Anesthesia Business Consultants Communique Summer 2013 Edition

7/22/2019 Anesthesia Business Consultants Communique Summer 2013 Edition

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ANESTHESIA

BUSINESS

CONSULTANTS

BACKGROUND

It is ofen suggested that an anes-

thesiology department should have more

complete and readily accessible data

about the clinical care provided in the

operating rooms and the delivery suitethan any other department o the acil-

ity; but how ofen is this actually the

case? Anesthesia providers review and

document enormous amounts o clinical

detail and critical events or every patient

they see, but little o this inormation is

actually captured in a way that allows

or its logical indexing and retrieval.

Most anesthesia groups and their billing

services have been so ocused on the

data necessary to calculate a charge and

generate a claim that they have virtu-

ally ignored what is potentially the

most valuable o inormation o all. Te

implementation o electronic medica

records is slowly inspiring a change in

a very traditional way o thinking abou

the clinical details o the peri-operative

continuum. Progress, however, is slow

INSIDE THIS ISSUE:

Continued on page 4

CREATINGACLINICAL

DATABASE: OPENINGTHE

PANDORASBOXORMINING

THETREASURETROVEAman Mahajan, MDChair, Department of Anesthesiology, University of California, Los Angeles, CA

Jody Locke, CPC

Vice President of Anesthesia and Pain Management Services, ABC

Anesthesia Business Consultants is proud to be a

SUMM

ER

2013

VOLUM

E

18,ISSUE

3

Creating a Clinical Database: Opening the Pandoras Box . . . . . . . . 1or Mining the Treasure Trove

Securing the Future for Anesthesiology and Pain Medicine Practices . . . 2

Strengthening Your Anesthesiology Group . . . . . . . . . . . . . . . . . . . . . . 3

Timing Is Everything: Divining the Wisdom of Anesthesia . . . . . . . . 12Aggregation in the Current Environment

Student Training Programs May Pose Signifcant Liability. . . . . . . . . 15Exposure to Anesthesiologists

Are You Ready for ICD-10? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

A Retrospective Study of a Gastroenterology Facility: . . . . . . . . . . . . 20Are the Patients Sicker?

Event Calendar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

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THE CO MMU NI Q U SU MMER 2013 PAG E 2

SECURINGTHEFUTUREFORANESTHESIOLOGY

ANDPAINMEDICINEPRACTICES The decisions that anesthesiologists

and pain medicine specialists must make

are more fundamental and consequential

than ever as we enter the final months

before implementation of Obamacare

in January 2014. Adding staff, adding

locations or even altering income dis-

tribution systems are easy decisions in

comparison, especially since they lend

themselves to well-defined quantitativeanalysis. Creating and selecting options

that involve the very nature and iden-

tity of groups is much more challenging.

Three of the articles in this issue of the

Communiqu explore different aspects

of the answer to the question, How do

we secure our future?

The broadest view and the most basic

recommendations are to be found in

Will Lathams article Strengthening Your

Anesthesiology Group. Mr. Latham pro-

poses two steps groups can take to reduce

the pervasive environmental uncertainty:

strengthen group governance and, with a

more predictable decision-making pro-

cess in place, develop a group-endorsed

strategic plan. From defining the groups

collective vision through recognizing

opportunities and dangers on to setting

objectives and strategies, strategic plan-

ning is critical for groups that want to

control their direction and identity.

Jody Lockes article Timing isEverything: Divining the Wisdom of

Anesthesia Aggregation in the Current

Environment describes an example of

anesthesia practices that have merged to

create an important new player in the

region, implementing a highly strategic

long-range plan.

In Creating a Clinical Database:

Opening Pandoras Box or Mining the

Treasure Trove, UCLA Anesthesiology

Department Chair Aman Mahajan,

MD and Jody Locke take a new look at

the role of databases in creating power

and influence in groups hospital re-

lationships. The authors clarify the

differences between familiar databases

that serve billing and accounts receivable

purposes, on the one hand, and those

that can answers larger questions about

quality, potential savings and clinical

opportunities for practice expansion,on the other. They consider frequently-

heard arguments against developing

powerful clinical databases such as cost,

time spent away from patients, and the

already-high quality of anesthesia care

and demonstrate that all of these are

outweighed by the potential benefits of

databases designed to capture and logi-

cally index all the information generated

case by case. The most successful groups

seek to manage their data in such a way

as to identify issues that no one else has

thought about and to change the existing

practice paradigm. Vital to that goal is

having valuable data that can be shared

with hospital administrators to identify

rate-limiting steps in existing processes

and to propose solutions that uniquely

reflect the value anesthesia brings to the

facility. It is only when this is the focus

and intent of the data, that it becomes

truly useful.

In the shorter term, groups need toask themselves whether their prepara-

tions for the implementation of ICD-10

diagnosis coding next year are on track.

Joette Derrickss articleAre You Ready for

ICD-10?points the way.

Groups who work with trainees

whether medical residents or allied

health professionals such as emergency

medical techniciansshould take note

of the need to match the patient to the

trainees skill level, as illustrated by

Brian Thomas, Esq. in Student Training

Programs May Pose Significant Liability

Exposure to Anesthesiologists. Kim

Riviello, DNP, CRNA examines another

risk management issue In A Retrospective

Study of Gastroenterology Facility: Are

the Patients Sicker? and provides a syn-

thesis of published studies to show that

outpatient facilities that anesthetize pa-

tients without anesthesia professionalsshould be aware of the prevalence and

consequences of co-morbidities.

Readers often ask me how we are

able to come up with new topics for this

quarterly publication and our weekly

Alerts. You know as well as I do that we

live and work in a dynamic, exciting en-

vironment. There is always something

new to say even when the topic is a famil

iar one such as the need for data. There

are always new voices, too. If you would

like to share an analysis, review or study

in these pagesor to comment on what

you have readwe are eager to hear

from you.

With best wishes,

Tony Mira

President and CEO


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Most people choose unhappiness

over uncertainty. imothy Ferris

Anesthesiology groups are acing

unprecedented challenges. How willthe Affordable Care Act affect them?

What will happen when ACOs get up

and running? Should our group sell to

an investment group? Should we pursue

hospital employment?

Tese are truly uncertain times.

Unortunately many groups are in

a reactive mode, struggling with how to

deal with threats and opportunities in

the marketplace. Tis is ofen because

their governance and management

processes were ormed at a time

when there were ewer stressors and

challenges. Some group are sprinting

towards relationships that appear to

offer financial reward and some level o

security, but at the same time have the

potential to severely limit the groups

and the physicians autonomy.

While there are situations where

employment may be appropriate,

many groups that pursue this course

are choosing unhappiness over

uncertainty.

I your group intends to remain

independent, or i you are independent

now and are still trying to decide

which long-term option to choose,

there are two steps that you can do

to reduce uncertainty. You cant

eliminate the environment threats, but

you can significantly strengthen your

organizations ability to cope with such

threats.

STRENGTHENGROUPGOVERNANCE

Te first step is to strengthen your

groups governance. You can find a

number o resources to help you do this on

our website at www.lathamconsulting.com

(choose Resources and then Special

Reports), including Special Reports on:

Practical Governance or Medical

Groups Characteristics o Effective Boards

A Code o Conduct Improves

Behavior

However, many groups have never

established even basic agreements about

how they will decide things and govern

their practice. Many groups still suffer

rom what we call the dirty little secret.

Tis secret goes like thisonce

decisions have been made by the group,

many physicians believe that supporting

the decision is optional depending on

whether or not they like the decision. I

they didnt vote or it, they eel like they

dont have to do it, support it or adhere

to it!

As you may have already discovered

this can prevent a group rom moving

orward on important decisions and

initiatives.

How can the group improve its

ability to make and stick to decisions?

Group members must ask themselves

three undamental questions. We believe

these are the most important questions

that any group can ask itsel:

1. How will the group make

decisions? It is critical that the

group agree on how it will make

STRENGTHENINGYOUR

ANESTHESIOLOGYGROUPWill Latham, MBA

President, Latham Consulting Group, Inc. Chattanooga, TN

Continued on page 9


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CREATINGACLINICALDATABASE: OPENINGTHEPANDORASBOXOR

MININGTHETREASURETROVEContinued from page 1

and there continues to be a general

reluctance to invest time and resources

in clinical databases. Te Anesthesia

Quality Institute (AQI) has made a start,

but its database o 10 million cases repre-

sents only a small percentage o total U.S.

surgical volume and thus ar relatively

ew o these cases include any clinical

outcomes data. Small-scale individual

initiatives are being undertaken across

the country but ew groups or depart-ments can truly claim a robust clinical

database. Tis state o affairs raises some

undamental philosophical, economic

and practical questions about the value

o such data in the current health care

environment where the purported ocus

o policy is on quality improvement,

saety and cost containment.

DEFININGADATABASEAND

ITSPURPOSE

Te term clinical database has

varying definitions depending on the

community. What data elements would

be most useul in the current debate?

odays clinical documentation tends

to include two types o inormation:

specific events and ongoing data streams.

I all the data streams rom physiologic

monitoring, drug administration and

provider interactions were captured,

each case would result in a massive file

o questionable value, except to thoseseeking to answer clinical research ques-

tions. Te key elements would be those

potentially predictive o complications

or that confirmed the outcome o care.

In comparison, creating the database or

billing and accounts receivable manage-

ment would be considerably easier

because the basic elements were defined

in the orm o the standard CMS 1500

claim orm. Inevitably the requisite

clinical elements have to be defined in

reerence to those already being captured

or billing.

Te standard anesthesia billing

dataset includes patient demographics,

date o service, surgical procedure, diag-

nosis, start and end time and the details

o any incidental procedures perormed.

Tese bits o inormation are intended to

define what services were provided and bywhom. We call the current system o reim-

bursement ee-or-service because it pays

providers or individual patient services.

Although payor policies purport to iden-

tiy unnecessary services, little attention is

actually ocused on the appropriateness o

cost-effective care, especially in anesthe-

sia. Te diagnosis code is a case in point.

ICD-9 is supposed to provide a reasonable

justification or the services provided but

todays diagnosis codes ocus only on the

rationale or the surgical procedure andnot the need or or mode o anesthesia.

Teir application to the specialty is little

more than a vestigial inconvenience.

Tere should be a code that justifies the

administration o anesthetic care in terms

o the pain and inconvenience, medical

management and complexity o monitor-

ing during the surgery.

I a provider indicates that a general

anesthetic was administered, it is never

questioned by a payor. Te appropriate-

ness o a MAC anesthetic or endoscopy

or the use o a nerve block or post-oper-

ative pain management might be, bu

even here there is little consistency. Wha

a curious state o affairs this is given

the detailed pre-operative assessments

documented or such a large percent-

age o surgical cases. When things go

wrong this inormation is also usually

documented, but rarely are the two

ever correlated. Te path is slowly beingcharted by a handul o visionary prac-

tices that hope to use the inormation

to demonstrate their superior quality o

care.

Groups wishing to make the invest-

ment in a relevant and useul clinica

database must make some critical deci-

sions up ront. Inormation only becomes

knowledge i it has some practical appli

cation. Data elements could logically be

selected based on their utility to some or

all o the ollowing:

Te ability to validate or confirm

the quality o care provided;

Te ability to identiy categories o

patients who would be best served

by particular drugs, agents or

specific clinical protocols;

Te ability to monitor patterns

or trends specific to individua

members o the practice, which

could support various types o

provider profiling or opportuni-

ties or specific skills training;

Te ability to identiy clini-

cal opportunities or practice

expansion;

Te ability to identiy potentia

savings through more appropri-

ately targeted clinical protocols;

Te ability to benchmark and

compare practices.

Tere is a tendency to look at projects

like the development o a clinical data


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base as a daunting enterprise that will

require expensive consultants, significant

resources and the serious commitment o

key members o the practice. While oneshould never minimize the significance

o adding data elements to a database,

the process need not be perceived or

promoted as an insurmountable task.

Consider the bits o inormation that

are only captured haphazardly today,

indicators such as ASA physical status

and diagnosis. oo ofen these are only

retained when they have an impact on

charge calculation or payment. Databas-

es should evolve logically and be driven

by a set o reasonable and practical ques-tions. Te act is that most anesthesia

providers already have a good idea o the

issues that merit monitoring and areas

where potential improvements in care

can be realized.

BUILDINGADATABASE :

CHALLENGESANDPITFALLS

Te peri-operative continuum offers

us three clearly defined areas o inves-

tigation: pre-operative observations,intra-operative events and post-operative

complications. Because anesthesia risk

actors have been so well studied over the

years, reasonable and appropriate lists

are available or each phase o care. Any

o these would represent a good start-

ing point or the ormulation o a data

capture strategy.

How would this additional data be

captured? Te good news is that comput-

er memory continues to get cheaper and

more powerul. For practices imple-menting automated anesthesia records,

capturing additional data is easy. Others

that are not so technologically advanced

may want to consider including key

elements rom pre-operative assessment

or intra-operative complication orms

into their data entry process. Suffice it to

say that with all the technological options

available, data capture is not the practical

obstacle that it used to be. Tere is more

than ample evidence that practices that

truly want to distinguish themselves in

the market have ound ways to consis-

tently and cost-effectively capture the

data they eel they need.oo ofen the potential value o a

robust clinical database is more o a

theoretical proposition than a practical

reality. Why is this? Standard arguments

tend to all into three broad categories:

the philosophical, the economic and the

practical. Considering the concerns one

cannot help but wonder to what extent

they are serious arguments versus veiled

excuses or inaction.

Every anesthesia practice distin-

guishes itsel based on the values, beliesand outlook o its principals. Philoso-

phy is an especially powerul actor in

the specialty. I you want to appreci-

ate its impact just ask anesthesiologists

across the country their eelings about

working with other anesthesia providers.

Te geographic distribution o practices

corresponds quite neatly to a philosophi-

cal spectrum o views where those in the

East find nurses integral to the specialty

to those in the West who tend to avoid

working with CRNAs at all cost.

Philosophical attitudes clearly

underlie the arguments surrounding

the need or more clinical data capture.

A strong belie in the value o American

clinical training, the appropriate us

o monitoring and a broad armamen

tarium o powerul drugs tends to resulin a belie that trending and analysis are

both unnecessary and inappropriate

Tere are many providers who remind

patients that they are at greater risk

driving to the hospital than undergoing

general anesthesia. How much bette

can clinical outcomes possibly get? And

then they drive the point home with

cautionary note. Capturing risk actor

and outcomes can only be used agains

providers who, or one reason or another

are perceived as outliers.Further, philosophical prejudice

ocus proponents primarily on th

evidence that supports their position

than what might undermine it. T

stronger the position, the more impen

etrable the filter. Tere is no greate

obstacle to change than the belie tha

change can only be or the worse.

Te next bastion o opposition

tends to cloak itsel in economics. T

economic realities o ee-or-servic

medicine have conditioned physician

to accept that i the market values some

thing, it will pay you to do it. Conversely

i the market is not willing to pay or a

service, then it is probably not a service

that needs to be provided. Tis mental

ity has inused the specialty, conditioned

thinking about compensation system

and ultimately proved to be one o th

greatest challenges to group governance

Why should someone spend valuabl

time doing work or the group as a wholei they do not get compensated or it?

o a large extent data capture

strategies continue to be defined by th

economics o health care. Data element

such as PQRS Quality Data Codes are

only added when there is a financial moti

vation to do so. Te act that capturing

particular indicator or piece o inorma

tion would not result in a reward would

Continued on page 6


6/24


be a huge disincentive. Te government

understands this principle all too well.

Meaningul Use o electronic health

records is a perect example.

Te reality, o course, is that there

are short and long-term economic lenses.

Tose who believe that the Account-

able Care Act is going to usher in more

cost-cutting and a ocus on gain-sharingargue that having the data to identiy and

develop strategies or improving produc-

tivity and profitability is actually the

most important economic argument one

can offer. Tey argue that the belies and

strategies that have gotten us to where we

are today wil l not get us to where we need

to be tomorrow.

None o this is to imply that the

practical challenges in capturing more

data rom each anesthetic are inconse-

quential. Every additional data elementcaptured rom clinical practice requires

three distinct steps. First the inorma-

tion expected must be clearly defined

and providers must know exactly where

and how it will be captured. A process

or mechanism must then be established

to capture the inormation and include

it in a database o some sort, either in

the practices master billing database or

some other database. Ideally, all required

inormation would be captured in one

large integrated database but this is not

always possible. Finally, any additional

data must be validated.

Here is a case in point. A practice

decides that it wants to start capturing

the anesthetizing location where each

case is perormed. A decision has been

made that having this inormation will

allow or the calculation o much more

precise productivity metrics. In this case

the group must first define how each

location will be labeled and work with

the sofware vendor to establish a field

or the data to be captured. Providers are

instructed where to note the location on

the anesthesia record. A month passes

and a QA process must be perormed on

the resulting data. 25% o the providers

either did not mark the location or each

case or did not report it consistently. In

some cases the data entry team missed

some o the locations. Ultimately, it takes

three o our months or the group to

achieve 95% data capture.

Capturing risk actors and outcomes

that could potentially be used against the

provider poses even greater challenges

and issues. Sel reporting requires great

discipline and honesty. Inevitably the

practice must ensure the confidentiality

o the inormation and make certain that

it will be used only in a blinded statistical

manner. For maximal success, the prac-

titioners need to perceive this process asbeing essential, unbiased and helpul.

While these are all legitimate and

practical concerns, they should not be

used as reasons not to orge on. Rather,

they should be part o a serious conversa-

tion about an appropriate approach. Te

act is that many practices have already

embarked on this path. Tose that find

the process too daunting are likely to be

lef behind by those who rolled up their

sleeves and worked it out.

Process changes such as those

presented here should ideally be imple

mented with an eye to addressing issues

o specific relevance to the practice or

to anticipating changes believed to be

taking place in the market. So what are

the big clouds on todays anesthesia

landscape? Most observers would agree

that virtually all anesthesia practices

must deal with three general practice

management concerns. Tese could be

defined as (1) the revenue challenge, (2)

the security challenge and (3) the strate

gic challenge. In order to remain viable

every anesthesia practice must secure a

revenue stream sufficient to recruit and

retain appropriate numbers o qualified

providers to meet the expectations and

service requirements o their acilities

Given the reality o expanding cover

age requirements and limited revenue

opportunities, most practices must find

ways to justiy hospital support.

Asking or financial support rom a

hospital comes with its own set o risks

When administrators pay or services

they typically want assurances that they

are getting value or the money they

spend. odays hospital contracts are

more extensive and complicated than ever

Tey ofen include metrics and standards

o care that must be met. Anesthesiology

practices find themselves caught between

accepting the hospitals data and metricsand building their own databases.

Tis new reality has given rise to a

significant concern about the security

o a practices contract. Te increasing

use o Requests or Proposal (RFPs) and

the growth o national managemen

companies only heighten the anxiety o

the providers. Clearly, many practices

are seriously at risk o losing their ran-

chises. Te problem is that many do not

appreciate just how much they are at




7/24


risk o being displaced. Te anecdotal

evidence rom around the country can

be quite disconcerting.

Practices now have to consideroptions and ormulate all back strategies.

Te undamental strategic question being

discussed by large numbers o practices

around the country is whether it is worth

trying to remain independent versus

joining a larger entity. In other words,

every group must consider whether it can

sufficiently distinguish itsel and provide

consistently superior care or let some

other entity define its destiny.

Ironically, or all the observations

and experience o its providers, anes-

thesia has let others define the quality

o care provided rather than defining it

themselves. Te result has been a airly

myopic ocus on negative or unexpected

anesthesia outcomes. Te ASA supports

considerable research in anesthesia saety

and modalities, but most o the papers,

their conclusions and recommenda-

tions are intended only or the specialists

themselves. Te result, o course, has

been dramatic increases in quality andsignificant reductions in anesthesia

morbidity and mortality. As clinicians,

anesthesia providers have tended to

live in the shadows in their respective

medical communities. Tis is why an

article about the chairman o anesthesia

at North Shore University Hospital in

Manhasset, New York was entitled, Who

is Tis Masked Man? While a sense o

humility has served the specialty quite

well thus ar, it is unclear it will serve the

specialty well in the competitive medicalmarketplace o the uture.

Tese general themes are playing

themselves out in three specific arenas.

Tere is an increasing ocus on the cost

o anesthesia care. Customer service has

become the issue o the day. All practices

are scrambling to find new services and

venues so that they can remain viable.

Each o these has significant practice

management and governance implica-

tions. Growing numbers o physicians

are simply throwing in the towel rather

than radically redefine what they do and

how they do it.

Te cost question is particularly

challenging to many practices. How do

you reduce the cost o a service where the

only significant actor is the compensa-

tion o the providers? Physician-only

practices have to consider care team

options. Care team practices are looking

at using more CRNAs. Tere are no

really good options, however, when thereal driver o their costs is the unrealistic

coverage requirements o administra-

tion. Few practices have many good tools

or strategies to reset administration

expectations. Tis is where having reli-

able data and a compelling way to use it

becomes so critical.

Customer service is another partic-

ularly rustrating issue or practitioners

who have always seen theirs as the quint-

essential customer service specialty. Te

act is, though, that in the customerseyes good clinical outcomes are a given

and not the definition o good customer

service. Tey want all three o the tradi-

tional anesthesia As: ability, affability

and availability.

odays hospital administrators have

high expectations. Tey want account-

ability, collaboration and innovation.

Tey want business partners who are

willing to share ideas and risk. Tey

want anesthesia to take ownership o

what happens in the O.R., not simply to

profit rom it. Committee involvemen

and the sharing o data and ideas are the

new reality o todays medical staff.So how does more data make a

practice more secure? In and o itsel, it

doesnt. odays large anesthesia prac

tices and staffing companies are taking a

very different approach to data manage-

ment. Perhaps inspired by the Googles

and the Facebooks o the world, they are

not just looking to validate what they

know, but to identiy issues that no one

else has thought about. Differentiation

and innovation are the driving actors in

todays marketplace. Te new anesthesia

mega-group strategy is to use the power

o the anesthesia database as leverage to

gain recognition and acceptance. Tese

anesthesiologists are no longer willing to

accept a role o subservience. Tere is no

security in being useul to the adminis-

tration, the surgeons and the rest o the

medical community. Power comes rom

control and influence. Teir goal is not

simply to profit rom the existing para-

digm but to change it. Vital to that goais having valuable data that can be shared

with hospital administrators to identiy

rate-limiting steps in existing processes

and to propose solutions that uniquely

reflect the value anesthesia brings to the

acility. It is only when this is the ocus

and intent o the data that it becomes

truly useul.

Ironically, this is what most hospita

administrators have been waiting or

Te ollowing is a short summary o a

typical hospital administrators wishlisor its anesthesia department.

Anesthesia should be a significan

contributor to ongoing process

improvements.

Departments o anesthesia should

be constantly monitoring and

managing their own resource

allocation.

Tey should be models o custom

er service.

Continued on page 8


8/24


Why would they have such expec-

tations? In large part they have such

expectations because this is what the

biggest and most aggressive o the

nations practices are offering and

providing. Once the bar gets raised every

group must compete at a new level.

Te landscape o anesthesia has

clearly changed. Is it too late or most

practices? Have they already allen so ar

behind as to make it impossible to catch

up or compete? Absolutely not. For one

thing, not every administration wants

to deal with a mega-group or national

provider organization. For another,

being competitive is less about the what

than the how. While commitment

and enthusiasm will never overcome

substandard service or inconsistent care,

they still count or a lot.

Expanding a practices database

to include more than just the requisite

details necessary to bill a patient and his

or her insurance is a undamental exercise

in change management. Like many other

initiatives that an anesthesia practice

might consider, this one must be clearly

ramed and sold to the membership.

Selling it is about overcoming concerns

and objections. Effective change manage-

ment inevitably requires three things:

a champion, a vision and a plan. Te

importance o leadership in managing

change in an anesthesia practice cannotbe overstated. Given the independent

nature o so many anesthesiologists, it

is essential that there be a uniying orce

and ocus to the initiative. Tis is not

something that will ever happen spon-

taneously. Independent thinkers need to

have all their issues addressed and their

objections overcome. Te leader must be

able to address each category identified

earlier in this discussion: the philosophi-

cal, economic and practical.

What is the vision that inspires

physicians to report more details o each

clinical encounter that could potentially

be used to identiy them as outliers, or

worse yet, as providers o inerior care?

It is not an easy question to answer,

especially or doctors who believe

that the quality o care they provide is

already very good. It must be a vision

o something more proound than clini-

cal outcomes. It must remind providers

that their very success has consistently

diminished the perceived value o the

services provided. It must inspire the

specialists to think beyond their own

individual value and compensation. It

must remind them o the undamental

nature o the specialty, as the quintes-

sential service specialty. It must speak

to the heart and core o customer

service, which always seeks to provide

a sae, comortable and compassion-

ate surgical experience. It must remind

each and every member o a practice

that quality is defined by the least effec-

tive clinician in the practice. It must

offer a compelling argument or doing

things differently, and or being willing

to innovate and take risks. Where these

kinds o thoughts are persuasively

communicated there will be a more

enthusiastic endorsement.

oo ofen, however, the vision is

neither clear not compelling and thatmakes the challenge ever more difficult.

Tere is a saying in sales that when

the customer is conused, he will not buy.

Being able to sell the concept o a robust

clinical database is important, but it is

only the beginning o the process. Anes-

thesia providers tend to think through

issues very systematically and to solve

problems based on their well-ingrained

sense o decision-tree models. Tis is

why the planning process is so critical.

Most people preer off-the-shel solu

tions. Te leader must not only sell a

vision, he or she must clearly outline the

roadmap to implementation.

Tis may all sound daunting

Effecting a change that affects provider

behavior and requires the commitmen

and involvement o I resources that

might not yield the desired results is a

risky proposition, but is there really an

option? Tat is the question that every

practice must address in todays rapidly

changing economic landscape.



Jody Locke, CPC,serves as Vice Presidentof Pain and AnesthesiaManagement for ABC.Mr. Locke is respon-sible for the scope andfocus of services pro-vided to ABCs largestclients. He is also re-sponsible for oversight and managementof the companys pain management billingteam. He will be a key executive contact forthe group should it enter into a contract forservices with ABC. He can be reached [email protected].

Aman Mahajan, M.D.,

Ph.D., FAHA, is Chairat the Departmentof Anesthesiology, aswell as Professor ofAnesthesiology andBioengineering and

he holds the Ronald L.Katz Endowed Chair inAnesthesiology at the David Geffen School ofMedicine at UCLA. Dr. Mahajan is a leaderin the field of cardiac anesthesiology andcardiac electrophysiology & biophysics. Aholder of numerous patents, Dr. Mahajanserves on various medical and scientificcommittees including the National ScientificResearch Board. He can be reached at (310)267-8680 or [email protected].


9/24


STRENGTHENINGYOURANESTHESIOLOGYGROUPContinued from page 3

decisions. ypical ly the group has

our choices as outlined in able

1. In our experience, the best

option is to seek consensus first,

and then vote i consensus cannot

be reached. Ofen the president

is charged with the responsibility

o determining when the group

should move to vote.

2. What is expected of each

physician once a decision has

been made? Tis is the crucial

question. Te best groups answer

this question by agreeing that

once a decision has been made

in the agreed-upon decision-

making method, every physician

(whether they agreed with the

decision or not) will actively

and ully support the decision,

to include encouraging others

to support the decision. Fullysupport means doing what

they have agreed to, actively

promoting implementation, and

not sabotaging the decision.

3. What are a physicians options

if he or she still doesnt like the

decision? Tere should be only

three options:

a. Do it anywaythats group

practice.

b. ry to get it changed in the

appropriate orum, but keep

adhering to the decision until it

is changed.

c. Sel-select yoursel out o the

group.

Tis last option is the one that

causes people heartburn, but

without it people will believe

they have the option to stay with

the group while not adhering to

group decisions.

We know that it is unrealistic to

believe that all physicians will

adhere to the commitment to leave

the practice i they dont adhere

to group decisions. However,by asking and answering these

questions, the group can remind

outliers that they all agreed to

support group decisions once they

were made. Since many physicians

consider themselves the last

gentlepersons in the world, and

that their word is their bond, this

ofen brings them back into line.

Groups also requently develop

ormal processes to deal with

those that dont live up to their

commitments. Tese processes

might include a Code o

Conduct that outlines acceptable

physician behavior. Tey also

typically develop a step-by-step

process that the group can use

to resolve physician issues. An

example o such a process can be

ound at the end o this article.

A ew years ago we worked with

a group that had this discussion at the

beginning o their strategic planning

retreat. One o the physicians said, So

i we make a decision, we are really going

to do it? I responded in the affirmative

to which he replied, Well, I guess I wil

have to pay attention at this meeting!

I your group is having a problem

making (and sticking to) decisions, i

is probably because your group has not

asked, and answered, these three critica

questions.

GROUPSTRATEGICPLANNING

A second step in strengthening your

group is to develop a group-endorsed

strategic plan. Decisions acing anesthesiology

groups today are significant and have

long-range implications.

Each o these decisions require

substantial resources and lead times

In addition the decisions are ofen

interrelated.

But the significance o the needed

decisions is only one actor highlighting

Continued on page 10

Table 1 Decision-Making Methods

a. All decisions requireunanimity.

A bad idea, typically leads to no decision.

b. Decisions require consensus.Consensus means working to a

point where all dont agree with

the decision, but all will support it.

The key positive is that it improves the chance of successin implementation. The negative is that it takes longer to

reach a deal that all feel reasonably good about.

c. Decisions are made by a votewith majority ruling.

Good to use when you have limited time to make a

decision, or when there are fundamental differences of

opinion that are unlikely to be changed via discussion.

d. Seek consensus first, but if itcannot be reached vote on theissue.

In our experience, this tends to be the best decision-

making approach for medical groups. Someone must

direct the group (often the groups President) as to when

to move from consensus-building to voting.


10/24

the importance o long-range planning.

Without planning, physicians in

anesthesia groups rarely have a common

vision o the direction their firm ismoving. Tis can result in inefficient

utilization o resources, lack o direction

or the administrative staff, and lack o

any progress or the group.

Why is long-range planning

important?

Significant changes in the

environment can hurt or help the

group. Planning helps identiy

these issues and prepare or them.

Te planning process allows each

physician to communicate his orher vision o the uture, and work

to develop consensus in their

objectives and goals.

Key issues are highlighted,

discussed and resolved.

Te plan provides direction to and

sets priorities or the administrative

staff or implementation.

Te planning process and completed

plan improves communication to

both physicians and staff.

I progress is tracked against the

plan, perormance measurement

can be improved.

Physician recruitment may beenhanced as potential recruits can

quickly understand i their long

range goals are in line with the

group.

Resistance to long-range planning is

normally the result o at least one o the

ollowing actors:

Physicians do not understand the

importance or benefits o long-

range planning.

Te physicians have no clear

decision-making process to

initiate planning.

Planning has been tried, but the

physicians are not convinced o its

benefits.

In each o these instances, group

leadership should communicate the

need or and benefits rom long-range

planning and then work to implement a

process to develop the plan.

What Is Strategic Planning?

All organizations, at one time or

another, struggle with the ollowing

questions:

Where are we going?

How will we get there?

Why do we want to do it as a group?

o answer these and other important

questions, many anesthesia groups are

turning to a ormal strategic planning

process or their organization.

Strategic planning has been defined

as a process of developing an integrated

coordinated and consistent long-range

plan of action for the organization. One o

the first steps in the process is to develop

a vision statement or the group. Tis

statement describes the groups preerred

uture and what it intends to become.

Developing this statement involves

answering the ollowing key questions

Looking out over the planning horizon

(which is likely 3-5 years at the most): What services and specialties do

you plan to offer?

What geographic region do

you intend to serve? How many

locations are you likely to have?

How big will the group become

Will you grow to fill the service

needs o the market, or wil l you se

an upper end limit on the number

o physicians in the group?

What type o relations wil

you have with others? Will youremain an independent group?

As previously discussed, this is a

very important question in today

environment.

What benefits do you hope to

provide or the owners and

employees?

Te next step in the strategic

planning process is to look at all orces

outside o the group that could affect the


STRENGTHENINGYOURANESTHESIOLOGYGROUPContinued from page 9


11/24

groups unctioning. Tis step is called

environmental analysis, and its purposeis to identiy opportunities and threats

that the group aces.

Te environmental analysis looks at

three areas:

1. External Constituent Demands:

An external constituent is a group

or individual who is capable o

taking action or has needs which

could avorably or unavorably

impact the group. For example, a

major external constituent or an

anesthesiologist group might bethe hospital it is associated with.

It is very important or this type

o a group to understand the

actions that the hospital might

take or the needs they have.

2. Competitors: Individuals or

organizations who compete or

the same set o customers as

the group are identified and

analyzed or major actions which

might affect the group.3. Macro-environment:Te macro-

environment includes large scale

undamental orces that shape

opportunities and pose threats

o the group. Te group should

review significant economic,

political, demographic, and

technological events and trends

and their impact on the group.

Once the major actions, events or

trends are identified, they should be

categorized as opportunities or threats.

Opportunities are any avorable

situations in the groups environment

that support demands or a new service

or permit the group to enhance its

position. Treats are challenges posed

by unavorable trends or specific events

in the environment that would lead,

in the absence o purposeul action, to

the stagnation, decline or demise o the

group or one o its services.

Te third major step in strategic

planning is to look within to identiy

the strengths and weaknesses o the

group. Significant areas o the practice

(e.g., personnel, management, decision

making) are reviewed to identiy areas

either capabilities that will lead to or

limitations that will prevent the group

reaching its objectives.

It is important to identiy strengthsso that they might be used in planning

how to achieve objectives. Weaknesses,

on the other hand, may point to the need

or programs to correct them.

At this point the group has

collected significant data about itsel

and its environment. Now it is time to

put that inormation to use by setting

objectives.

An objective is a description o

some situation in the uture that you

would like to see come about, and whichyou have a reasonable expectation o

accomplishing. Objectives should be

developed when:

Something is wrong (a weakness)

and needs to be corrected;

Something is threatening (a

threat), and needs to be prevented;

Something is inviting (an

opportunity), and needs to be

pursued.

Objectives should flow rom the

previous work youve done in developinga vision statement, identiying

opportunities, threats, strengths and

weaknesses, and rom your vision o the

uture o the group.

Te final step in developing a

strategic plan is to develop and agree

on strategies to be used to attain your

objectives. Strategies are decisions and/or

major action programs employed by the

group to ulfi ll its vision. Once strategies

are identified, the group can assign

responsibilities and completion dates. It is important that both the physician

and administrative staff understand tha

this is their plan and requires their inpu

and participation. I your group has no

developed such a plan, how does it know

where its going?


Will Latham, MBA,President, LathamConsulting Group,Inc., Chattanooga,TN. Latham Consult-ing Group helpsmedical group physi-cians make decisions,resolve conflict, andmove forward. For more than twenty-five

years Mr. Latham has assisted medicalgroups in the areas of strategy and planning,governance and organizational effective-ness, and mergers, alliances and networks.During this time he has: facilitated over 900meetings or retreats for medical groups;helped hundreds of medical groups developstrategic plans to guide their growth and

development; assisted over 130 medicalgroups improve their governance systems

and change their compensation plans;and advised and facilitated the mergers

of over 120 medical practices represent-ing over 1,200 physicians. Latham has an

MBA from the University of North Caro-

lina in Charlotte and is a Certified PublicAccountant. He is a frequent speaker atlocal, state and national, and specialty-specific healthcare conferences. He can bereached at (704) 365-8889 or [email protected].


12/24


Te specialty o anesthesiology is

experiencing an unprecedented level o

merger activity and practice acquisitions.

Te idea o two or more practices joining

orces to secure their market position or

enhance their strategic options is hardly

a new phenomenon. Te past ew decades

has seen the emergence o some very

large anesthesia organizations that have

dramatically changed the landscape in

their respective markets. Once a pioneer

in large group practice management, the

Anesthesia Service Management Group

(ASMG) and its 150 plus physicians in

San Diego has become a model to emulate

and refine. By some accounts, we havealready reached a point where ewer than

100 organizations employ more than 15

percent o all anesthesia providers, but this

is only a rough calculation, made espe-

cially challenging by the recent inusion

o venture capital money that is inspiring

an impressive list o practice acquisitions

across the country. Tis dramatic rethink-

ing o the very nature o an anesthesia

practice as not just a way o satisying the

requirements o an exclusive contract with

a particular hospital or surgery center butas a serious business organization bent on

increasing market share raises some very

undamental questions that are inspiring

lively debates in anesthesia board rooms

across the country. Essentially there are

three options open to any hospital based

practice.

Te first option is to stand firm and

find ways to define the group as a niche

practice uniquely qualified to meet the

specific expectations and requirements o

a particular acility. Tere is no shortage o

anesthesia practices that could well meetthis criterion. Independent rural hospi-

tals tend to be a case in point. Specialty

hospitals that have very unusual service

requirements may also be candidates or

small, monogamous practices. What does

not fit the bill is the practice that simply

chooses not to be a competitor and which

chooses not to ocus its energies on the

highest level o customer service. In the

current environment, going it alone can

be a very risky strategy. With increasing

requency, unsuspecting physicians arecoming to appreciate just what it means to

be the recipient o a Request or Proposal

(RFP). No three letters evoke such anxiety.

Second, groups that dont have a plan

or a strategy o their own may consider

selling out. Practices that have never

invested in the development o a strong

administrative inrastructure may choose

to affiliate themselves with entities that

have more evolved business structures.

Te underlying logic here ollows a classic

line o reasoning: i you cant compete

effectively on your own, then merge with

a practice that has proven its ability to be

master o its own destiny. Tis saety in

numbers approach may offer many advan-

tages, but it can also prove to be less than

ideal, especially i the price o admission

includes a serious buy-in or material loss

o constituency. Nothing is more peril

ous than negotiating rom a position o

weakness.

It is the rare group that has the

courage or conviction to ollow the third

optionto take the lead in creating a new

competitive mega-group. It is always easier

to find a proven solution than to craf onerom scratch. Te leadership must believe

they have a significant strategic advantage

to leverage. Maybe they are the preerred

anesthesia practice within a strong hospi-

tal network. Maybe they are a practice tha

has invested in their administration and

inrastructure. It is also possible that they

have an in-house billing service they are

hoping to offer other anesthesia groups.

While many practices talk about

leading the pack, it is the rare group that

is successul. Te challenges can be signifi-cant. What worked in one practice is no

always transerable to another. Te vision

o one leadership is not always the vision

o another, especially when that vision is

tested by the practical realities o gover-

nance, compensation and ownership

Te political challenge o getting multiple

practices to agree on one billing solution

is ofen the atal flaw in the equation. Even

those that do agree to merge do not always

stay merged.

TIMINGISEVERYTHINGDIVININGTHEWISDOMOFANESTHESIAAGGREGATION

INTHECURRENTENVIRONMENTJody Locke, CPC

Vice President of Anesthesia and Pain Management Services, ABC


13/24


A review o todays largest practices,

all o which are the result o at least a ew

mergers, reveals three essential criteria

or success: rationale, structure and inra-

structure. Large groups survive and thrive

because their members have confidence

in their vision, leadership and manage-

ment. Tis is not an easy combination o

qualities to achieve and the law o entropy

definitely applies to anesthesia practices:

there are more actors working against

their survival than or it.

RATIONALE AND STRUCTURE FOR

AMERGER

As is true o any business proposal,

the vision comes first. How will the group

distinguish itsel in the market place; how

will it get and keep customers and what

will its value proposition be? Tere has to

be a clear and compelling rationale or the

merger that makes sense and which can be

simply articulated by all participants. It is

not enough to claim that a bigger group

will get better rates or reduce its cost o

doing business, however important these

may be perceived to be. Strong leadership

and vision can ofen finesse the objections

but ultimately i there is no consensus, the

new entity will orever be encumbered

by its history and diverse cultures and

outlooks o its members.

Te proposed structure can also

prove critical. Tis is where lawyers earn

their ees. Tis is much more than a simple

question o C-Corp, S-Corp, partnership

or LLC. Tese are just labels. Te orm

and structure o the entity must supportits unction. It is a delicate balancing act

to find the right structure that will make

new members eel comortable enough to

join but which will give the entity the legal

leverage to achieve its business objectives.

Inrastructure is critical and the

final necessary prerequisite. oo many

practices are simply too nave about the

breadth and depth o their administrative

inrastructure. Te administrative team

or its surrogate must have the resources

and experience to smoothly integrate new

shareholders and employees. Seriously

disgruntled employees can derail even themost compelling plan.

A newly emerging and already quite

substantive entity, Midwest Anesthesia

Partners, Ltd. (MAP) is the brain child

and offspring o Park Ridge Anesthesiol-

ogy Associates, Ltd. (PRAA) and Lake

County Anesthesiologists, Ltd., signifi-

cant practices based at Lutheran General

Hospital in Park Ridge, Illinois and

Condell Hospital in Libertyville, IL. Well

known preeminent anesthesia groups in

the area associated with one o the promi-nent hospital systems, Advocate Health,

their leadership believes the time is right

to leverage their combined position in the

local market. Preliminary numbers indi-

cate that MAP could manage more than

150 physicians and CRNAs by the end o

the year. Te enthusiasm o MAPs presi-

dent, David Rosen, MD, inspires at least

three obvious questions: Why now? What

does MAP hope to accomplish? How likely

is the group to succeed?

Te timing o the ormation oMAP is no accident. It is directly related

to the implementation schedule or the

Patient Protection and Affordable Care

Act (ACA). Tere are always necessary

and sufficient causes or launching a new

practice initiative. PRAAs long history at

Lutheran General and its reputation in the

community were necessary prerequisites

but until the ACA was signed into law

there was no one specific and sufficient

motivation to dramatically restructure the

practice model. MAP ounders believe,

and they are certainly not alone in this

belie, that three actors set the stage or

the passage o the law and that these will

continue to be the actors that will drive

uture developments in health care.

Any discussion o health care starts

with the cost. Te national cost o health

care has been one o the astest growing

items in the Federal budget or years,

despite tight price controls on Medicare

and Medicaid rates. Te cost o health-

care is the number one cause o persona

bankruptcy. Increasingly businesses have

had to opt out o health care coverage due

to spiraling premiums. Numerous provi

sions o the ACA are intended to address

the cost o health care and availability and

affordability o health insurance.

One o the undamental concerns

with the current system is that it rewards

physicians or providing services whether

necessary or helpul or not. Tis tradi-

tion o ee-or-service medicine has been

the basis or the entire medical paymen

system or as long as anyone can remem-

ber. Te standard bible o all billing

personnel is the AMAs CP book thanumerically codifies all medical services

so that payors can develop ee schedules

and payment criteria. Te system has

become so complicated that it spawned

yet another reerence, the Correct Coding

Initiative (CCI) to identiy which proce

dures can reasonably be billed with others

It started as a good idea and a very logica

way to ensure that providers got paid or

the services they deemed appropriate o

good patient care. Te system has clearly

encouraged the development o hundredso new modalities that have contributed

to an ever higher standard o care. Te

problem is that or all the good it did, i

has also encouraged providers to exploi

the system through creative coding and

unbundling. Te ACA includes various

provisions or pilot projects and othe

initiatives to change the incentive rom

ee or service to ee or outcomes, or pay

or perormance (P4P).



14/24

Te second major driver behind the

ACA is a concern with the quality o care

provided. By most accounts, Americans

pay more or healthcare than most indus-

trialized nations but our outcomes and

quality rank us well below the leaders. Tis

problem has inspired a concerted effort to

implement and expand the use o Elec-

tronic Medical Records (EMRs). Tere

is considerable consternation across the

country as hospital administrations and

health systems move orward with EMRs.

Not all providers accept that capturing

more details about each patient interaction

will necessarily improve the quality o care

and outcomes. Most observers believe,

however, that the underlying theme here

is already quite clear. Physicians must do

a much better job o substantiating the

quality o care provided and whether the

desired outcome was achieved. Te belie

is that this will become a significant actor

in the payment calculation. Tis intense

ocus on the justification or payment is

at the heart o the new diagnosis coding

system (ICD-10) that is scheduled to be

implemented next October.

At the heart o MAPs strategic plan

is a belie that only organizations o a

sufficient mass can afford to develop the

inrastructure necessary to reposition

anesthesia practices to compete aggres-

sively in what is anticipated to be a ar

more competitive market or health care.

Ultimately, every hospital administration

that must select a new provider group

hopes to base its decision on cost, quality

and a belie that the entity is positioning

itsel or the uture o health care.

MAP is a partnership o corporate

members. Te intent is to provide suffi-

cient reedom and flexibility or groups

that want to join to maintain their corpo-

rate culture and integrity while achieving

economies o scale. Essentially, the struc-

ture encourages individual member groups

to continue to ocus their energies and

efforts on customer service or the acili-

ties they serve. Te role o the partnership,

by contrast, is to negotiate with payors or

optimum payment rates, provide corporate

and support services and to market the

entity as a whole.

Tus ar the strategy appears to be

working. Interest in the partnership has

been intense.

Te ormation o this new entity raises

a number o interesting questions about

why, when and how markets or anesthe-

sia services change. In some senses, MAP

is late to the game. Cities like San Diego

and Portland have been experiencing the

market impact o very large anesthesia

groups or years. Te NAPAs o the world

are a more recent phenomenon. Why

did it take so long or such an entity to

coalesce in the Chicago market? Tere are

two prevailing theories. Te first ocuses

simply on economics. Chicago practices

have done airly well compared to those

in the rest o the Midwest. While anes-

thesia compensation levels have not been

the highest in the country, they have been

very competitive. Tere have simply not

been the kind o dramatic market orce

imposed by managed care plans that have

distinguished places like Philadelphia and

Houston, where other very large entitie

were organized a dozen or so years ago

Even now the initiative inspiring MAP is

more pro-active than reactive.

Te other actor is ar more subtle. For

reasons that are unique to the local marke

one management firm, Merus Manage-

ment, has enjoyed the trust and respect oa significant percentage o the areas anes-

thesia practices or years. In effect, Merus

has provided a level o service and practice

management that other practices have el

they needed to create or themselves. It

comes as no surprise that the ormation o

MAP is the logical next step in the evolu

tion o Meruss influence in the market.

So what does the uture hold? Te

ounders o MAP are cautiously optimistic

Tey would be thrilled i MAP represents

200 providers by the end o 2014. In their

view the logic o consolidation is selling

itsel. Tey are also realistic enough

however, to understand that the group mus

deliver on its promises. Tis will be the ulti-

mate validation o the concept but wha

they would say is that i you get enough

people believing in the uture o MAP and

willing to work to make it a strong orce in

the Chicago market, it will be.


TIMINGISEVERYTHING: DIVININGTHEWISDOMOFANESTHESIA

AGGREGATIONINTHECURRENTENVIRONMENTContinued from page 13

GROWTH OF MIDWEST ANESTHESIA PARTNERS, LTD. (MAP)

Founding Groups Physicians CRNAs

Park Ridge Anesthesiology Associates, Ltd. 46 6

Lake County Anesthesiologists, Ltd. 21 18

Joining Groups

Northwest Suburban Anesthesiologists, Ltd. 36

Lincoln Park Anesthesia and Pain Management , Ltd. 10

Totals 113 24

Jody Locke, CPC,

serves as Vice Presidentof Pain andAnesthesiaManagement for ABC.Mr. Locke is respon-sible for the scope andfocus of services pro-vided to ABCs largestclients. He is also re-sponsible for oversight and managementof the companys pain management billingteam. He will be a key executive contact forthe group should it enter into a contract forservices with ABC. He can be reached [email protected].


15/24



STUDENTTRAININGPROGRAMS

MAYPOSESIGNIFICANTLIABILITYEXPOSURETOANESTHESIOLOGISTS

Brian J. Thomas, JD

Senior Claims Attorney & Director of Risk Management, Preferred Physicians Medical, Shawnee Mission, KS

Anesthesiologists are requently

requested to participate in student train-

ing programs or emergency medicaltechnicians (EMs)1, student nurse

anesthetists (SRNAs), medical residents

and students and respiratory therapists

to provide training and supervision or

intubation proficiency and airway main-

tenance. While most proessional liability

carriers provide coverage or participat-

ing in these student training programs,

the ollowing case summary underscores

the significant liability exposures that can

arise.

A 20 year old emale, 54, 38.5 kg,with a medical history significant or

kidney removal, duodenal obstruc-

tion and persistent vomiting or 4 days

presented or Roux-en-Y gastric bypass

and appendectomy. A nasogastric (NG)

tube had been placed on the day o the

procedure, but the NG tube had been

sneezed out approximately two hours

prior to the procedure. Te surgeon was

aware the NG had come out; however,

that inormation was never conveyed to

anesthesia. Te anesthesia group had a contract

with the county emergency medical

services (EMS) program or teach-

ing EM students intubation. An EM

student being supervised by an anes-

thesiologist and a certified registered

nurse anesthetist (CRNA) attempted a

standard intubation. Te EM student

intubated the patients esophagus on

his first attempt. Te patient aspirated a

significant amount o gastric contents

that was suctioned. Te esophageal intu-

bation was immediately recognized and

the CRNA successully intubated on the

second attempt. An NG tube was placed

and approximately 600 cc o gastriccontents was suctioned rom the patients

stomach.

Te surgery was completed without

urther complication. However, a chest

x-ray showed aspiration pneumonia

requiring prolonged intubation and venti-

lation. On the seventh post-operative day

the patient had a period o ventriculartachycardia and it was thought she was

having an acute myocardial inarction

Te patient was transerred to another

acility where she underwent urgent

cardiac catheterization. Te patient had

a complicated medical course ollowing

the aspiration requiring various hospita

admissions or pneumonia, aspiration

strokes and complications rom trache-

ostomy. Te patient was subsequently

diagnosed with significant brain damage

and was unable to perorm activities odaily living.

Te patients parents, on behal o

their daughter, sued the hospital, the

supervising anesthesiologist and his

anesthesia practice group.2 Plaintiffs

allegations included, but were not limited

to, ailing to employ adequate diagnos

tic procedures and tests to determine

the nature and severity o the plaintiff s

medical status and/or conditions; ailing

to employ appropriate treatments and

procedures to correct such conditionsnegligently permitting, without notice to

and/or the consent o the plaintiff, an EM

student to attempt intubation; negligently

ailing to inorm the plaintiff o the risks

reasonably associated with permitting

an EM student to attempt intubation

and ailing to exercise reasonable care

in the treatment and management or

the complications and sequelae associ

ated with aspiration o gastric contents

1Te term Emergency Medical echnician (EM) encompasses several different levels o training, responsibility, experienceand skill. EM-Basic is an entry level certification including basic airway management. EM-Intermediate is a step betweenBasic and Paramedic and includes additional education and skills instruction. EM-Paramedic requires either a two year degreeor a certification program and is the most advanced level o EM. Paramedic skills include, among others, advanced airwaymanagement including endotracheal intubation, orcep use or airway obstruction and emergency surgical airway skills.2Plaintiffs did not sue the EM student despite the act the county employer carried $1,000,000 in insurance coverage or claimsagainst its EM students.


16/24


causing permanent and irreversible brain

damage and related injuries.

Plaintiffs anesthesiology expert,

Corey Burchman, MD rom York, Penn-sylvania, was prepared to testiy that the

supervising anesthesiologist violated the

standard o care by allowing an EM

student to attempt intubation on a patient

with a significant risk o aspiration due

to her bowel obstruction. Plaintiffs

expert additionally criticized the ailure

to perorm a rapid sequence induction.

Dr. Burchman was also critical o the

response and intervention to the observed

aspiration.

Te deense anesthesiology expert

opined there was no deviation in thestandard o care to have perormed an

esophageal intubation that was recog-

nized immediately with the tube removed

and reintubated. Te deense expert also

asserted that aspiration is one o the recog-

nized risks associated with intubation and

not the result o a breach o the standard o

care. Te deense expert was prepared to

testiy it was not below the standard o care

to allow an EM student to perorm the

intubation under supervision. However,

the deense expert conceded he would nothave allowed an EM to attempt intuba-

tion on this patient due to her increased

risk or aspiration.

Te plaintiffs economic exper

estimated the plaintiffs lost earnings at

present value were $1,606,554. Plaintiff s

economic expert estimated uture care

costs or in-home care at $16,155,770

to $21,969,117 and in a care acility a

$29,945,398 to $30,246,075.

Te anesthesia deendants partici

pated in a court-ordered, pre-tria

settlement conerence with the hospitaand plaintiffs. Based on the significan

damages and potential liability exposure

the proessional liability carrier or the

anesthesia deendants contributed to a

$7,000,000 global pre-trial settlement

with the hospital.

STUDENTTRAININGPROGRAMSMAYPOSESIGNIFICANTLIABILITY

EXPOSURETOANESTHESIOLOGISTSContinued from page 15

Brian J. Thomas,

JD, serves as Senior

Claims Attorney& Director of RiskManagement forPreferred Physi-cians Medical inShawnee Mission,KS. Mr. Thomas

has over twenty-one years of insuranceindustry experience, including fourteen

years devoted exclusively to defendinganesthesiologists and their anesthesiapractices. Thomas leads Preferred Physi-cians Medicals risk management effortsfor the development of enhanced riskmanagement tools for its policyholdersand is the Editor-in-Chief for PPMs riskmanagement newsletter, Anesthesia & theLaw. He also serves as Senior ClaimsAttorney managing high severity claim

and litigation files in twenty states. Mr.Thomas is a 1995 graduate of Washburn

University School of Law. Thomas is afrequent speaker at risk management

seminars, national and state professional

society meetings, and defense counselseminars. He can be reached by email at

[email protected] or at (913)262-2585.

Risk Management Tips for Participation in Student Training Programs

Carefully review any student training agreements or contracts.

Determine if students have malpractice insurance coverage through thehospital, employer or school.

Obtain copies of certificates of insurance confirming student malpractice

insurance coverage.

Verbal and written anesthesia informed consent must specifically disclose thatstudents may be involved in the patients care.

Patients must have an opportunity to refuse to allow students to participate intheir care.

Ensure students have been carefully screened and have the appropriate level ofeducation, training, experience and skills to participate in training program.

Carefully select appropriate patients to be intubated by students (For example,patients with no significant co-morbidities, easy airways and class 1 or 2 on

Mallampati classification).


17/24


On October 1, 2014, the United

States health care system will undergo a

major transormation. We will transition

rom the decades-old Ninth Edition o

the International Classification o Diseas-

es (ICD-9) set o diagnosis and inpatient

procedure codes to the enth Edition o

those code setsor ICD-10. Te enth

Edition is the version currently used bymost developed countries throughout the

world. ICD-10 allows or greater speci-

ficity and detail in describing a patients

diagnosis and in classiying inpatient

procedures, so reimbursement can better

reflect the intensity o the patients condi-

tion and diagnostic needs.

Tis transition will have a major

impact on anyone who uses health care

inormation that contains a diagnosis

and/or inpatient procedure code, includ-

ing hospitals, physicians, other providers,payers, clearinghouses, billing compa-

nies, etc.

Te change will affect all covered

entities as defined by the Health Insur-

ance Portability and Accountability Act

o 1996 (HIPAA). Covered entities are

required to adopt ICD-10 codes or

services provided on or afer the October

1, 2014 compliance date. For inpatient

claims, ICD-10 diagnosis and proce-

dure codes are required or all stays with

discharge dates on or afer October 1,

2014.

Note that the transition to ICD-10

does not directly affect provider use o the

Current Procedural erminology (CP)

and Healthcare Common Procedure

Coding System (HCPCS) codes.

ABOUTICD-10

Te World Health Organization

(WHO) publishes the International Clas-

sification o Diseases code set, which

defines diseases, signs, symptoms,

abnormal findings, complaints, social

circumstances, and external causes o

injury or disease. Te ICD-10 is copy-

righted by the WHO (http://www.who.

int/whosis/icd10/index.html). Te WHO

authorized a U.S. adaptation o the code

set or government purposes. As agreed,

all modifications to the ICD-10 must

conorm to WHO conventions or the

ICD. Currently, the United States uses

the ICD code set, Ninth Edition (ICD-9),

originally published in 1977, and adopted

by this country in 1979 as a system orclassification o morbidity data and

subsequently mandated as the Medicare

claims standard in 1989 in the ollowing

orms:

ICD-9-CM (Volume 1), the tabular

index o diagnostic codes

ICD-9-CM (Volume 2), the alpha-

betical index o diagnostic codes

ICD-9-CM (Volume 3), institu-

tional procedure codes used only in

inpatient hospital settings

In 1990, the WHO updated its inter

national version o the ICD code set or

mortality reporting. Other countries

began adopting ICD-10 in 1994, but

the United States only partially adopted

ICD-10 in 1999 or mortality reporting.

Te National Center or Health

Statistics (NCHS), the ederal agency

responsible or the United States use oICD-10 developed ICD-10-CM, a clini

cal modification o the classification or

morbidity reporting purposes, to replace

our ICD-9-CM Codes, Volumes 1 and

2. Te NCHS developed ICD-10-CM

ollowing a thorough evaluation by a

technical advisory panel and extensive

consultation with physician groups, clini

cal coders, and others to ensure clinica

accuracy and useulness.

HOW DO ICD-9 AND ICD-10DIFFER?

Tere are several structural differ

ences between ICD-9-CM codes and

ICD-10 codes1. able 1 on page 18illus

trates the difference between ICD-9-CM

(Volumes 1 and 2) and ICD-10-CM.

ICD-10-CM/PCS consists o two parts:

1. ICD-10-CM or diagnosis coding

in all health care settings

2. ICD-10-PCS or inpatient proce

dure coding in hospital settings

Te General Equivalence Mappings

(GEM) are a reerence mapping that

attempts to include all valid relationship

between the codes in the ICD-9-CM diag-

nosis classification to the ICD-10-CM.

By moving to an expanding code

system, ICD-10 will provide governmen-

tal agencies and payers with more specific

AREYOUREADYFORICD-10?Joette Derricks, CPC, CHC, CMPE, CSSGBVice President of Regulatory Affairs & Research, ABC


1http://www.ama-assn.org/ama1/pub/upload/mm/399/icd10-icd9-differences-act-sheet.pd


18/24


data than ICD-9. Tis expanded data

capability will aid in:

Capturing Quality data

Reducing coding errors

Analyzing disease patterns

racking and responding to public

health outbreaks

Identiying raud and abuse

PREPARINGFORTHETRANSITION

Most hospitals, physicians groups,payers, clearinghouses, and billing

companies have been preparing or

the transition or several years. Te

conversion to ICD-10 requires adequate

planning, training o coders, billers and

clinical providers, converting system

programs, testing and developing backup

contingency scenarios. In addition, every

organization needs to assess their current

workflow and processes to determine i

and how the conversion to ICD-10 may

impact production or service to patients.

For example, the pre-authorization

process generally requires diagnosis inor-

mation. Hospitals and physician practices

need to look at how that process works

today in their organization and what may

need to change.

alk to the users and examine all

documents that in any way reer to or

require diagnosis inormation. A ew

questions to ask include: Do the orm(s)used to record the pre-authorization

requests need to change? What level o

training do the employees that handle the

pre-authorization require? By assessing,

questioning, communicating, training,

revising and implementing new or differ-

ent policies and procedures now you

will minimize the potential risks that the

Centers or Medicare & Medicaid Servic-

es (CMS) has identified. Tese include

potential delays in payments, increased

accounts receivable and higher deniarates.

Since ICD-10 is more specific

research has shown that physicians may

need to document differently to ensure

that the medical record has sufficien

inormation to allow coders to assign

the ICD-10 code. Many hospitals and

large physician groups are putting in

place a clinical documentation improve

ment process (CDI) at this time to help

communicate and educate physicians

on what additional inormation may be

required when the conversion to ICD-10

occurs. A CDI process requires the code

to examine the physicians current docu

mentation and identiy whether it is or

isnt sufficient to allow an ICD-10 code to

be identified. Feedback is then provided

to the physician on what additional inor

mation should be incorporated into the

medical record documentation going

orward so when the transition occurs

the complete and accurate documentation will be available and thus the risk o

delays or denials will be diminished. Te

additional documentation is inormation

that the physician would know at the time

o the service. It includes inormation

such as location, laterality, type o visi

(initial or subsequent), etc.

TABLE 1: DIAGNOSIS CODE COMPARISON

CHARACTERISTIC ICD-9-CM (VOLS. 1 & 2) ICD-10-CM

Field length 3-5 characters 3-7 characters

Available codes Approximately 14,000 codes Approximately 69,000 codes

Code composition(numeric or alpha)

Digit 1 = alpha or numericDigits 2-5 = numeric

Digit 1 = alphaDigit 2 = numericDigits 3-7 = alpha or numeric

Available space fornew codes

Limited Flexible

Overall detail

embedded withincodes

Limited detail in many

conditions

Generally more specific (allows description

of comorbidities, manifestations, etiology/causation, complications, detailedanatomical location, sequelae (aftereffectsof a disease, condition, or injury suchas scar formation after a burn), degreeof functional impairment, biologic andchemical agents, phase/stage, lymph nodeinvolvement, lateralization and localization,procedure or implant related, age related, orjoint involvement)

LateralityDoes not identify rightversus left

Often identifies right versus left

Sample code 81315, Open fracture ofhead of radius

S52122C, Displaced fracture of head ofleft radius, initial encounter for open

fracture type IIIA, IIIB, or IIIC

AREYOUREADYFORICD-10?Continued from page 17


19/24

HELPFULRESOURCES

Te CMS has a dedicated website

with some excellent tools for hospitals

and physician practices of all sizes. In

addition, the American Medical Asso-

ciation (AMA), specialty associations,

major health insurance payers and

clearinghouses all have information ontheir websites to help providers with the

transition. If you have not yet heard

from your coding or billing department

it may be beneficial to review some basic

information and then reach out and see

where your organization is in regards to

the ICD-10 transition.

Following are some links to learn more:http://cms.gov/Medicare/Coding/ICD10/

index.html

http://www.cdc.gov/nchs/icd/icd10cm.htm

http://www.ahima.org/icd10/whatisicd10.aspx

http://www.aapc.com/ICD-10/

http://www.ama-assn.org/ama/pub/physician-

resources/solutions-managing-your-practice/

coding-billing-insurance/hipaahealth-

insurance-portability-accountability-act/

transaction-code-set-standards/icd10-code-

set.page


Joette Derricks, CPC,

CHC, CMPE, CSSGB

serves as Vice Presi-

dent of Regulatory

Documents

Anesthesia Business Consultants Communique Summer 2013 Edition