threats to our prosperity alexander a. hannenberg, m.d. first vice president american society of...
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Threats to Our Prosperity
Alexander A. Hannenberg, M.D.Alexander A. Hannenberg, M.D.
First Vice PresidentFirst Vice PresidentAmerican Society of AnesthesiologistsAmerican Society of Anesthesiologists
Tufts University School of MedicineTufts University School of MedicineNewton-Wellesley HospitalNewton-Wellesley Hospital
Newton, MANewton, MA
Areas of Concern
DemographicsDemographics Recalibrated Hospital DRG PaymentsRecalibrated Hospital DRG Payments Rapid Growth Anesthesia ServicesRapid Growth Anesthesia Services Shift to Quality-Based PaymentShift to Quality-Based Payment
Unprecedented Lift in Anesthesia Work Value
$16.19$16.19$55.00 = 29.4%$55.00 = 29.4%
$20.19$20.19$55.00 = 36.7%$55.00 = 36.7%
2008 Best Case Scenario2008 Best Case Scenario
Medicare Eligible Population Growth
Sources: Projections of the Population by Age are taken from the January 2004 Census Internet Release. Historical data are taken from "65+ in the United States," Current Population Reports, Special Studies, P23-190 Data for 2000 are from the 2000 Census and 2002 data are taken from the Census estimates for 2002.)
mill
ions
Dependency on Hospital SupportAcademic Anesthesia Departments
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
2000 2002 2003 2004
Average Support / FTE
Tremper KK et al Anesth Analg 2006;102:517–23
Rebasing Medicare DRGS (Healthcare Advisory Board)
Shifting Profit from Surgery to Medicine?
MarginMargin
UtilizationUtilization
CostCost
Specialty Supply & DemandResidency Enrollment 1999-2007
-15%
-10%
-5%
0%
5%
10%
15%
20%
25%
30%
-15%
-10%
-5%
0%
5%
10%
15%
20%
25%
30%
JAMA 9/6/2000; 9/5/2007
Medicare One Year Spending Growth2005-2006
01905 Anes, Spine Inject, X-Ray/Re01926 Anes, Tx Interv Rad Hrt/Cran01930 Anes, Ther Interven Rad, Vei
64445 N block inj, sciatic, sng64447 N block inj fem, single64448 N block inj fem, cont inf64470 Inj paravertebral c/t64475 Inj paravertebral l/s64555 Implant neuroelectrodes64561 Implant neuroelectrodes64581 Implant neuroelectrodes
101%22%27%
20%17%49%40%21%
148%46%34%
Responses to Rapid Growth
Medical Necessity RequirementsMedical Necessity Requirements Payment ReductionPayment Reduction
Less Complex Typical Patient / ServiceLess Complex Typical Patient / Service Advanced Technology / PharmacologyAdvanced Technology / Pharmacology
Non-Coverage DeterminationNon-Coverage Determination Service-Specific SGR CalculationService-Specific SGR Calculation
Volume Volume Annual Update Annual Update
Growth in Endoscopy AnesthesiaMedicare 2003-2006
22%
27%
31%
33%
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
2003 2004 2005 20060%
5%
10%
15%
20%
25%
30%
35%
Anesth For EndoEndoscopy% Anesth
Anesthesia for All Endoscopy
-2002 Endoscopy volume per CDC-Anesthesia Fee = 5 Base + 3.74 Time Units
Medicare CF $17.76Non Medicare CF $50
Procedures Fee CostNon-Medicare 9,200,000 437.00$ $4,020,400,000Medicare 5,000,000 155.22$ $776,112,000Total 14,200,000 $4,796,512,000
Procedures Fee CostNon-Medicare 9,200,000 437.00$ $4,020,400,000Medicare 5,000,000 155.22$ $776,112,000Total 14,200,000 $4,796,512,000
Aetna: May 2006
ASA 1-2: No payment in office settingASA 1-2: Payment at Sedation Service fee in facilityASA 3-4: Base+Time MethodologyAll: Manual Submission & Review
Shift to Quality-Based Payment
Medicare PQRI 2008: $1.35 BillionMedicare PQRI 2008: $1.35 Billion California IHA: $55 Million --> 200 groupsCalifornia IHA: $55 Million --> 200 groups Massachusetts BCBS: $190 MillionMassachusetts BCBS: $190 Million Medicaid: 43/50 ProgramsMedicaid: 43/50 Programs
1 of 74 PQRI Measures 1 of 74 PQRI Measures available to available to anesthesiologistsanesthesiologists
2008: 140 Measures2008: 140 Measures 2 Measures for OR Practice2 Measures for OR Practice 2 Measures for ICU Practice2 Measures for ICU Practice
Opportunities for P4P Revenue
Anesthesiology Medicare:Commercial Ratio2007 Update
$16.19$16.19$55.00 = 29.4%$55.00 = 29.4%
Bierstein K ASA Newsletter Jul07
Medicare Payment Increase
RUC Recommended 32% Work Value IncreaseRUC Recommended 32% Work Value Increase Work = 77.2% of Anesthesia CFWork = 77.2% of Anesthesia CF Maximum Impact --> $4.00 Increase (2008)Maximum Impact --> $4.00 Increase (2008)
32% x 0.772 x $16.1932% x 0.772 x $16.19 $16.19 --> $20.19$16.19 --> $20.19
Other FactorsOther Factors Budget Neutrality ($0.33)Budget Neutrality ($0.33) Practice Expense ($0.19)Practice Expense ($0.19) SGR Reduction ($1.95)SGR Reduction ($1.95)
Expected Range: $20.19 - $17.72Expected Range: $20.19 - $17.72
American Society for Gastrointestinal Endoscopy
Guidelines for the use of deep sedation and anesthesia for GI endoscopy
“The routine assistance of an anesthesiologist for average risk patients undergoing standard upper and lower endoscopic procedures is not warranted and is cost prohibitive.”
Gastrointest Endoscopy 56:613, 2002
Anesthesia for Interventional RadiologyMedicare 2005-2006
$0 $1 $2 $3 $4 $5 $6 $7 $8
Millions
Anes, Spine Inject, X-Ray/Re
Anes, Tx Interv RadHrt/Cran
Anes, Ther IntervenRad, Vei
Peripheral Nerve Block Procedures
$0 $1 $2 $3 $4 $5 $6
Millions
N block inj fem, single
N block inj, sciatic, sng
N block inj fem, cont inf
Growth in Interventional Pain Procedures
$0 $10 $20 $30 $40 $50 $60 $70 $80 $90 $100
Millions
Destr paravertebral n add-on
Inj paravertebral c/t add-on
Destr paravertebrl nerve l/s
N block, other peripheral
Inj paravertebral c/t
Inj foramen epidural add-on
Inj paravertebral l/s add-on
Inj paravertebral l/s
Inj foramen epidural l/s
Medicare 2005-2006