Recently there has been a significant focus on hospital employment of primary care and proceduralist physicians. This shifting foundation also portends dramatic changes of employment trends for hospital based physician services. In an environment of integrated delivery of care, many healthcare leaders believe that employment of hospital-based physicians offers the clearest path to control of pricing and maximized coordination of care. In the vital area of surgical care, anesthesia providers play a pivotal role in developing a high quality, efficient OR delivery system. Their integration into an aligned surgical delivery team will be crucial to success in the new world order.
Background
Traditionally, anesthesia has been provided by independent groups often with an exclusive contract to provide services at a hospital. However, by 2007, approximately 80 percent of hospitals were paying subsidies to secure anesthesia services [1], a number which was up sharply over the preceding decade and is likely to have grown since that time. Since such arrangements have often been structured as income guarantees and many hospitals came to view such subsidies as de-facto employment, a baseline trend toward anesthesia employment has existed for some time. For example, by 2009 36 percent of certified registered nurse anesthetists were employed by hospitals. [2]
What is likely in the future?
With the challenges of integrated delivery of surgical care peering over the horizon, strategic imperatives for employing anesthesia providers are greatly enhanced and the trend to employment should continue to increase. As these models become more prevalent hospital executives should remain cognizant of the unique attributes of anesthesia services which require careful development of comprehensive employment structures distinctly different from those applied to other physician specialties.
Therefore as new anesthesia employment models are being created or existing arrangements restructured, facilities will be best served by creating a framework which will act to align providers as true facility partners. Successful models will facilitate integration, while incentivizing efficiency and quality of care. Many components of these models are unique to anesthesia; therefore working with anesthesia experts to co-manage your employed group can offer the best of both worlds — a differentiated, aligned product with true control and integration.
The 10 keys
1. Engaged leadership. Identifying and cultivating the right leaders is a fundamental building block for success. Successful anesthesia leaders must provide ongoing communication to surgeons as well as operating room and hospital directors. They should seek to continuously improve the safety and efficiency of surgical care, and be actively involved in tracking performance and outcomes. It should be expected that anesthesia directors actively participate in all peri-operative committees and play a key role in OR process improvement initiatives.
2. Total peri-operative care. Prevailing reimbursement mechanisms lead many anesthesia groups to focus most of their resources on intra-operative care (while the patient is in the operating room). In order to optimize the potential anesthesia value proposition to an integrated delivery system, expectations for services should expand to encompass the entire peri-operative period (from patient pre-operative preparation to post-operative care). Successful approaches should frame out the specific role for the anesthesia provider group in pre-operative patient preparation, peri-operative process improvement and post-operative care. Protocols for evidence based practice and incorporation of standard post-operative pain management approach must be a part of the methodology as well.
3. Performance tracking. Items related to the quality and efficiency of anesthesia services should be tracked and ideally linked to a portion of provider compensation. The obvious items include CMS/SQIP measures such as timely antibiotic administration, sterile technique during central line placement and maintenance of normothermia. Many additional items may be monitored as applicable to each clinical and operational environment. Examples include surgeon satisfaction scores, day of surgery cancellations, completion of pre-operative evaluation prior to the day of surgery, and response time on call. The most important metrics are often displayed monthly, as a departmental scorecard or dashboard which is tracked by facility and group leaders.
3. Aligned incentives. While there is widespread recognition that productivity and performance incentives should be incorporated into any physician employment arrangement, the calculations for anesthesia groups are somewhat unique. While providers typically receive a base compensation, we increasingly see components of total compensation placed at risk based upon a number of anesthesia specific issues including productivity, performance and quality.
5. Quality oversight. As reimbursement becomes increasingly linked to quality and outcomes, anesthesia departments must be able to track and document quality. Once again, there are targeted metrics which are best tracked via an anesthesia specific tool.
6. Behavioral oversight. Inappropriate behavior on the part of anesthesia providers can have a negative impact on staff morale and surgeon satisfaction. Nonetheless, many groups have been reluctant to actively monitor and appropriately address inappropriate behavior. Development of predefined mechanisms of tracking and evaluating behavioral issues, evaluating them through peer review, and identifying consequences of such actions should be in place for all hospital based physician groups.
7. Clinical process maps. Provider variation in response to common clinical issues is a frequent source of dissatisfaction among surgeons and operating room staff. Such items may include lab value abnormalities, pre-operative preparation of patients with cardiac disease, NPO status and requirement for consultation reports, etc. As with any service-oriented business, consistency leads to customer satisfaction. An employment platform gives OR and anesthesia group leaders an ideal opportunity to develop written policies defining how they will address common clinical issues.
8. Cost control. Costs of anesthesia medications and supplies is a significant operating room line item. A number of opportunities exist to reduce or substitute anesthetic agents or supply items without detracting from patient care. In conjunction with pharmacy and OR management, anesthesia leadership should be informed of costs and develop clinical protocols to provide cost effective care without compromising patient safety.
9. Pain management. The use of catheters, long acting regional blocks and adjustment of intra-operative medication can significantly reduce post operative pain. Anesthesia groups appropriately utilizing such techniques can improve patient satisfaction (HCAHPS) scores, reduce post-operative complications and length of stay. Each of these results represents value added anesthesia care, and also will be differentiators allowing facilities to be more competitive under bundled payment arrangements.
10. Integrated surgical care. One clear theme in healthcare reform efforts is that closer integration will be required throughout the continuum of care. In the operating room, that will involve closer clinical and process related coordination among Anesthesia, Surgeons, OR nurses and other supporting services. Your employed anesthesia provider should be in the forefront, creating a tightly aligned delivery model for all types of surgical cases and throughout the entire peri-operative experience.
Summary
Facility leaders should recognize that simply applying a “cookie-cutter” approach to anesthesia providers which was designed for primary care and referring specialists is not a blueprint for success. In an optimally aligned model, one needs to understand the unique attributes of anesthesia practice, as well as the boundaries and limitations within which anesthesia can have a positive impact on your surgical services. Working with anesthesia subject matter experts to co-manage employed models can ensure that your employed practice will be a strong force helping to position your facility for surgical volume gains in today's market while creating an important foundation to optimize integrated surgical delivery in the near future.
Footnotes:
[1] “Anesthesiology Practice Costs, Revenues, and Production Survey Data”, American Society of Anesthesiologists Newsletter, April 2007.
[2] American Association of Nurse Anesthetists' Fiscal Year 2009 “AANA Practice Profile and Demographic Surveys & Database.”
Background
Traditionally, anesthesia has been provided by independent groups often with an exclusive contract to provide services at a hospital. However, by 2007, approximately 80 percent of hospitals were paying subsidies to secure anesthesia services [1], a number which was up sharply over the preceding decade and is likely to have grown since that time. Since such arrangements have often been structured as income guarantees and many hospitals came to view such subsidies as de-facto employment, a baseline trend toward anesthesia employment has existed for some time. For example, by 2009 36 percent of certified registered nurse anesthetists were employed by hospitals. [2]
What is likely in the future?
With the challenges of integrated delivery of surgical care peering over the horizon, strategic imperatives for employing anesthesia providers are greatly enhanced and the trend to employment should continue to increase. As these models become more prevalent hospital executives should remain cognizant of the unique attributes of anesthesia services which require careful development of comprehensive employment structures distinctly different from those applied to other physician specialties.
Therefore as new anesthesia employment models are being created or existing arrangements restructured, facilities will be best served by creating a framework which will act to align providers as true facility partners. Successful models will facilitate integration, while incentivizing efficiency and quality of care. Many components of these models are unique to anesthesia; therefore working with anesthesia experts to co-manage your employed group can offer the best of both worlds — a differentiated, aligned product with true control and integration.
The 10 keys
1. Engaged leadership. Identifying and cultivating the right leaders is a fundamental building block for success. Successful anesthesia leaders must provide ongoing communication to surgeons as well as operating room and hospital directors. They should seek to continuously improve the safety and efficiency of surgical care, and be actively involved in tracking performance and outcomes. It should be expected that anesthesia directors actively participate in all peri-operative committees and play a key role in OR process improvement initiatives.
2. Total peri-operative care. Prevailing reimbursement mechanisms lead many anesthesia groups to focus most of their resources on intra-operative care (while the patient is in the operating room). In order to optimize the potential anesthesia value proposition to an integrated delivery system, expectations for services should expand to encompass the entire peri-operative period (from patient pre-operative preparation to post-operative care). Successful approaches should frame out the specific role for the anesthesia provider group in pre-operative patient preparation, peri-operative process improvement and post-operative care. Protocols for evidence based practice and incorporation of standard post-operative pain management approach must be a part of the methodology as well.
3. Performance tracking. Items related to the quality and efficiency of anesthesia services should be tracked and ideally linked to a portion of provider compensation. The obvious items include CMS/SQIP measures such as timely antibiotic administration, sterile technique during central line placement and maintenance of normothermia. Many additional items may be monitored as applicable to each clinical and operational environment. Examples include surgeon satisfaction scores, day of surgery cancellations, completion of pre-operative evaluation prior to the day of surgery, and response time on call. The most important metrics are often displayed monthly, as a departmental scorecard or dashboard which is tracked by facility and group leaders.
3. Aligned incentives. While there is widespread recognition that productivity and performance incentives should be incorporated into any physician employment arrangement, the calculations for anesthesia groups are somewhat unique. While providers typically receive a base compensation, we increasingly see components of total compensation placed at risk based upon a number of anesthesia specific issues including productivity, performance and quality.
5. Quality oversight. As reimbursement becomes increasingly linked to quality and outcomes, anesthesia departments must be able to track and document quality. Once again, there are targeted metrics which are best tracked via an anesthesia specific tool.
6. Behavioral oversight. Inappropriate behavior on the part of anesthesia providers can have a negative impact on staff morale and surgeon satisfaction. Nonetheless, many groups have been reluctant to actively monitor and appropriately address inappropriate behavior. Development of predefined mechanisms of tracking and evaluating behavioral issues, evaluating them through peer review, and identifying consequences of such actions should be in place for all hospital based physician groups.
7. Clinical process maps. Provider variation in response to common clinical issues is a frequent source of dissatisfaction among surgeons and operating room staff. Such items may include lab value abnormalities, pre-operative preparation of patients with cardiac disease, NPO status and requirement for consultation reports, etc. As with any service-oriented business, consistency leads to customer satisfaction. An employment platform gives OR and anesthesia group leaders an ideal opportunity to develop written policies defining how they will address common clinical issues.
8. Cost control. Costs of anesthesia medications and supplies is a significant operating room line item. A number of opportunities exist to reduce or substitute anesthetic agents or supply items without detracting from patient care. In conjunction with pharmacy and OR management, anesthesia leadership should be informed of costs and develop clinical protocols to provide cost effective care without compromising patient safety.
9. Pain management. The use of catheters, long acting regional blocks and adjustment of intra-operative medication can significantly reduce post operative pain. Anesthesia groups appropriately utilizing such techniques can improve patient satisfaction (HCAHPS) scores, reduce post-operative complications and length of stay. Each of these results represents value added anesthesia care, and also will be differentiators allowing facilities to be more competitive under bundled payment arrangements.
10. Integrated surgical care. One clear theme in healthcare reform efforts is that closer integration will be required throughout the continuum of care. In the operating room, that will involve closer clinical and process related coordination among Anesthesia, Surgeons, OR nurses and other supporting services. Your employed anesthesia provider should be in the forefront, creating a tightly aligned delivery model for all types of surgical cases and throughout the entire peri-operative experience.
Summary
Facility leaders should recognize that simply applying a “cookie-cutter” approach to anesthesia providers which was designed for primary care and referring specialists is not a blueprint for success. In an optimally aligned model, one needs to understand the unique attributes of anesthesia practice, as well as the boundaries and limitations within which anesthesia can have a positive impact on your surgical services. Working with anesthesia subject matter experts to co-manage employed models can ensure that your employed practice will be a strong force helping to position your facility for surgical volume gains in today's market while creating an important foundation to optimize integrated surgical delivery in the near future.
Footnotes:
[1] “Anesthesiology Practice Costs, Revenues, and Production Survey Data”, American Society of Anesthesiologists Newsletter, April 2007.
[2] American Association of Nurse Anesthetists' Fiscal Year 2009 “AANA Practice Profile and Demographic Surveys & Database.”