Central Line

Episode Number: 149

Episode Title: ANESTHESIOLOGY 2024 Revisited

Recorded: October 2024

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VOICE OVER:

Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ADAM STRIKER:

Hello everyone and welcome to Central Line. I’m your host and editor, Dr. Adam Striker. To wrap up the year, we’re reflecting on some of ASA’s accomplishments from 2024. Specifically, we’re revisiting key moments from this year’s annual meeting with clips from TopMedTalk interviews, which were hosted live in the Exhibit Hall with leaders from the specialty.

To kick us off, let’s here from ASA’s past and current presidents. Dr. Ron Harter was transitioning the role to Dr. Donald Arnold. Dr. Harter spoke about key challenges that are also transitioning…

DR. RON HARTER:

There hasn't been too many dull moments throughout the year. So it's it's been terrific. I think the the things that I think back on of the year, we had a number and continue to have, unfortunately for Don, a number of challenges on the payment front. Um, there's further Medicare cuts in the offing unless Congress acts before the end of the year. And, the important piece of this that I think is getting finally more recognition by by Congress is that this is about access to health care for our for our senior citizens. And it just can't continue where the price of providing care, along with the price of everything else, is going up. And yet we see reductions in payments for the care, you know, to the physicians for caring for Medicare patients, year after year after year. It's simply it just needs to be fixed and significantly fixed if if our seniors are going to continue to be able to truly have access to care. It's it's nice to have a Medicare card but if nobody accepts it, then what's what's the point? So so that's an ongoing challenge. And then on the commercial payer side, we're seeing increasingly where Blue Cross Blue Shield, Aetna, other major payers are just unilaterally determining that they no longer want to pay for things that they've paid for decades. Like, you know, care for complex patients, ASA class 345, that they just are no longer going to pay it. And it's not because, well, we no longer take care of complex patients. Clearly it's about their own profits.

DR. STRIKER:

He reminded us that fair payment is not only about caring for our elders, but for all of us, which is why ASA is committed to advancing equitable payment for the specialty.

DR. HARTER:

It's about anesthesia practices remaining viable and being able to continue to provide care for patients in various settings -- rural, urban, you know, throughout the country. So this is really a concerning thing that that we continue to address. But the economic issues I would say are probably the, the biggest thing that I've, you know, had to, had to engage in this year.

DR. STRIKER:

He also shared one of his proudest accomplishments…

DR. HARTER:

One of the things that I'm most proud of is, we launched Safe Haven, which is a subscription program for wellness services. So coaching, counseling, 24-7 crisis management services, work life balance--to sort of describe it broadly—resources, legal assistance, financial assistance and information, child care resources within your area. We've already had it launched in June, and we have over 150 people that have already subscribed to it. And we're already getting some really positive anecdotal reports back. Really it's it's not just mental health services. It's, you know, career advancement resources. So I think anybody at any point in their career is going to find resources that will be of value to them.

DR. STRIKER:

Dr. Arnold addressed these headwinds. He shared his thoughts on priorities and his vision for the coming year…

DR. DONALD ARNOLD:

There are four different areas that we're really trying to put additional emphasis on, because we believe that they’re areas that are important for us to make an investment in, because of their potential to favorably change the arc of the profession over the next 3 to 5 years. And one of those is investments in areas that advance quality and safety of patient care, patient experience of care, the experience that clinicians have providing that care. And all of those are important. A certain commitment that we've made that supports this is the Center for Perioperative Medicine, which is really to support implementation, identification and implementation of best practices in perioperative medicine. So that's an area of emphasis as well as an interest in looking at benchmarking clinical practice to support, uh, local departments and practices in improving quality and safety. Ron offered some comments on things that we have underway in terms of responding to the challenges to the economic integrity of the specialty. The fact that Medicare is a broken system, and that the commercial insurance industry is looking for additional ways to fuel their year over year profit increases, puts not only providers, but hospitals and health systems under significant pressure. And in the current economic environment, we're finding that there's a need to to put more resources into helping our departments and practices team effectively with their facilities, whether it's an ambulatory surgery center or hospital or a health system around value proposition and around areas where we can bring increased value to care at a point in time that we have shared challenges with the resources that facilities and we as providers have to work with.

DR. STRIKER:

He flagged some initiatives he’s particularly excited about.

DR. ARNOLD:

Well, one on the economic front that I should mention is our Center for Anesthesia and Perioperative Economics, CAPE, and that's, uh, an initiative that is going to unify and organize all of the internal ASA work done by committees and done by staff in the area of strategy for economic policy for the profession, and will help then provide a unified point of engagement within the health care ecosystem. So that's something that I should mention. But I think one of the other things that is worthwhile mentioning, while we have a strategic plan, what really drives that is serving our patients and serving our, our, our members, and we're really trying to emphasize relevance to members. We think that there's, ASA provides a value proposition for clinicians, for anesthesiologists in practice, and our commitment is to identify ways to support the individual practicing anesthesiologists in their practice to make them as successful as they can be, whether it is in an academic, private practice or clinical practice. So we are trying our best to identify resources, communication channels, ways to connect with different member groups and align them with resources that best meet their needs.

DR. STRIKER:

Technology was also on Dr. Arnold’s mind as he transitions into the role.

DR. ARNOLD:

One of our core strategic priorities for the next 3 to 5 years is really to look for ways to adopt and advance technologies in two different ways. We're looking at a lot of wonderful clinical technologies, and that's a piece of it. Things that are going to improve our ability to care for patients, improve the physician and anesthesia care teams’ ability to deliver care, and then also learn from our care. And a piece of this is also around learning technology, AI, large language models that will help us with data collection, analysis and really learning from the care that we're providing, improving care as we move forward. The second technology piece is more of a member focused piece, looking at how we can use emerging technologies to better communicate and connect with our members.

DR. STRIKER:

Dr. Harter reminded us that there’s plenty to be optimistic about.

DR. HARTER:

The silver lining around the gloom, gloom and doom cloud of workforce challenges is medical student interest in our specialty has never been so great. And we are, um, not only the quantity of, of applicants, but the but the quality of them is, it's, we've never seen really this level of, of high quality candidates. So that is just critically important to continue to, to work to, to meet the demand for our services and to continue to have, you know, physician leadership of the of the care, you know, anesthesia care that our patients deserve.

DR. STRIKER:

Innovation was also front and center when Drs. Sean Runnels and Barrett Larson, co-directors for the swimming with the sharks initiative, took the stage. They talked about the value of innovation and their hopes for the initiative they chair together.

DR. SEAN RUNNELS:

What we'd like to do with swimming with sharks is to reopen that channel of value between industry and, you know, ASA membership, because it's it's actively been closed over the last 25 years for all sorts of different reasons. And so industry has a hard time understanding what we need. And we don't understand that, you know, things like 70% of what you buy is marketing and sales, you know, in, in the cost of a product. So, so I think reopening that channel so we can get value flowing both ways again is where we're going to get innovation and get it into business and scale it. And actually, you know, bring value to our patients.

DR. BARRETT LARSON:

In order for these things to succeed, it really does take a village. And you need mentorship, you need guidance, you need support, you need community. And that's what we're trying to do here with swimming with the sharks is just try to develop that community and foster a sense of innovation in this environment that we can hopefully, hopefully encourage the next generation of entrepreneurs and innovators to do cool things.

DR. STRIKER:

Dr. Runnels gave us some insight into how the initiative is faring.

DR. RUNNELS:

We reviewed 45 applications for swimming with sharks, something like that this year. Next year it will probably be 70. Those are all anesthesiologists that are trying to solve a problem. And for industry to be able to see into what is actually the problems they're trying to solve is, you know, that's that's a very valuable thing for industry. And we really like to have this be a collaborative effort between the ASA and the industry to really be able to open up that channel so that we can communicate. And so that's, that's kind of what we're strategically doing and tactically structuring things to, to, to optimize that.

DR. STRIKER:

And Dr. Larson talked about the process and the results.

DR. LARSON:

So just the way the process worked, we had a call for applications probably about six months ago or so, and we had the applicants submit a really short elevator pitches. So we had them record like two minute little videos to see if they could effectively get their message across. Because in our view, if you can't deliver the message very quickly and concretely, it's probably not going to do very well on the on the main stage here at swimming with the sharks. So that was how we ended up getting people to to apply. Then we went through a pretty rigorous process where we scored all of the applications along various different vectors, and then we selected four finalists, and then Sean and I worked with the finalists over the last couple of months, and we had the the final presentations yesterday. And the winner was a company called Flotherm. The other three companies were Vine, which was a soft robotic intubation device. We had Art OR which was an esophageal manometry device for optimizing ventilation. We had Surge, which was a kind of single cell omics immunologic assay for a risk profiling patients before surgery. And then the winner for Flotherm was a device that combined essentially SCD and warming.

DR. STRIKER:

Another initiative featured in the Exhibit Hall was the ASA Toolbox. Drs. Ben Houseman and Mike Hofkamp spoke to TopMedTalk about ASA’s resident educational platform and collaborative learning community.

Dr. Hofkamp explained the origins of Toolbox, which was started to teach people how to do regional anesthesia, particularly ultrasound guided regional anesthesia…

DR. MIKE HOFKAMP:

Because this was an emerging technology, a lot of attending physicians hadn't trained on it as a resident, but we needed to get them up to speed and learn this new emerging therapy. It kind of evolved, saying, well, we can do this with regional anesthesia. Let's do this with other disciplines such as obstetric, pediatric. And now we have a full complement of material. We're constantly updating it. We're constantly reinventing it.

DR. STRIKER:

And Dr. Houseman talked about why he was drawn to the solution.

DR. BEN HOUSEMAN:

I chose to subscribe to the Toolbox for our health system program because both my residents and my faculty were in need of a resource that they could use and share. And I think that the faculty, I would say, benefit the most in the sense that they don't have to create content for basic education in curriculum development for any of the anesthesia levels. So the Toolbox is great in that it has like a medical student curriculum for a rotating medical students. It has curricula for all of the required rotations in the first, second and third year of anesthesia residency, and also even has fellowship level curricula for regional and pediatric anesthesia right now. Since ASA has taken it over, they've enhanced it even further with the quiz bank and the question of the day and a couple of other resources.

DR. STRIKER:

He shared advice for those considering Toolbox.

DR. HOUSEMAN:

Take a look at the Toolbox, see what resources are available, and then adapt those to your session and utilize those with residents. Furthermore, you can grab some quiz questions and maybe grab a problem-based learning discussion and that will help you run your educational session on this topic with our trainees at any level you want. It really has made it easier for me as a program leader to kind of take the burden off of them. Because even though everyone has been a resident, a lot of people kind of lose their resident, you know, teacher mojo after being in practice for 15, 20 years. And everybody remembers how to ride a bike. They just need to get a little bit of help to get back on it and go at a really high speed.

DR. STRIKER:

They shared insights into how they ensure the product is of the highest quality.

DR. HOFKAMP:

It’s a rigorous peer review process. I can tell you that I have submitted journal articles that are now PubMed indexed, that required less scrutiny than some of the educational content that I've submitted. Yeah, it's it's a daunting process. We go through it with a fine-tooth comb. It has to be the highest quality because, particularly now it's being backed by the ASA, factually it has to be correct, obviously. And then educational wise it has to be the right format. Sometimes we get people who submit podcasts that really should be learning modules and vice versa. And so we will provide that feedback to the creator of the content. And we'll work with them to get them across the finish line.

DR. STRIKER:

In addition to Toolbox being tried and tested, it also benefits from diverse formats.

DR. HOFKAMP:

Some of it is podcasts like this. Some of it is learning modules where the learner interacts. Attending physicians know we all hate the HealthStream mandatory learning modules that our employers have us do. But it's the same technology, but it's for educational content. And we have materials for the instructors too. We have PBLDs, problem-based learning discussions, that the attending physicians can take into the operating room and use to teach the residents. And we also have a quiz bank. And so the quiz bank is for the residents to test their knowledge on the subject matter. And that's probably one of the more popular components of our platform.

I think that the Toolbox continues to evolve. We'll look at best educational practices, and we will continue to modify our content to make it relevant to the learner. And we hope that it continues to be valued as a resource and we’ll continue to do it.

DR. STRIKER:

Throughout the meeting, experts addressed the economics of anesthesiology, including this interview with Drs. Lois Connolly and Jonathan Gal, who shed light on some of the challenges anesthesiologists face dealing with commercial payors.

DR. LOIS CONNOLLY:

Our commercial payers want to push us down to Medicare government payer rates. An average case probably bills 12 anesthesia units. Just let's do the math. 12 units times a conversion factor of $20 per unit. Yeah, that doesn't get you too much, does it? So the commercial payers often are individual contracts that negotiate with their employer benefit plans or their commercial payers, so they set proprietary levels of conversion factors based on the types of practice that they are. For example, I work in a level one trauma center, do liver transplant, heart transplants. We take care of sick babies. We have an air ambulance for them. Really high acuity care. And we're a referral center. We'll go in and negotiate a private contract. You do your negotiation, say $300 per unit, to offset your government payers. We're a graying population, which means, I guess they call it the grey tsunami, which means more people are on Medicare than ever before. So the number of patients that are receiving care are higher. So our Medicare payer mix is getting higher and higher. So what happens is, is our commercial payers need to be able to balance that payment out a little bit for us so that we can maintain our practices and how we practice.

DR. STRIKER:

Dr. Gal talked about the importance of showing our fair market value to payers.

DR. JONATHAN GAL:

The negotiations you want them having with these commercial payers is more of that fair market value. You get to show the value that you bring, the training that your group has, the types of complex cases that you wind up having, previous contracts you've had in the past, and how the benchmark of federal payers, whether it be Medicare or Medicaid, it's our fair market value, not the government mandated rates that you want to have in that negotiation. So it's crucial to have a strong negotiating power comes to those discussions to try and get the conversion factors there that can help you actually have a more viable practice.

DR. STRIKER:

The two of them also discussed recent challenges, how events outside of the health care system can impact our pay, and predatory behavior.

DR. CONNOLLY:

We can start off with the beginning of the year 2024, a revenue cycle billing company that United owns underwent a cyberattack on their system. That attack affected almost every bill, be it pharmacy, hospital bill, physician billing in the whole US. And it shut down all revenue coming forward in that cycle. And that played out for quite a few months.

DR. GAL:

February 21st of 2024. They got the cyberattack and essentially, they’re a main clearinghouse for all types of bills. It's kind of like like a bank clearinghouse, but for healthcare things. So anesthesia practices across the country, hospitals, pharmacies, whatever, they couldn't send bills to payers and they couldn't collect for the bills that they already sent. So it was kind of just a shutdown period. And now all these practices are having to still make payroll two weeks from now, but they can't get any collections come in to help pay for that payroll. And so United, who you know is their sister company is Optum. Optum owns Change Healthcare, which kind of took advantage of this, this situation. So there was a couple practices that couldn't make payroll. They're now in dire straits. And Optum is going in and trying to buy the practice. How awful was that?

DR. CONNOLLY:

It was pretty predatory. On the smaller groups that used change for their revenue cycle management company really suffered tremendously under under the cyber attack. This went on for months and months, uh, to top it all off, United offered to loan them money at an interest rate to be able to meet their payroll. A lot of anesthesiologists went any payment to themselves just to be able to, you know, meet their obligations, took out short term loans or whatever. We did survey our ASA members and it was quite significant.

DR. GAL:

They represent about half the transactions nationwide. And so fair to say, at least half of the anesthesia practice nationwide in one way, shape or form were impacted by this.

DR. STRIKER:

They explained what ASA did to support the anesthesia community.

DR. GAL:

We wrote letters. We filed complaints. We got, you know, articles published and everything. We we raised awareness of this sort of stuff. When bad acting, you know, was happening on the behalf of the United and stuff, we were able to, you know, go to the press with that sort of stuff as well. We did surveys. We tried to help support the practices. We wanted to be supportive and provide resources and that sort of thing.

DR. CONNOLLY:

Even before all of this, ASA had filed an antitrust complaint against United Health Care in 2021. So we've had our eye on the predatory nature and the anti-competitiveness of United Health Care for a while. And this year, I think the DOJ has investigated United Health Care and has put them on notice. I don't know what the outcome of that is at this point in time.

DR. GAL:

We put a lot of efforts, put letters into the Department of Justice. They've done their investigation, took a solid three years or so, and now they've come out with some formal reports about the anti-competitive and antitrust behavior between Optum and United, and they're going further with that now as well with more investigations.

DR. STRIKER:

Finally, they gave an update on the No Surprise Act and how the independent dispute resolution process, or the IDR, is playing out.

DR. GAL:

The most recent reports that have come out from CMS on the IDR process were for the last two quarters of 2023. And in those two quarters, anesthesia practices were winning around 80 plus percent of the time. The amount that they're winning is about a solid 200% or so of what the initial qualifying payment amount they got from the from the payer. So if the payer only offered them 50 bucks a unit, they're now getting more a little over $100 a unit back. And when they go through this process and they're winning around 85% of the time.

DR. STRIKER:

Dr. Connolly reminded us of how we got to where we are now – the battles won and the battles still to come.

DR. CONNOLLY:

So one of the things that the insurers were doing was putting ghost rates in, in the qualified payment amount for you and calculating what they should pay you. They would put ghost rates or zero zero rates in there. So you would get a very low, um, you know, qualified payment amount. So that's pretty much cleaned up with TMA one and two.

DR. GAL:

That was three, yeah.

DR. CONNOLLY:

The regulation on this is really pending. And they're expecting this to be released. And it was supposed to be November, but I think they delayed it to January of 2025 to really push the insurance companies to pay within an expected amount. But where's the teeth? I mean, it's will they? I don't know. Yeah. I mean they could they could hold out. And I know, um, you know, the people who are very successful in the IDR process usually are bigger groups. You know, North Star. Teamhealth actually is one of the bigger ones. And they I mean, it's all public knowledge. They win over 90% of them, but they they have a well-oiled group working through the IDR process. You know, they've been very successful.

INTEVIEWER:

Um, I can't imagine what it's like for small group practices.

DR. CONNOLLY:

Exactly. Those are, those are the people that really are suffering in the IDR process.

DR. GAL:

Well, it kind of goes to almost every bill that's out there. The No Surprises Act is no different. It is just a jobs program. Honestly. So with this whole process now, there's all these companies that will do the IDR process for you. They'll they'll, you know, a small practice can now hire a vendor who's probably here in this exhibit hall. Go stop by if you're a small practice and find one that's good for you that can do this process for you.

DR. STRIKER:

Finally, they offered advice to those in search of more information.

DR. GAL:

You can go to the Payment Progress Initiative, which is on the ASA website, asahq.org. In there you can find timely topics on economic issues and practice management issues. And those kind of run the gamut of all the different things we're talking about. CMS decreasing our payments and other things that are coming out. There's resources on there too, that you can buy as well for the ASA crosswalk, ASA Relative Value guide. Those help you understand how all the different CPT codes, uh, roll up to to how everyone gets paid and everything. And then, you know, we frequently have, in our Monday morning outreach by our ASA president that comes out every Monday morning, there's usually things in there that also remind our members of other resources that are, you know, live as as we go along throughout the year that are related to these different payment issues as well.

DR. CONNOLLY:

And what I really want to say is, if you're dealing with any issues, especially with a insurer in your area, for example, we're very interested at the ASA from hearing from groups that are facing these issues. Because the more we know about what's going on there in your world, the better we can help address some of these these issues with the payers.

DR. GAL:

We need the data points, right? The data points to make the Arguments.

INTERVIEWER:

So reach out to the committees. And Dr. Connolly, you as professional affairs and things like that, I think it's really important to maintain that communication.

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DR. STRIKER:

As always, we left ANESTHESIOLOGY 2024 more informed, more inspired, and more dedicated to the specialty. We hope you’ve enjoyed our review of TopMedTalk’s conversations with leaders. And we hope you’ll join us again soon for more Central Line.

VOICE OVER:

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