Congress asked GAO to examine the effects on beneficiaries' costs if Medicare's fee-for-service cost-sharing included a single deductible, uniform coinsurance above the deductible, and an annual cap.
Modernizing and simplifying Medicare fee-for-service cost-sharing designs so that they resemble private plans is doable, but it comes with trade-offs, a Government Accountability Office studyshows.
Congress asked GAO to examine the annual and multiyear effects on beneficiaries' costs if Medicare FFS cost-sharing included a single deductible, uniform coinsurance above the deductible, and an annual cap.
GAO calculated the distribution of 28 million beneficiaries’ one-year, four-year, and eight-year annual cost-sharing responsibilities—including the median and maximum responsibility—under the current cost-sharing design and each of the four illustrative designs, compared these distributions, and found that:
During year one, the cost-sharing designs that feature relatively low deductibles and relatively high caps would result in a median annual beneficiary cost-sharing responsibility that is close to the current design.
In contrast, designs with relatively low caps provide greater beneficiary protection from catastrophic costs, but would increase annual cost-sharing levels above the existing design.
After eight years, there would still be differences in the median annual beneficiary cost-sharing responsibility across different designs, but they would be less pronounced.
Modernizing Medicare's cost-sharing design would have both direct and indirect effects on beneficiaries’ costs, GAO said in the study.
"The direct effect would be how the revised design would change beneficiaries' cost-sharing responsibilities for a given set of services," GAO said.
"The indirect effect would be that the altered incentives under a revised design would trigger behavioral responses, such as changes in beneficiaries' utilization of healthcare services, enrollment in supplemental insurance to help cover their Medicare cost-sharing responsibilities, or enrollment in Medicare FFS or Medicare Advantage."
Medicare's existing cost-sharing design is largely unchanged since the program was created in 1965. As a result, GAO notes, concerns have been raised that FFS design is confusing to beneficiaries, and leads to overuse of some services. In addition, the lack of an annual co-pay cap exposes some beneficiaries to catastrophic costs that can exceed tens of thousands of dollars each year.
As an example of the potential for confusion under the existing cost-sharing design, GAO noted that Medicare includes two separate deductibles: a relatively high deductible under Part A for hospital services, which are usually not discretionary and are less likely to be influenced by cost-sharing requirements, and a relatively low deductible for Part B outpatient services, which are more often discretionary and likely to be influenced by cost-sharing requirements.
The pharmacy giant saw net revenues up 4% to $185 billion in 2017, and anticipates at least $1.2 billion in cash benefits in 2018 from the Tax Cuts and Jobs Act, half of which will be used to pay down debt.
CVS Health CEO Larry Merlo says he "absolutely agrees with the goals and objectives" laid out in the healthcare partnership announced last week by Amazon, JPMorgan Chase and Berkshire Hathaway.
Now, like everyone else, he wants to see the details.
"We all saw the announcement last week," Merlo said in an earnings call with analysts on Thursday. "We absolutely agree with the goals and objectives that were outlined in that press release, but it’s important to acknowledge that the press release had few details and acknowledged that there isn't a plan."
Meanwhile, he says, the Woonsocket, RI-based company’s proposed $69 billion acquisition of Aetna will achieve many of the goals that Amazon/JP Morgan/Berkshire Hathaway hinted at, and that a potential partnership could emerge with Amazon if the proposal ever becomes reality.
"What that group aspires to is what we are going to deliver as part of this CVS/Aetna combination," Merlo says. "We have the infrastructure. We have the assets. We certainly have the healthcare expertise resident in both companies. And, we've demonstrated that we can execute on goals and objectives."
"We are chomping at the bit to get started," he says. "We want this new CVS/Aetna combination to be an open source model that, as we build out these capabilities, we can make them broadly available in the market. We are looking forward to partnering with all groups of individuals, including this new combination of Berkshire, JP Morgan and Amazon."
Thursday’s hour-long conference call was supposed to be about fourth quarter earnings and 2017 financial results. The company saw fourth quarter net revenues increase 5.3% to $8.4 billion, when compared to the fourth quarter of 2016.
For 2017, net revenues increased 4.1% to $185 billion. The company also expects a $1.2 billion windfall from the Tax Cut and Jobs Act. Half of that will be used to pay down debts, and the remainder will be used for in-store employee pay raises, and capital improvements.
However, the Aetna deal dominated the questions from analysts.
Merlo says the acquisition could create a broader, deeper footprint for the company’s Minute Clinic service line.
"Today we’ve got just over 1,100 clinics in 33 states and the District of Columbia," he says. "We see an opportunity to expand the breadth and the scope of practice that exists in Minute Clinics. There are a number of things we are thinking about, whether it's broader management of chronic diseases, or even the ability to do blood draws in the clinics."
Expanded services are needed, he says, to keep pace with an evolving retail environment.
"We are beginning a broader rollout of audiology and optical," he says. "We're making healthcare a retail option, recognizing that healthcare is becoming local. We are looking to deliver healthcare to where people are, whether it's in their local community or in many cases perhaps even in their homes."
Merlo also downplayed any concerns about the Department of Justice's request last week for more information about the deal.
"There is nothing that has surfaced that has come as a surprise. Things are moving forward as planned," he says. "Obviously, we've begun discussions. There is a good level of engagement. We feel good in terms of how the process is moving along at this point."
CVS's existing pharmacy benefits clients, which include Aetna competitors, are curious about the acquisition, Merlo says, because they understand that "the lines between competitors and partners are blurring like never before."
"We have examples of that in our own business today when you think about Medicare Part D and the fact that we manage the Part D component for more than 40 health plans," he says.
COO John Roberts says CVS is in an ongoing dialog with health plan clients about the Aetna acquisition "and I would describe the dialog as constructive."
"We serve Aetna today as a PBM and our goal would be to continue to serve Aetna and all of our healthcare clients," he says. "We have firewalls in place today that allow competition to occur as we support health plans on the pharmacy benefit to compete with each other."
A new biosurveillance system is helping Great Neck, NY-based Northwell Heath prepare for an influx of flu patients in the region. And that data is being shared with local authorities to pinpoint flu outbreaks in the community.
Just in time for the flu season, Northwell Health has a new dashboard that tracks and responds in real-time to the huge volume of influenza cases coming into its hospitals on Long Island and New York City.
Over the past week, the 12 Northwell hospitals that use the tracking system have seen more than 10,500 patients with flu-like symptoms, of which about 2,700 were admitted for inpatient treatment. Five other Northwell acute-care hospitals will be integrated into the system in the coming months.
Mark Swensen is an emergency management coordinator at Northwell and a member of the team that developed the dashboard. He spoke with HealthLeaders Media. The following is a lightly edited transcript.
HLM: How is Northwell's response different now using the dashboard?
Swensen: What we have now is a real-time look at case rate uptick and physical location of cases that we had no visibility for before. We are delayed by 24 hours, which is the time it takes our computer systems to sync the data into the data base. We're able to see, probably six to seven days ahead of time, where those cases rates upticks are more affecting our facilities and where we can devote resources.
HLM: What adjustments do you make when you have the data, that otherwise you would not be able to make?
Swensen: I credit our clinical staff in that they are capable of handling so much. We've been ready to deploy staffing but we haven't had to. We've moved some resources such as alcohol hand sanitizers and masks and courses of Tamiflu if necessary. We're prepared to act, as opposed to being reactionary. We've had plans in place if it continues to get worse. But because our staff is doing such a great job we haven't had to bring on additional staffing in anyone facility.
HLM: How does this dashboard work when a patient comes in with flu-like symptoms?
Swensen: All of our hospitals use electronic medical records. The dashboard uses text-based searching. The information is stored in the computer system based on chief complaint, admit or discharge diagnosis. We are using filters to capture people with things like fever, difficulty breathing, those types of influenza-like illnesses.
HLM: How do you determine ROI?
Swensen: That's a tough thing to quantify. If we are able to respond to the community and prevent additional exposures through education, because we're able to see where these case rate increases are happening, I would think the health system leadership would believe it pays for itself.
In terms of how much we spent on it, I can't answer that. This is one of a number of projects we are working on. All of these are investments in our health system and the community and it's important to spend the money and do these types of things because it helps us to be more proactive with public health.
HLM: What metrics do you use to determine if the dashboard is working?
Swensen: We're tracking emergency department hold times; the time it takes for a patient to be admitted until they find a bed. That's a good measure of hospital load. To be able to determine what the load is allows us to respond to the hospital. If we are able to prevent the load from exceeding certain markers, then we have used it to our advantage. If I am able to move resources in a controlled manner, then we’re taking advantage of the system, which is allowing us to respond more normally as opposed to reactively.
HLM: Can the dashboard be used to pinpoint flu outbreaks outside of the hospital walls?
Swensen: Our electronic record tracks the home Zip Code of the patient. So, we are able to determine where these cases are living, and in doing so we can determine which communities are more at risk. If we determined a community is more at risk we can notify schools, the local health department, and any number of agencies that can help with the education and the outreach.
HLM: Can you build a historical record on Northwell’s flu response that could be referenced in future years?
Swensen: Absolutely! We can't just flip the switch and start using it. We need a baseline. Over the past 24 months we've established the baseline and what is normal for our area. Without that baseline we don't have any visibility as to whether or not we are looking at something that could be abnormal.
HLM: Could the dashboard track other diseases?
Swensen: Yes, it could expand. This is filtering information in the medical record. If we change that filter to look at some other syndrome or chief complaint, we could use it in other areas. I don't know of any plans to do that at this time, but it's possible.
A review determined that the kidney, cardiac, and urgent care specialists failed on several occasions to heed HIPAA's risk analysis and management rules, HHS says.
Fresenius Medical Care North America will pay $3.5 million to the federal government and adopt corrective actions to address five separate data breaches, the Department of Health and Human Services announced Thursday.
HHS's Office of Civil Rights said their investigation showed that Fresenius failed to conduct an accurate and thorough analysis of risks and vulnerabilities to the confidentiality, integrity, and availability of all of its electronic medical records.
As a result of those procedural failures, HHS said, the Fresenius facilities improperly disclosed the electronic medical records of patients by providing unauthorized access, which is a violation of the privacy provisions of the Health Insurance Portability and Accountability Act.
Fresenius on Thursday issued the following statement: "We take the protection of our patients’ health information very seriously. It is a top priority for our company and a critical issue facing the entire healthcare industry."
"We recently entered into a settlement agreement with the U.S. Department of Health & Human Services Office for Civil Rights to informally resolve alleged HIPAA violations stemming from incidents that occurred in 2012, most of which involved theft of company computers and equipment."
"The settlement is not an admission that we violated HIPAA, and there is no evidence that any of our patients' health information was improperly accessed or misused. We have and will continue to take additional steps to protect patient data. We strive to enhance security, better train staff and reduce incidence of equipment theft.”
The breaches occurred between February and July of 2012 and were reported to HHS by Fresenius in January 2013.
The affected facilities are as follows:
Fresenius Medical Care Duval Facility in Jacksonville, FL, which failed to implement procedures to prevent unauthorized access, tampering, and theft;
Fresenius Medical Care Magnolia Grove in Semmes, AL which failed to properly oversee the receipt and removal of hardware and electronic media that contained patient information;
Fresenius Medical Care Ak-Chin in Maricopa, AZ, which failed to implement procedures to address security breaches;
Fresenius Vascular Care Augusta, (GA), which failed to implement safeguards against unauthorized access, tampering, and theft.
Fresenius Medical Care Blue Island (IL) Dialysis, which failed to implement safeguards against unauthorized access, tampering, and theft.
Fresenius’ Magnolia Grove and Augusta clinics also failed to install a mechanism to encrypt and decrypt electronic patient records, HHS said.
In addition to a $3.5 million fine, Fresenius will submit a corrective action plan that: addresses risk analysis and risk management; revises policies and procedures on device, media and facility access controls; develops an encryption report; and educates staff on policies and procedures, HHS said.
Fresenius provides kidney dialysis services for more than 170,000 patients in several states. Fresenius employs more than 60,000 people, with a care network that includes dialysis clinics, outpatient cardiac and vascular labs, urgent care centers, and hospitalist and post-acute providers.
Hospitalized drivers aged 60 to 69 in states with in-person renewal laws were 38% less likely to have dementia than drivers in states without such laws.
New evidence shows that mandating physicians to report dementia patients to state driver's license bureaus does not reduce hospitalizations from motor vehicle crashes.
The results, published today in Neurology, suggest that physician reporting laws – mandated or legally protected – either aren't working or lack any observable safety benefits.
"This was surprising, as we know that older drivers stop driving based on the advice of their physicians and, if reported to licensing authorities, few regain driving privileges," said lead author Yll Agimi, a health data scientist who did the research while a doctoral student at Pitt Public Health.
"Physicians are required to ensure the well-being of patients with dementia by also monitoring their driving competence," Agimi said. "That leads us to conclude that other licensing requirements may act as the principal means of identifying at-risk older drivers, before physicians identify and report a patient with a medical impairment, such as dementia."
The study analyzed the crash-related hospital admissions from the states reporting data between 2004 and 2009. Among 136,987 hospitalized older drivers, 5,564 had a diagnosis of dementia.
Hospitalized drivers aged 60 to 69 in states with in-person renewal laws were 38% less likely to have dementia than drivers in states without such laws and 23% to 28% less likely in states with vision testing at in-person renewal.
However, physician reporting laws were not associated with a lower likelihood of dementia among hospitalized drivers. These findings held even after the researchers accounted for other factors that could influence crash rates, ranging from police enforcement of safe driving to inclement weather, the study showed.
At the time of the study, Pennsylvania, Oregon and California required physicians to report drivers with dementia to licensing authorities. Twenty-seven states provided legal protection to physicians who report their patients, regardless of whether such reporting is required by law.
Only five states do not require that drivers present in-person – which allows licensing personnel to assess driving fitness – for license renewal at least once within two or three renewal cycles. Two states require road testing at licensing renewal, and 36 states require vision testing.
"The results of our study point to age-based licensing requirements as an effective way to improve safety," said co-author Steven M. Albert, chair of the Department of Behavioral and Community Health Sciences at Pitt.
"But such requirements also may cause social isolation and depression, and may be seen as ageist and discriminatory," Albert said. "So it is very important that our findings spur further study to determine the best approach to ensure safe driving for all on the road while avoiding a negative impact on the mental health of older adults."
In its ongoing efforts to shed about $1.5 billion in debts, Community Health Systems sold one of its Tennessee hospitals to Rennova Health, which is facing its own financial issues after being delisted from Nasdaq this week.
It’s been an eventful week for Rennova Health.
On Tuesday, Rennova was delisted by Nasdaq for excessive stock splitting, and closed with a market cap of $112,793, and shares valued at less than $1 a pop.
On Wednesday the company that once specialized in urine testing services finalized the purchase of a Tennessee hospital owned by Community Health Systems, the Franklin, TN-based for-profit hospital chain that is selling dozens of hospitals to pay off about $15 billion in debts.
The acquisition of 85-bed Tennova Healthcare in Jamestown, TN, doubles the number of hospitals owned by Rennova Health, which in 2016 bought the financially troubled 25-bed Scott County Hospital in Oneida, renamed it the Big South Fork Medical Center, and reopened last August.
Financial terms of the Jamestown acquisition were not disclosed in the media release.
CHS said the deal is expected to close in the second quarter, subject to regulatory approval. Jamestown’s sale was one of the planned divestitures announced by CHS in its third quarter 2017 earnings call.
"This acquisition further demonstrates our commitment to expanding Rennova's rural hospital model to provide necessary services to patients while securing more predictable recurring revenues," Seamus Lagan, CEO of Rennova, said of the Jamestown deal.
Lagan said in that the Jamestown hospital "is approximately 38 miles (less than a one-hour drive) from our current hospital in Oneida and will benefit by receiving patients from Oneida that require operations and treatment not provided there. The synergy of management and services in a close geographic location creates numerous efficiencies for Rennova and will allow us to support a greater number of health care providers and residents in the local area."
An email sent by HealthLeaders Media to Rennova requesting an interview on Wednesday afternoon was not returned.
On it’s website, Rennova describes itself as a “dynamic, vertically integrated company delivering innovation-driven solutions to meet critical healthcare provider needs.”
However, the Palm Beach Post reports that the company has had a long history of financial problems and that for the first nine months of 2017, Rennova posted a net loss to shareholders of $85 million on revenue of just $3 million.
HHS plans to cut $1 billion in federal funding that underwrites New York State's Basic Health Program, which creates one more challenge for the nation’s largest municipal health system.
If the Trump administration makes good on its plans to cut about $1 billion in funding for New York State's Basic Health Program, then a big share of the burden of doing more with less will fall upon the state's safety net hospitals.
John Jurenko Jr., vice president of government relations at New York City Health and Hospital Corp., says about 73,000 patients at the nation's largest municipal health system rely on the BHP for coverage. If that funding goes away, Jurenko says, NYCHHC will have to find another way to provide the care. NYCHHC already provides approximately $1.4 billion in uncompensated care annually.
"Eliminating this program, which essentially could restrict access to coverage for some people in the state, runs against healthcare policy that you want people to have continuous coordinated care so they stay healthier, they stay out of hospitals, and out of the emergency departments when they come in at the end when they are really sick," he says. "This is very short-sighted for the federal government to do this."
About 700,000 New York state residents are covered under the BHP, which began in 2015 and which is also called the Essential Plan. The funding, created under the Affordable Care Act, targets people who earn between 133% and 200% of the federal poverty level: the working poor who make too much to qualify for Medicaid, but not enough to afford health insurance premiums. While the program was made available to all states, only New York and Minnesota have BHP programs. Minnesota's BHP covers about 100,000 people.
Earlier this week, Minnesota and New York filed a joint lawsuit against the Trump administration and the Department of Health and Human Services, claiming that the funding cut violates the Administrative Procedure Act protocols for making administrative payment decisions. In mid-December, HHS told New York state officials, via email, that they would not receive a payment of $266 million for the first quarter of 2018.
"The Essential Plan is a lifeline for over 700,000 low-income New Yorkers. The abrupt decision to cut these vital funds is a cruel and reckless assault on New York’s families – and we will not allow it," New York Attorney General Eric T. Schneiderman said in prepared remarks. "I won't stand by as the federal government continues to renege on its most basic obligations in a transparent attempt to dismantle the Affordable Care Act. We’re suing to defend these vital funds and the quality, affordable health care they ensure for New Yorkers."
Jurenko says that many of the people on New York’s Essential Plan would be hard pressed to find affordable coverage without help, and would likely have to rely upon charity care.
"If it were to go away, it would make our jobs harder because we would see more and more uninsured folks," he says. "That's bad financially and bad for the patients in terms of the continuity of care, and it seems to run counter to what state and federal policies on the healthcare side had been; where it was to ensure access to coordinated healthcare services where you don't want to have people coming in for episodic care in the emergency department."
It's unlikely that New York can step in to fund the program, he says, because state legislators are already wrestling with a $4 billion shortfall. With few other options on the table, Jurenko says NYCHHC may have to make do with less.
Last year NYCHHC served a patient base of 1.2 million people, about 410,000 of whom were uninsured, Jurenko says. "We would not want to see that number go up. We have been doing everything we can to try to get more and more people who are eligible but not enrolled to get them coverage. This only makes matters worse," he says.
"Our CFO has already lost all his hair, because it's very hard to plan with all this uncertainty," he says. "But our commitment to New Yorkers is unwavering. We will always serve New Yorkers regardless of their ability to pay."
"But, it makes it hard because at the end of the day someone has to pick up the tab for the care," he says. "We will have to pick up any shortfall on the financial side for people who come in and are uninsured. Our staff in our facilities, our hospitals and community health centers, would be working with individuals to see if they're eligible for public health insurance."
"We are not going to eliminate programs. It will make it more financially difficult for us if we have larger numbers of uninsured, but we are still going to provide services to them."
Medicare Advantage markets are more robust, with higher private insurer participation and lower average premium growth than the Affordable Care Act marketplaces.
The success of Medicare Advantage could be a roadmap for the struggling ACA marketplaces, an analysis from the Urban Institute suggests.
Researchers examined why MA plans thrived in 2017 as marketplace plans struggled, and how the programs differ—including insurer participation, the risk-adjustment system, and provider payments. They concluded that adopting policies to increase enrollment in marketplace plans as well as insurer participation could make the ACA marketplaces stronger and more stable.
The Medicare Advantage market included 19 million enrollees in 2017, or 33% of the total Medicare population. These enrollees stick with their plans year after year and are generally not very sensitive to changes in price. Medicare Advantage also has a risk adjustment system that is relatively favorable to plans and is not budget-neutral, the study found.
Conversely, ACA marketplaces include more intense competition between insurers, have more price-sensitive enrollees, enroll fewer covered lives in the non-group market, calculate benchmark premiums differently, and have less favorable risk adjustment for insurers.
"ACA marketplaces and Medicare Advantage may seem similar, since they are both highly regulated direct to consumer insurance markets," said Katherine Hempstead, senior adviser at the Robert Wood Johnson Foundation, which funded the study.
"Yet Medicare Advantage has been much more successful, due in large part to regulatory features that give insurers greater certainty about bidding, risk adjustment, and provider payment," she said.
The study offers five policy recommendations based on Medicare Advantage’s success to strengthen the marketplaces for long-term stability, including:
Raise enrollment in marketplace plans by increasing premium and cost-sharing subsidies and eliminating short-term plans;
Cap provider payment rates at Medicare rates or a fixed percentage above them;
Standardize cost-sharing within metal tiers, or limit the number of plan designs available;
Lift the budget neutrality requirement for risk adjustment in the marketplaces;
Use a higher benchmark than the second-lowest-cost silver plan for calculating premium tax credits.
The fourth level of stroke center certification is a collaboration with the American Heart Association/American Stroke Association, and identifies hospitals that meet standards for performing mechanical endovascular thrombectomies.
David Baker, MD, executive vice president for Health Care Quality Evaluation at The Joint Commission, said the new certification program was developed after surveys showed that one-third of certified primary stroke centers routinely performed endovascular thrombectomies.
"Multiple studies have proven EVT treatment to be effective in saving lives and lowering disability from stroke, particularly if performed within six hours of the last time the patient was known to be well," says Baker.
"This certification was developed in response to a revolutionary technology and trying to make sure that everyone has good access to that technology in a timeframe that is going to achieve optimal outcomes," he said.
Baker spoke with HealthLeaders Media about the new TSC certification. The following is an edited transcript.
HLM:What hospitals should consider this certification program?
Baker: Right now, one third of our primary stroke centers are doing mechanical thrombectomies. We are looking for the strongest hospitals in that group; the ones that are able to do high-quality thrombectomies and post-procedure care. They've got substantial volume with strong experience. Importantly for us, this was originally developed to address areas where there wasn’t good access to a comprehensive stroke center.
HLM: What are the advantages to mechanical thrombectomies?
Baker: In 2015 three landmark studies showed that for patients that have the worst strokes, basically clots in one of the big blood vessels in the neck or the brain, a very large part of the brain is affected by this and the patients will be devastated by this.
These studies showed, and I am not overstating this, some of the most dramatic improvements that we have seen with any therapy. So, if you can get somebody to a hospital who can do this procedure -- they put a catheter into the large vessel, and they remove that blood clot so it restores blood flow to that area of the brain that is affected -- if you look at the numbers of people who were able to regain almost complete function, it's a vast improvement.
HLM: What should hospitals look at internally when deciding to pursue this?
Baker: This is probably something that would be taken up by hospitals that are already doing these procedures. They are going to have to make sure they can provide 24/7 coverage. Ideally, there should be a working relationship with EMS so that they know that if they gear up and can do this with 24/7/365 coverage and the costs associated with that, that they are going to get the volume of patients.
The calculation is how many patients are we seeing? How many more patients would we see if we got this designation, and will our emergency transport system recognized that? Particularly in some of these rural areas, if there was something there it would get a lot of traffic.
HLM: How does this accelerate access to proper care?
Baker: Again, two-thirds of the primary stroke centers are not doing mechanical thrombectomies. So you're EMS and you’ve got three primary stroke centers that you could go to but you don't know which one is capable of doing the mechanical thrombectomy. You go to the closest center, they evaluate the patients and then they have to transfer the patient to presumably a comprehensive stroke center to do the procedure. That is a huge delay that dramatically affects how much function a patient can regain.
This certification tells EMS who is capable of doing this. The hard part is in the field for EMS to determine who has one of these large vessel occlusions? Who has a clot in a major artery? There are a few rules that they can use and they need to learn how to use them. But, if EMS can identify those patients in the field, instead of going 90 minutes to a comprehensive stroke center I can go 20 minutes to a TSC and know that the patient is going to get good care.
HLM: How do you measure ROI for this certification?
Baker: That's going to depend on the local situation. You have to look at all the different aspects, the 24/7 coverage, the imaging procedures, and technology that is required and then be able to do your own estimate of ‘OK if we think we are going to get 15 or 20 cases per year brought in by EMS is it going to make sense?’
HLM: How long does the certification process take?
Baker: There is huge variability. There are some that thought they would be ready for survey within a month or two. Others it's taken them three or four months. It all depends upon what the baseline state is, so that is a difficult question to answer.
Physician-researchers offer practical, common-sense, easy-to-implement actions to improve outcomes, shorten hospital stays, and lessen the amount of opioids needed to control pain post-discharge.
Research presented this week at the American Society of AnesthesiologistsPRACTICE MANAGEMENT 2018meeting found that anesthesiologists can take a lead role in improving the patient experience -- from the decision to have surgery through discharge and beyond -- which can improve outcomes and reduce costs.
Colorectal and bariatric surgery patients benefited from an enhanced recovery after surgery (ERAS) program, left the hospital sooner and required fewer opioids to control pain, according to new research from Providence Anesthesiology Associates in Charlotte, NC.
PAA compared the results of 621 patients undergoing colorectal or bariatric surgery who participated in an ERAS program to historical data prior to the implementation of the ERAS.
Colorectal patients in the ERAS group stayed in the hospital 2 days compared to 4.5 days for non-ERAS patients. Bariatric patients in the ERAS group stayed 1 day vs. 2.15 for non-ERAS patients. Patients in both ERAS groups used significantly fewer opioids after surgery than those in the non-ERAS groups and had shorter stays in the post anesthesia care unit. Costs were reduced by 20% per case among the colorectal surgery ERAS patients compared to non-ERAS patients.
The ERAS program included preoperative patient education beginning in the surgeon's office and more extensively at the preadmission testing clinic, carb loading the night before surgery and three hours before the procedure, administering preoperative Alvimopan to restore bowel function after surgery, and employing pain methods other than opioids including transversus abdominal plane blocks to reduce or eliminate opioids after surgery.
"Our results demonstrate the benefits of physician anesthesiologists and surgeons working collaboratively to lower costs and improve our patients' outcomes," said Vicki Morton, DNP, director of clinical and quality outcomes at PAA.
Another study from the University of Pittsburgh Medical Center study found that pre-surgical consultation with pain medicine specialist eases anxiety about post-surgical pain management for some chronic pain and substance abuse patients.
The study reviewed 12 spinal fusion patients who consulted with an anesthesiologist pain specialist before surgery. The patients either had a history of substance abuse and were on outpatient addiction maintenance therapy, had a history of high opioid use before surgery, or specifically requested a pain clinic consultation.
Each met with the physician anesthesiologist, who consulted with the surgeon and patient to formulate a plan for the most appropriate pain management after surgery.
The patients reported they were less stressed about surgery, less anxious during the perioperative period and more satisfied with pain control after surgery.
"Some of these patients refuse to leave the hospital after surgery until they feel they are on the right pain regimen, and therefore stay longer," said Trent Emerick, MD, director of quality improvement and innovation, Chronic Pain Division, in the Department of Anesthesiology at the UPMC. "We believe that by working to address these issues before surgery we can decrease costs while improving satisfaction."
Researchers at Beaumont Health in Royal Oaks, MI, believe that evaluating older patients for frailty should be part of standard anesthesia pre-surgical screening. They recommended using a short screening questionnaire, such as Fried's Frailty criteria, because frailty can be an independent predictor of postoperative complications.
Patients who are identified as frail before surgery should be optimized before undergoing the procedure through nutrition, strength training, improving balance and mobility, counseling and medications, the researchers said.
"A healthy 80-year-old is not the same as a healthy 30-year-old, but they often are assessed for surgery in the same way," said Laura Lepczyk, DO, a clinical anesthesia resident at Beaumont.
"Further, some 80-year-olds are strong and vibrant and others are weak," she said. "A frailty assessment before surgery can help providers determine whether a patient is strong enough for surgery and if not, help determine if the patient's health can be optimized to enable the procedure."
