.

Dodging Proton Bullets and the Lighter Side of Anesthesiology

Steve Wirtz — Thu, 15 Sep 2011 15:11:00 GMT

Being a practicing anesthesiologist has a long list of hazards these days, and the list is growing. Just going to work every morning has some risks, but think briefly on the environmental risks alone for professionals in the anesthesia field today.

Walking into your OR can get you some nice exposure to:

Radiation to your thyroid,eyes, and other vital organs
Trace anesthetic gases
Pharmaceuticals used in IV pumps

The pressure and professional demands can also lead to substance abuse, and even suicide. Are we having fun yet? And, we haven't even started to list all of the business "threats" (healthcare reform, ACOs, ICD-10 codes, EMRs, and others) that did not exist even three to five years ago. You can be easily left scratching your head from time to time asking, "why did I get into this?"

Taking a Whiff of the Nitrous?

So, a cannibal comes to see an anesthesiologist, and complains that he is bored and depressed. After a few minutes, the anesthesiologist says "the problem with you is that you are fed up with people."

Sound familiar?

That list might include on a given day for you:

A surgeon?
Your wife??
A colleague?
A patient?
A practice manager?

Some days if you did not laugh, you would cry--or maybe a little of both on a long day. A group of Minnesota-based CRNAs put some new words to an old song (http://www.youtube.com/watch?v=WOrjcLJ2IE0).

Yes, waking up is hard to do, and the Laryngospasms have their own Web site where they convert some other tunes, too.

Have you heard the one about two anesthesiologists talking at a bar?

To learn more about updating news about healthcare reform and issues affecting anesthesiology, subscribe to Vital Signs, our quarterly e-newsletter.

Anesthesiology and the Ambulatory Setting

Steve Wirtz — Tue, 13 Sep 2011 17:19:00 GMT

Medical advances and improved anesthesia practice techniques are moving some surgeries outside of the traditional hospital setting-and fast. Almost one-half of all surgeries are now being done in an outpatient facility or medical office. Patients are voting with their feet, and they like the flexibilty, comfort, and convenience of having a procedure done in an office setting, often with a return home later that same day. Some of the same techniques used in a hospital OR or ambulatory care centers are now being used in a medical office.

They can include:

General anesthesia, which involves the total loss of consciousness
Monitored anesthesia, during which a patient receives medications that alleviate pain and make the patient drowsy
Regional anesthesia, which can include spinal blocks, epidural blocks, and extremity blocks
Local anesthesia, which involves pain management or numbness to a small area of the body

In addition to the patient convenience, flexibility, and comfort, some experts say you can add additional safety to the list of reasons why venues outside of a hospital are increasingly preferred. Healthcare is already a high-risk business, but hospitals are becoming known as places where infections can be acquired, and complications due to medical errors can occur. The Institute of Medicine Report in 1999 (" To Err is Human") tabulated those human costs (see previous post - 9 Ways the Anesthesia Practice Is Like Aviation).

Riskier than Flying?

A recent report from the newly appointed envoy for patient safety at the World Health Organization (WHO) stated that said,"millions of people die each year from medical errors and infections linked to health care and going into a hospital is far riskier than flying." (http://www.reuters.com/article/2011/07/21/us-safety-idUSTRE76K45R20110721

He went on to say,"Your chances of dying due to an error in health care would be 1 in 300. This compared with a risk of dying in an air crash of about 1 in 10 million passengers."

Some of the health care reform measures in the new Patient Protection and Affordability Care Act are designed to improve quality and patient care, but healthcare delivery has a long way to go. Anesthesiology as a specialty has set up the Anesthesia Quality Institute (AQI), to gather data that can improve the profession.

To learn more, stay in touch through our blog and RSS feed. Subscribe to our e-newsletter, Vital Signs.

To Prepare or Not to Prepare for ICD-10

Deb Dietsch — Thu, 08 Sep 2011 16:52:00 GMT

As the deadline for ICD-10 implementation nears, it’s amazing the number of providers who are both unaware of this transition and not preparing for it. Unfortunately, the transition from ICD-9 codes to ICD-10 codes is not optional. All healthcare providers, hospitals, and software vendors who use CPT codes must transition to the new version on October 1, 2013. Many providers believe this deadline may slide due to so many other changes with healthcare reform.

Is it too much at one time?

The deadlines include:

ANSI 5010 on January 1, 2012

ICD-10 on October 1, 2013

EMR implementation in 2014

While these deadlines are federally mandated, the most significant one is the EMR implementation. It is not only costly, but penalties are likely to be levied on entities dealing with patient healthcare data unable to upgrade themselves to electronic record technologies in 2015 and beyond.

The time to prepare is now!

It doesn’t look like healthcare changes will be slowing down anytime soon.

PPMIS has addressed many of these issues on its blog. The most recent one is The EMR and Anesthesiology. Learn more.

Read our related articles:

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The Final ACO Rules & Anesthesia Care Teams

Deb Dietsch — Wed, 07 Sep 2011 15:50:00 GMT

Labor Day is behind us, and after a long, hot summer of the federal government getting an earful about Accountable Care Organizations (ACOs), we can expect the final regulations pretty soon. The Secretary of Human Health Services has to get this concept up and running by January 1, 2012 according to the statute. So, the questions remain about the role of specialists in general, and anesthesiology in particular, with the pioneer model of ACOs suiting primary care-only. A lot has to happen between Labor Day and the new year.

So What Now?

What this new model means for anesthesia practices and the independent anesthesiologist remains to be seen. There were significant legal, financial, and risk concerns voiced during the comment period after the March 2011 issuance of the proposed rules. Many providers and medical groups saw significant financial risk in just starting up an ACO ($1.8MM estimate by Centers for Medicare & Medicaid Services [CMS]), in addition to the concerns over how they would capture the incentives for hitting the quality of care targets and measurements. What about the retrospective assignment of beneficiaries? Can hospitals clear the legal hurdles allowing them participation in the Shared Savings? Time is running out, and CMS has given no indication of the definitive answers to these questions.

Anesthesiologists as Leaders in ACOs

As hospitals, Ambulatory Surgery Centers (ASCs), and provider groups formulate the transparent partnerships the new rules demand to participate in an ACO, anesthesia is the integral linchpin to achieve the goals of this new concept. Anesthesiology is the central cog in the wheel in the initial assessment and further management of a patient's care through most procedural, surgical, and obstetrical areas of both acute and ambulatory settings.

In addition, the specialty is a champion of patient safety, and has been gathering great data through the AQI (Anesthesia Quality Institute) for years. Recent professional editorials have also talked about creating a "surgical home" or Accountable Anesthesia Organization as concepts where anesthesiologists can lead a team dedicated to the goals of an ACO. A recent article published in the Journal of the American Medical Association addressed the potential mistakes in implementing ACOs, particularly in failing to recognize interdependencies (http://jama.ama-assn.org/content/306/7/758.full)

As we get further into September, we will cover the CMS response on the final rules for ACOs when they are made available. You can stay informed by subscribing to our e-newsletter called Vital Signs.

The EMR and Anesthesiology

Steve Wirtz — Tue, 30 Aug 2011 16:40:00 GMT

Have you ever found yourself loving new technology, and hating it at the same time? The promise is always a brave new world, and improved patient care to boot. Anesthesia care teams have always looked to new tech as the way to enhance patient safety, and move ahead while reducing the dwindling numbers of medical errors that are preventable in the OR and perioperative environment.

But technology can also give you a headache, especially when there is a steep learning curve, and you are used to gliding through your workday. A new smartphone looks great in a showroom or on a commercial, but someone has to input the numbers and data--and work through its quirks. Whether the nature of your practice is pain management, you are contracted to hospitals or ASCs, or a blend of both, the questions are always:

What is the ROI for the practice?
How quickly can an EHR be implemented,trained, and integrated?
What are the interruptions and work flow breaks going to cost me?

Without those answers, purchasing one can be a costly mistake that can pull at the business seams of your busy practice. No shortcuts can be taken in the review process for a system or product. You must invest the time (and money) up front to screen medical & billing software vendors. Look at the commitment like you would a marriage, and look ahead for the type of solid support and service you will need if you encounter a rough patch during the installation or training.

The Questions to Ask

Practice managers need the time and hands-on experience to know how a product will perform during the normal day of a medical practice. Here are some questions you may want to ask in advance:

Does the software meet the meaningful use & certification criteria?
Is your practice eligible for a subsidy or grant that could help you with costs?
Will you be able to interview practices that have already installed this product?
Have you mapped out how the system will be used? Today and in the future? (Meet the 2014 deadline?)
Have you also budgeted for upgrades? Interfaces with existing software?
Do you want other features like patient portals? Secure connections with tablet computers? Mobile?
Is everyone in your practice on board with the change?
Will you be ready for new compliance standards? (ANSI 5010 and ICD-10)
Does your vendor have preferred status with the Anesthesia Quality Institute (AQI)?

These are some questions to get you thinking, and starting off on the right foot towards success. To learn more on this subject, and other areas critical to good practice management, you may want to subscribe to our new e-newsletter called Vital Signs.

Does Your Revenue Cycle Have a Flat?

Steve Wirtz — Wed, 24 Aug 2011 14:38:00 GMT

Every office needs to periodically re-examine the revenue process going on in their medical billing system. Anesthesiology is certainly no different, in fact it is a harder specialty to bill for with all of the additional codes that have to be correct. It is estimated that Medicare denies 11% of all claims, and pays more on the 65% that are re-submitted after denial. There has never been more pressure to make sure your medical billing software works well, and claims are submitted accurately the first time. If you are using a medical billing service, you are still on the hook for their accuracy.

So what can you do to ensure that your providers are being properly reimbursed for the services they deliver to your patients? Having a checklist, along with some data-driven dashboards can save you money and headaches in the long run.

Your checklist might include:

Accounts receivables? (% over 90 days?)
Claims denials/rejections (Over 45 days? Harder to collect!)
Patient collection issues? (How many are going to collections?)
Payer issues? (Correct codes? Right modifiers in combination?)
Net revenues/cash flow?
Unusual expenses (EMR purchase and other equipment?)

Armed with this checklist, FierceHealth has four other tips for practice managers to get them through the recession. http://www.fiercepracticemanagement.com/story/4-tips-strong-post-recession-practice/2011-08-10

Stay informed

To stay up with future installments of business tips for your practice, sign up for our e-newsletter called Vital Signs. Our latest issue covers the pending reductions in Medicare payments for physicians in 2012.

Future issues will delve into the real-world changes that Accountable Care Organizations (ACOs) and new reimbursement models will have on anesthesiology and other specialty practices. A potential "surgical home" model for anesthesiology might make a big difference in putting the experience of the specialty at the head of a team, using years of patient safety data to work for patients. Read more about measuring the quality of care from our Blog article "Why Is Quality of Care Vital in an Anesthesia Practice?"

Thinking about operating your revenue cycle management in a paperless office. Read our blog:

The Triple Threat Facing Anesthesiology Practices

Steve Wirtz — Tue, 23 Aug 2011 18:47:00 GMT

Remember when a triple threat used to be a football term? Running, passing, or the pitch will return to sports pages very soon as fall approaches, but running a successful medical practice faces a new "triple threat," with the clock ticking down on all of them every day.

Medical practices all over the U.S. are scrambling to install, test, and fully implement EMRs/EHRs before the 2014 deadline. The federal government meaningful use requirements were designed to give physicians the first carrot (and stick) towards information sharing. The investment of nearly $20BB by the feds towards "meaningful use" of EHRs was part of the Health Information Technology for Economic and Clinical Health (HITECH) Act. That acronym is a mouthful, but the basic intent is to put the U.S. physician population into position to share clinical information about patients with hospitals and each other through Health Information Exchanges (HIEs), with the goal of improving patient care through a timely electronic data exchange in real time.

Where Do We Stand Today?

With only an estimated 7 to 10% of U.S. office-based physicians using a fully functioning system today, there is a lot of growth (and pain) ahead of us still. But the high cost of an EMR ($21,000 per physician), combined with a small return on investment are main reasons why many physicians are slow to adopt systems. And how about specialties like anesthesiology? Many of which are using a hospitals' EHR/EMR during a surgical procedure, but really don't have a need back in their own office--if they have one. Where some EMR functions such as billing and note capture financially benefit physicians, most of the return on investment goes to health plans in many cases. The factors of anesthesia billing require specialized software that is time-based and specific, and one size does not fit all. Only in cases where a hospital, grant, or government entity subsidizes it can some medical practices afford it. With the deadline in 2014, most practices have time to catch up.

Your Coding Issue

Next on the countdown is the introduction of a whole new set of medical codes called ICD-10. It is the expansion from the 13,000 codes of version ICD-9, to over 150,000 codes contained in ICD-10. This new set of codes has been in place in Europe, and is finally finding its way to the U.S. medical system. This new requirement will be installed in 2013. For more on this subject, read our previous blog post "Why Is the United States (Finally) Moving to ICD-10?"

Your Cashflow Issue

And finally, there is the issue that could shut down your cash flow and reimbursement cold in 2012. ANSI 5010 compliance will be necessary for all practices and billing companies on January 1, 2012. Unlike ANSI 4010, the deadline will apparently not be moved. Learn more from CMS about the upcoming week slated for testing here (http://www.cms.gov/Versions5010andD0/Downloads/5010_National_Testing_Week_7-12-2011.pdf)

You can also visit our previous posts on what you can do to prepare your practice at the PPMIS Blog.

You and your practice administrators can stay in touch with these issues by subscribing to our e-newsletter, Vital Signs, published quarterly.

Propofol Shortage and Anesthesiologists

Deb Dietsch — Thu, 18 Aug 2011 14:32:00 GMT

Guest Blog: Posted by Jim Johnson, VP Sales, Preferred Physicians Medical (www.ppmrrg.com)

The propofol shortage began in 2009 when two manufacturers halted distribution and recalled several lots of propofol products because of quality problems. In July, 2009, Teva Pharmaceuticals (Teva) recalled five lots of its propofol after 20 patients who received the drug had adverse reactions with flu-like symptoms. Teva discovered high levels of endotoxin, apparently linked to contaminated egg yolk used in the manufacturing process, in vials of the sedative pulled from the affected lots. In November, 2009, Teva recalled eight more lots as a precaution and in May, 2010, Teva informed the FDA it had halted all manufacturing of propofol and wouldn't resume production or distribution of the drug.

Drug shortages can have a profound effect on patient care since they limit the treatment options available to health care practitioners and patients. As well, anesthesiologists face significant potential liability exposure from the risks associated with misusing a product. Anesthesiologists should scrupulously adhere to label instructions for the use of any drug, even during a time of shortage; and, this is especially important for sterile, injectable products such as propofol. The FDA has received numerous reports of adverse events resulting from multiple entries into single-use vials of propofol to obtain multiple doses, contrary to label recommendations. This dangerous practice has resulted in life threatening illnesses due to contamination.

To read more about how the propofol shortage continues to create patient safety concerns and risks for anesthesia providers, download our anesthesia specific risk management newsletter discussing this issue in greater depth.

Deja vu: Medicare Payment Reductions Threaten Again

Deb Dietsch — Wed, 17 Aug 2011 17:52:00 GMT

Brenda Morrow, HealthCare Reimbursement InSIGHT

Medicare Part payments for services provided in 2012 will be 29.5% lower than in 2011 if provisions governing updates to the Medicare Physician Fee Schedule (MPFS) are implemented as proposed by the Centers for Medicare and Medicaid Services (CMS) earlier this year.

While CMS has proposed similar but smaller reductions in payment every year for the last nine years (as required by Medicare law), Congress has taken action each time to override the rate decrease. As a result, Medicare reimbursement rates for physicians have remained relatively static or actually increased in small increments from year to year. Next year should be no exception: the President's budget for 2012 specifies a zero percent update that would override the slated 29.5% decrease, and ongoing deficit reduction talks contain provisions that address the issue that has created the annual payment reduction issue (known as the "sustainable growth rate," or SGR). In addition, a proposal put forth by a Senate committee as this article is being written would eliminate the SGR over ten years and provide a fix to this particular uncertainty permanently.¹

However, a lot can happen between now and January 1, 2012, and we may not know until then where the MPFS update will actually land. If past history is any indication, the 29.5% decrease will probably not come to fruition. At this point, it may be realistic to anticipate that the President's proposed zero percent update will become the alternative solution, although the outcome of deficit reduction talks may change that as well.

Anesthesia practices beginning the 2012 budgeting process should not assume that "zero percent update" means that Medicare payment in 2012 will be equal to 2011 levels, however. You may recall that a "zero percent update" was applied to the MPFS in the first five months of 2010, but anesthesia conversion factors (CFs) were in fact higher or lower than 2009 CFs, depending on geographic location.

The same phenomenon should be expected to occur in 2012 for a number of reasons. While the "zero percent update" would apply to the basic anesthesia conversion factor (leaving it unchanged from 2011), there are several modifying factors that may also apply to the basic CF that would cause the final geographically adjusted rates to fluctuate from 2011 levels. These adjustments are outlined by CMS in a proposed rule discussing changes to Part B payment and policies, which was published in the Federal Register on July 19, 2011.²

The proposed change with perhaps the biggest impact is an adjustment to geographic practice cost indices (GPCIs), which are applied to the basic anesthesia conversion factor to compensate for regional differences in physician work costs, practice expense and malpractice expense. The sum of the physician work, practice expense and malpractice expense GPCIs for each geographic locality defined by CMS is collectively known as that region's Geographic Adjustment Factor (GAF). The application of GPCIs to the basic anesthesia CF is the main reason why Medicare anesthesia reimbursement rates are different from place to place.

For each time-based anesthesia procedure billed to Medicare, the Part B contractors processing the claim add the anesthesia Relative Value Units (RVUs) and fractional 15-minute time units representing anesthesia time reported for the case. That sum is multiplied by a geographically-adjusted CF (the basic anesthesia CF adjusted by the GPCIs for each region). The resulting allowable is the case rate, which applies to an anesthesiologist who personally performed the case, or is divided equally between a medically-directing anesthesiologist and a medically-directed CRNA.

CMS is required to review and update GPCIs as needed every three years, and an update will occur in 2012. As proposed, the impact varies widely from place to place. For example, providers in Puerto Rico could see a 14.84% reduction in the CF in their region attributable to changes in the GPCIs for that region, despite a "zero percent update" to the basic conversion factor. On the high end, providers in Seattle could see a 3.06% increase for the same reason.

CMS lists the proposed variations in GAFs for each Medicare Part B payment locality in Addendum D to the proposed rule, which is reprinted on the next page. Addendum D can be viewed on the CMS Web site at http://www.cms.gov/PhysicianFeeSched/PFSFRN/. In the list of Regulations in the middle of the page, do the following:

Click on CMS-1524-P, and then scroll down to the Downloads section.
Select CY2012 PFS Addenda, and then open the file referencing Addenda D and E.

The MPFS proposed rule is open for comments from the public through 5:00 P.M. (EDT) on August 30, 2011. Instructions for submitting comments can be found on the first page of the proposed rule, which can be viewed at http://www.gpo.gov/fdsys/pkg/FR-2011-07-19/pdf/2011-16972.pdf. CMS will consider comments after that time and is expected to publish the final rule affecting 2012 dates of service in November 2011.

__________________________________________________________________________________
¹ Kaiser Health News, July 19, 2011. "Gang of Six Plan to Cut Deficit by $3.7 T Includes Doc Fix, Gets Boost from Obama"; http://www.kaiserhealthnews.org/Daily-Reports/2011/July/19/pres-and-new-plan.aspx. Accessed July 19, 2011.

² Centers for Medicare and Medicaid Services. "Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012." Federal Register Vol 76, No 138. July 19, 2011. http://www.gpo.gov/fdsys/pkg/FR-2011-07-19/pdf/2011-16972.pdf. Accessed July 19, 2011.

ANSI 5010 Deadline: Will You Be Ready?

Deb Dietsch — Wed, 10 Aug 2011 15:48:00 GMT

Whether we want to admit it, January 01, 2012 is right around the corner. You might ask "why is this date more important than any other January 01?" Because this date is the deadline for ANSI 5010.

What is ANSI 5010? ANSI 5010 is the new version of HIPAA transaction standards that regulates the electronic transmission of transactions. ANSI 5010 replaces the existing standards for 4010A1.

Your preparedness will determine the impact this mandate has on your cash flow if you and your clearinghouse are not submitting electronic claims in 5010 format. Centers of Medicare and Medicaid Services (CMS) has made it perfectly clear that there will be no extensions to this date as was done with the ANSI 4010 conversion.

Anesthesiology practices are not different from other specialties when it comes to being properly prepared for the ANSI 5010 deadline.

It's not too late to start working with your software vendor to ensure you make this deadline. Not sure where to start?

Take these steps to get your practice on schedule--and prepared:

Verify that you software vendor is ready.
Ensure billing provider address matches PECOS and NPPES.
Remove P.O. boxes from billing provider address (P.O. boxes are allowed for Remit to address).
Verify 9-digit ZIP codes are entered for your billing provider and facilities.
Be prepared for possible claims disruption--even after mandated date.
Pay attention to ANSI 5010 information from payers, and your vendor regarding readiness.

Questions to Ask Your Software Vendor

In preparation for this mandate, CMS recommends that providers ask their software vendors the following questions about ANSI 5010.

Will I have to pay to have my interfaces upgraded to ANSI 5010?
Will my software vendor create human-readable reports for the new ANSI formatted reports 999 and 277CA?
When will I receive the new ANSI 5010 format?
Will I need to re-enroll with my clearinghouse and payers to send ANSI 5010?
Will the conversion to ANSI 5010 really happen January 01, 2012, or will it be delayed as ANSI 4010 was?
If I receive information from my specific payers or clearinghouses, should I forward that information to my software vendor?
Will my software vendor offer training on the ANSI 5010 changes?

For additional help, download our Frequently Asked Questions about ANSI 5010 to find out how PPMIS answers these questions for its clients.

Since June 2010, PPMIS has been diligently preparing for the ANSI 5010 implementation. PPMIS is able to relieve most or all of the concerns of its clients. Because we are prepared, our clients will be prepared and will not experience a lag in electronic transaction processing.

PPMIS was the first software vendor to have clients in production with Blue Cross Blue Shield of Kansas (BCBS KS) ASK. Currently, we have multiple clients submitting electronic transactions in 5010 format.

Stay informed about ANSI 5010 and other medical billing issues, subscribe to the PPMIS blog.

The Future of Anesthesiology is Walking

Steve Wirtz — Tue, 09 Aug 2011 16:46:00 GMT

Somewhere in one of the nations medical centers there is a young medical student walking the halls of a hospital with a decision to make. This young man or woman has gotten excellent grades, is developing a great set of clinical skills, has high hopes for the future, and can make a fantastic contribution to the medical profession that he or she has been dreaming about since high school-or even grade school.

Competition has been keen, but he or she has risen to the top 5% of their class, a mentor has advised that this talented individual has lots of options in choosing a specialty. Nephrology, cardiology, and anesthesiology are frequently discussed as possibilities. It's a big decision to make. Choosing a medical practice or specialty that will only consume every waking minute of this person's work life--for the next thirty years or so.

He or she loves patient care and interactions, and has found the time spent in the operating room to be both exciting and fulfilling. Surgeon or Anesthesiologist?

One of the staff anesthesiologists actually spent some time talking to the lowly medical students after one procedure they observed a few months ago. He talked about his residency, the fellowship at Duke after that, and what his day was like during a typical week. It sounds like it is a path that would be both challenging and rewarding.

The Future is Here

This medical student, and many others are going to have to choose anesthesiology as a specialty in order to infuse the profession with the talent, drive, and innovation that has been its backbone for decades.

The numbers of residency slots have not gone up, so the quality of people that fill them is all the more important. In the early 2000s, there was a country-wide shortage of trained anesthesiologists, and it could happen again. (http://www.beckersasc.com/anesthesia/study-dramatic-shortage-of-anesthesiologists-surplus-of-nurse-anesthetists-projected-by-2020.html) Dr. Mark Warner, head of American Society of Anesthesiology said, "The projected shortage of anesthesiologists suggests that this country will soon face a gap in anesthesiology services that is just as important to American's health as the projected gap for primary care services."

So a lot depends on the career choice of a talented group of medical students in our country. Will they walk toward the years of arduous training it takes with demands of perfection on every case?

Will they walk away and take an easier road?

How Well Do You Know Plus Billing Software?

Deb Dietsch — Wed, 03 Aug 2011 16:41:00 GMT

Functionality, usability, increased productivity are all terms we hear to describe software. Claim scrubs, EDC, EMC, ERA are terms you hear in medical billing systems to ensure HIPAA compliant claim processing.

Detail reporting, centralized account management, error checking, concurrency, and ERA processing are terms that identify the Plus Billing system.

But are you effectively using your billing software to its highest capabilities?

Whether you’ve been using the Plus Billing System for a while or are new to it, PPMIS wants to make sure you are aware of various features so that you fully utilize your billing software.

Did you know?

The Plus Billing software is very flexible and can easily work for most specialties. Currently, it is used to bill over 40 different specialties, besides anesthesia and pain management.
If your SQL Server database is smaller than 10 GB, you can use Microsoft® SQL Server® 2008 Express edition, which is FREE from Microsoft, instead of purchasing full editions of SQL Server. SQL Server 2008 Express edition has a few other limitations, but you could save money by using this version of SQL Server.
All applications are fully documented in a Help System. You can get a full description and ‘How To’ instructions of the various dialog boxes (screens) from anywhere in a PPM Plus ®application by simply pressing the F1 button. You can also access the Help System and the Release Notes for each software version from the Help menu. Use this documentation as a great resource when you are unsure why a particular field or dialog box is used or simply need to know how to perform a task, for example, Creating Charge Batches.
We have created over 135 Electronic Data Capture (EDC) interfaces from hospital system extracts, mobile charge capture systems, and Electronic Medical Record (EMR) systems. These interfaces are huge time savers for an office and are more accurate than manually entering charges.
You can hide the details of the service fee lines on an account by right-clicking on the Account Detail, and then selecting Collapse from the shortcut menu. This handy feature makes viewing an account much easier when the account has multiple service fee lines or a lot of activity (claims, payments, adjustments, and other transactions) on each service fee line.

For these tips and more, subscribe to Vital Signs, the PPMIS quarterly e-newsletter.

7 Questions to Ask Your Software Vendor about ANSI 5010

Deb Dietsch — Tue, 02 Aug 2011 19:49:00 GMT

As the deadline for ANSI 5010 nears, it’s becoming more and more important that you know what ANSI 5010 means to you:

What is ANSI 5010? ANSI 5010 is the new version of HIPAA transaction standards that regulates the electronic transmission of transactions. ANSI 5010 replaces the existing standards for 4010A1.

When does ANSI 5010 go into effect? January 01, 2012 is the mandated date. Centers of Medicare and Medicaid Services (CMS) has made it perfectly clear that there will be no extensions to this date as was done with the ANSI 4010 conversion.

Why is this date important to you? Your cash flow could be significantly impacted if you and your clearinghouse are not submitting in 5010 format.

Questions to Ask Your Software Vendor

In preparation for this mandate, CMS recommends that providers ask their software vendors the following questions about ANSI 5010.

Will I have to pay to have my interfaces upgraded to ANSI 5010?
Will my software vendor create human-readable reports for the new ANSI formatted reports 999 and 277CA?
When will I receive the new ANSI 5010 format?
Will I need to re-enroll with my clearinghouse and payers to send ANSI 5010?
Will the conversion to ANSI 5010 really happen January 01, 2012, or will it be delayed as ANSI 4010 was?
If I receive information from my specific payers or clearinghouses, should I forward that information to my software vendor?
Will my software vendor offer training on the ANSI 5010 changes?

Download our Frequently Asked Questions about ANSI 5010 to find out how PPMIS answers these questions for its clients.

What can anesthesia practices do now to prepare for 5010?

Anesthesiology practices are not different from other specialties when it comes to being properly prepared for the ANSI 5010 deadline.

Take these steps to get your practice on schedule--and prepared:

Ensure billing provider address matches PECOS and NPPES.
Remove P.O. boxes from billing provider address (P.O. boxes are allowed for Remit to address).
Verify 9-digit ZIP codes are entered for your billing provider and facilities.
Be prepared for possible claims disruption--even after mandated date.
Pay attention to ANSI 5010 information from payers, and your vendor regarding readiness.

To ensure that you are staying up-to-date with ANSI 5010, subscribe to the PPMIS blog.

Solid Cloud Strategies for Anesthesia Billing

Steve Wirtz — Thu, 28 Jul 2011 16:42:00 GMT

With cloud computing and storage becoming more popular and reliable, medical offices and anesthesia practices are looking for new methods to integrate systems and potentially lower their operational costs. Software as a Service (SaaS) and virtual server storage are convenient and efficient methods of handling day-to-day business processes.

There are some risks with cloud computing, but many of those risks are being offset with some strong business reasons for making the move, with convenience and $$ savings topping the list.

Whose cloud am I on?

The cloud really refers to the Internet. Cloud computing is a system and method where software programs and applications are used and accessed via an Internet connection.

If your medical billing software is a SaaS model, your practice manager or medical billing group can use it from any location. The costs are usually tabulated on a usage model, with payments being charged on an occurrence or usage basis. A practice operating with several locations and anesthesiologists working at several hospitals or clinics may find this capability to be a real advantage.

Some other advantages might include:

Robust reporting through real-time, data-driven dashboards. Customize reports and dashboards unique to your practice.
Streamline claims processing--capture insurance and patient information from completed appointments for import into online coding and charge entry with electronic claims submission. Eliminate duplicate data entry.
Central account management--process adjustments, refunds, reverse payments, and more; rebill claims; and manage collections from a central location.
Integrated document management--operate a paperless office with online document management--attach anesthesia face sheets, correspondence, EOBs, insurance cards, driver's license, and more to charges and payments. View pertinent documents for coding cases.
Electronic data interchange--capture EHR data and hospital demographics, submit claims, and process payments electronically. Recognize revenue faster.

Unless you have sunken costs in information technology infrastructure and specialists, you may want to take a look at the "cloud" for your practice. Software as a Service can offer the benefits we have covered, plus the security of rapid disaster recovery if something should happen to your office or place of business. For a no obligation demonstration of our PPM Connect platform, please contact us. Cloud gazing has taken on a new meaning.

Healthcare Reform: A Halftime Report for 2011

Steve Wirtz — Tue, 26 Jul 2011 21:49:00 GMT

Most of the summer is behind us now, and there has been a lot of commentary written about the action items that physicians and provider organizations are tasked with stemming from the Patient Protection and Affordability Care Act (PPACA) of 2010. Anesthesiology practices are still left wondering how they might fit into a new delivery model known as the Accountable Care Organization (ACO), that disperses both the responsibility and potential extra reimbursement for excellent patient care episodes. The largest body of practicing anesthesiologists in the U.S., the American Society of Anesthesiology (ASA), weighed in with their concerns in a previous post (Anesthesiologists Respond to ACO Proposed Rule).

Shouldn't the specialty with one of the best records and data on patient safety be leading most of their peers involved in a surgical event? Hospitals, payors, and health systems seem to like the idea of gain-sharing from improved quality and reduced utilization, but who is going to produce the great results?

There are still more questions than answers, and physician buy-in is still the biggest challenge to participation. Too many groups are still on the sidelines, waiting for the rules to be further clarified by CMS. Some of the largest medical groups like the Mayo Clinic are content to take a wait-and-see approach. They have some of best integrated systems to ensure patient outcomes. See the response from some of the largest medical groups in the U.S. at http://info.ppmconnect.com/bid/50561/ACO-Rules-Get-a-Chilly-Exam-by-Medical-Groups.

Where do we go from here?

Only time will tell if ACOs will truly be as successful as they are touted to be, but the reception by physicians and other healthcare providers who are at the point of care is lukewarm or negative right now.

In conclusion, our lawmakers truly believe that healthcare reform will improve the quality of care delivered to patients while increasing patient access and controlling overall medical costs. However, many physicians are critical because healthcare reform fails to address issues with the Medicare Sustainable Growth Rate (SGR), cost increases for pharmaceutical production, and changes to the Medicare benefit structure for patients. This issue will be covered in depth in our next issue of our e-newsletter called Vital Signs. Go to ppmconnect.com and click Get Connected!

No one knows for sure where we are headed with healthcare reform, but if one thing is for certain healthcare reform must be viewed as a process and not as a single event. Some of the ACO models we see today may fall by the wayside as we grind forward.

In recent weeks, PPMIS has posted many other articles related to the new healthcare reform law. To get more information, visit http://info.ppmconnect.com/.

Anesthesia Practices - Measuring Up to AQI Standards

Deb Dietsch — Fri, 22 Jul 2011 20:36:00 GMT

Anesthesia Quality Institute (AQI) is holding a Webinar series for educating anesthesia practices about quality in their practice, explaining about the AQI, and providing some real-world how to examples.

The first in the series called Introduction to the Anesthesia Quality Institute is scheduled for Wednesday, July 27, 2011 at 3:00 P.M. to 4:00 P.M. CDT.

Registration is FREE and open to anyone interested in learning more about AQI. So act now to ensure your spot.

Other Sessions

Session 2: Quality Management in Your Practice will be held in late August.

Session 3: Practice Application of QM in Your Practice will be held in late September.

For more information, visit the AQI Web site at www.aqihq.org.

Is your billing software vendor an AQI Preferred Vendor?

PPMIS is an AQI preferred vendor as a healthcare information technology company with a product that is actively meeting AQI requirements for data transfer.

We are very proud of this recognition by AQI and are dedicated to meeting our client not only in their needs in the area of patient care but as a billing solution.

PPMIS provides both billing software and billing services.

Contact us for more information.
Download product information to learn more.
Subscribe to our blog.

Why the 5 Lessons to Anesthesia Billing Still Matter

Steve Wirtz — Wed, 20 Jul 2011 13:34:00 GMT

As the calendar ticks down to another end of a month, you and your practice manager begin to huddle up and take a closer look at all of the key financial indicators of your anesthesia practice. All of the usual suspects are getting a closer look, like your:

Accounts receivable
Claims denials/rejections
Patient collection issues
Payer issues
Net revenues/cash flow
Unusual expenses (EMR purchase and other equipment)

Just as it is true that the mechanism of action of many medications used in anesthesia are simply not clear, the reasons why some anesthesia practices are profitable remains unknown, unless you are very observant and disciplined. Having a keen eye on the right data-driven dashboards is as important as the scan you keep up on a patient's vital signs.

5 Lessons- A Short Review

The “5 Lessons to Anesthesia Billing” guide is a primer for those who are just getting into anesthesia billing or have new employees who need to become familiar with the basics of anesthesia billing.

This guide describes:

The various types of anesthesia and how they are administered
The role of anesthesia providers
The elements of billing for anesthesia

Because anesthesia cases differ from other surgical procedures, it is billed differently. The complexity of the case, the number of cases in which a provider is directing, and the physical health of the patient can also determine how much the provider is reimbursed for a procedure. Many elements are factored in for billing the anesthesia procedures. If one or more of these elements are not well documented or coded, the provider may not be paid for the services rendered.

To learn more about the nuances of billing for anesthesia, download 5 Lessons to Anesthesia Billing.

For a brief but comprehensive demo of our PPM Connect platform, schedule one now:

2012 Medicare Payment Rate Changes for Physician Fee Schedule

Steve Wirtz — Wed, 13 Jul 2011 16:19:00 GMT

Just when you thought your anesthesia practice was caught up with most of the regulatory changes triggered by healthcare reform, here comes another one that affects your healthcare providers.

On July 1, CMS (Center for Medicare & Medicaid) issued a proposed rule that represents a 29.5% cut to Medicare physician payments unless Congress steps in to correct it.

See the CMS press release at http://go.cms.gov/kssRvx

Dr. Donald Berwick, head of CMS was quoted in the press release saying,

"This payment cut would have serious consequences, and we cannot and will not allow it to happen," said Dr. Donald M. Berwick, CMS administrator, in a statement. "We need a permanent SGR fix to solve this problem once and for all. That's why the President's budget and his fiscal framework call for averting these cuts and why we are determined to pass and implement a permanent and sustainable fix." Physicians groups have clamored for the SGR (Sustainable Growth Rate) formula to be overhauled as part of the deficit reduction process, but that would also come with a $300BB price tag.

Some provisions of the proposed rule include:

Physician Quality Reporting System (PQRS) - adding 26 new measures
Value-based modifier-CY 2013 as the initial performance year
Meaningful use
Misvalued code Initiative
Payment for certain Part B drugs
2012 e-prescribing incentive
Multiple procedure payment reduction (MPPR)
Physician payment during 3-day payment window

Comments are due back to CMS before August 30th. The final rule is expected by November 1st. This rule will remain a contentious issue, particularly with entitlement programs on the forefront of the deficit reduction talks going on now in Washington, DC. If the SGR is not overhauled by Congress, what medical or anesthesia practice could sustain a 30% reduction in their payments for Medicare patients? This issue will be covered in depth in our upcoming issue of our e-newsletter called Vital Signs.

Subscribe to Vital Signs:

Anesthesiologists and Healthcare Reform - the $1M Question?

Deb Dietsch — Tue, 12 Jul 2011 16:26:00 GMT

On March 23 2010, Congress passed and President Obama signed into law the Patient Protection and Affordable Care Act (PPACA). Included in this new law is the Health Care and Education Reconciliation Act (Reconciliation Act), collectively referred to as healthcare reform. The entire law is outlined in a 955-page document with hundreds of sections.

This new law primarily is comprehensive health insurance reforms that holds health insurance companies more accountable, lowers health care costs, guarantees more health care choices, and enhances the quality of health care and access for all Americans. Continuing through 2014, the Affordable Care Act will be implemented, increasing access to affordable health care for individuals, families, seniors, and businesses, or so it seems.

Many important benefits are already in place, including bans on the worst insurance company abuses; cost savings for seniors, families and small and large businesses; and coverage options for many Americans who otherwise are excluded from health insurance coverage because of a preexisting condition. An example of the cost savings to seniors is provided in a blog posted by Donald M Berwick, MD Administrator, Centers for Medicare & Medicaid Services on http://www.healthcare.gov/news/blog/index.html. In his blog, Dr. Berwick stated, “Thanks to the Affordable Care Act, almost half a million individuals enrolled in Medicare’s prescription drug benefit have received a 50 percent discount on their out-of-pocket costs in the first five months of 2011.”

While many patients may view heathcare reform positively, many healthcare providers are skeptical as to the real impact it will have on them. All physicians are impacted by this new law, which has provisions with a greater focus on patient care. The impact on primary care physicians and specialists are addressed separately. The law gives precedence to primary care doctors, which could put specialists at a disadvantage. The law also effectively prohibits doctors from having an ownership interest in a hospital.

Impact on all physicians

For all physicians, the reform legislation includes several incentives one of which being the Physician Compare Web site. From 2011 to 2014, physicians who participate in Physician Quality Reporting Initiative (PQRI) will receive Medicare incentive payments (1 percent in 2011 and .05 percent from 2012 through 2014). Currently PQRI participation is voluntary; however, beginning in 2015 participation will be required. For those who do not participate, there will be 1.5 percent reduction in Medicare payments.

A 10% bonus in Medicare payments will also be offered to primary care physicians and general surgeons working in rural areas from 2011 to 2016.

With the expansion of coverage, doctors will have a larger pool of prospective patients, theoretically increasing revenues. If many of those patients are on Medicare or Medicaid, low reimbursement rates could offset the increase in revenues. Under the Sunshine provision in the law, doctors must disclose every payment from drug and biotech companies over $100, including drug samples. This provision could add complexity to office accounting.

Impact on primary care physicians

Because of the predicted shortage of primary care physicians, medical students are being encouraged to concentrate on primary care. Beginning in 2011, healthcare reform provides for expanded funding for scholarships and loan repayments for primary care providers working in underserved areas. Starting in July 2011, training programs for primary care providers (physicians and nurses) are being expanded, for example, the Medicare Graduate Medical Education Program. Beginning 2013, primary care providers (pediatricians, family physicians, and internists) will also receive increased Medicaid payments, which will gradually increase to Medicare payments by 2014.

Impact on specialty physicians

For specialty physicians, healthcare reform means an increase in regulatory limitations on their practice. Physicians will be required at the time of referral to provide all patients, in writing, with a list of any alternative imaging providers other than the one suggested by the referring physician. So, what's wrong with this picture? Historically, specialists lead rather than follow in their field of expertise, but within the new team structure called an Accountable Care Organization (ACO) the specialist is not the quarterback calling the shots on patient care.

Many are wondering what role will they really play in the ACO. In a recent article posted on FierceHealthcare, "Organizations representing oncologists and other specialty physicians are expressing some concerns about how accountable care organizations will be regulated, reports AIS Health." Read more: Specialists question ACO integration, show reluctance to join

Are Anesthesiologists at a Bigger Disadvantage?

The biggest threat seems to be the prospect of ACOs. As stated in a recent blog article “How anesthesiology providers interact, work within, and are reimbursed by ACOs will be determined by these rules when they are set. In the meantime, surgical schedules will fill up, patients will be seen and treated, and your practice will need to function as optimally as possible given the uncertainties of today. Sound financial decisions and excellent revenue cycle management will be key elements to success.” Read more Vital Signs for Healthy Anesthesia Practices? A Checkup.

To read more, visit our blog article Medicare Proposes Accountable Care Organization (ACO) Guidelines (http://info.ppmconnect.com/bid/50733/Medicare-Proposes-Accountable-Care-Organization-ACO-Guidelines)

Anesthesiologists Respond to ACO Proposed Rule (http://info.ppmconnect.com/bid/54491/Anesthesiologists-Respond-to-ACO-Proposed-Rule)

ACO Rules Get a Chilly Exam by Medical Groups (http://info.ppmconnect.com/bid/50561/ACO-Rules-Get-a-Chilly-Exam-by-Medical-Groups)

No one knows for sure where we are headed with healthcare reform, but if one thing is for certain healthcare reform must be viewed as a process and not as a single event.

In recent weeks, PPMIS has posted many other articles related to the new healthcare reform law. To get more information, visit http://info.ppmconnect.com/.