As director of business development for Southeast Anesthesiology Consultants in Charlotte, N.C., Mr. Ippolito assists hospitals in redesigning surgical and anesthesiology programs. Here he explains four anesthesia trends that affect an organization and its ORs.
1. Fewer anesthesiology personnel mean fewer available ORs. The ongoing shortage of anesthesiology personnel can force a hospital to cut back its surgery operations or even close an OR. According to a 2008 survey by the American Society of Anesthesiologists, 47 percent of hospitals had to reduce OR hours due to anesthesia staffing challenges. “Closing just one OR can result in as much as $2.5 million in lost hospital margin per year,” Mr. Ippolito says.
How big is the shortage? Mr. Ippolito reports that there is a nationwide deficit of at least 3,000 anesthesiologists as well as a sizeable deficit of CRNAs. While increasing numbers of anesthesia assistants — PAs with specialized training in anesthesia — are helping to offset the CRNA shortage, new demands for services are likely to exacerbate the problem.
For example, medical advances have made surgery possible for patients who otherwise might not have survived surgery in past years. In addition, “an increasingly aging population needs more surgery and new procedure types result in additional case volume,” Mr. Ippolito says. “Also, anesthesia services are now required in settings such as specialty hospitals and endoscopy and radiology sites.”
Meanwhile, spreading anesthesia cases over more sites translates into lower utilization of anesthesia staff per site. “The anesthesia pie is cut into smaller pieces, requiring additional staff to provide services at higher expense without additional revenue,” Mr. Ippolito says.
2. Low Medicare reimbursements mean hospitals have to pay stipends. “Medicare and Medicaid pay a fraction of what most private payors reimbursement for anesthesia services,” Mr. Ippolito says. To illustrate the financial imbalance of payment rates, an anesthesiologist can earn $360 an hour in a hospital OR if all payments are reimbursed by a private payor but only $120 an hour if they are all reimbursed by Medicare and $65 an hour if all through Medicaid, Mr. Ippolito reports. “Hospitals with high levels of Medicare and Medicaid patients my have to pay anesthesia staff a stipend to recruit anesthesia staff at the lower reimbursement rates,” he says.
3. Hospitals with inefficient ORs may have to pay higher stipends. Inefficient OR programs will require more hours of anesthesia staffing than would be necessary if they were operated efficiently. Increased hours of physician and CRNA staffing can mean paying higher stipends, without additional revenue. “Typical inefficiencies result from poor schedule planning and administration, which results in decreased OR utilization levels,” Mr. Ippolito says. In addition, unnecessarily lengthy case times can take up an inordinate amount of anesthesia staff time.
Many hospitals now use an anesthesia care team, where one anesthesiologist medically directs 2-4 anesthetists at the same time. “The care team must be administered effectively to optimize efficiencies,” Mr. Ippolito says. For example, placing too many CRNAs under the medical direction of one anesthesiologist can reduce costs, but may actually slow down the OR and decrease surgeon satisfaction if the medically directing anesthesiologist does not provide the necessary oversight in a timely manner. One anesthesiologist can only be in one place at one time during critical stages of a case such as induction and emergence of the patient.
4. Payment for medical direction means following CMS guidelines. “CMS will pay an anesthesiologist for medical direction of CRNAs, but only if the anesthesiologist meets conditions that demonstrate close collaboration with the CRNA,” Mr. Ippolito says. For example, the physician must perform a pre-anesthetic examination, prescribe the anesthesia plan and personally participate in the most demanding aspects of the anesthesia plan, such as induction and emergence of the patient.
CMS payment guidelines also require anesthesiologists to be “readily available” to the CRNA, which is generally believed to mean being in the same building and no more than a few floors away with easy access to the CRNA if needed, says Mr. Ippolito. Also, directing anesthesiologists must not be performing a procedure that they cannot leave immediately if the CRNA requires assistance. For example, “the anesthesiologist can be administering a labor epidural to a patient in the OB unit a few floors away but cannot be administering anesthesia to a patient undergoing a C-section even in the next room,” Mr. Ippolito says.
Additional information regarding effective anesthesiology program development and efficient perioperative services program operations can be found on Jerry Ippolito’s blog at SEanesthesiology.wordpress.com
