Multipronged Approach Necessary to Avoid Serious Physician Shortage

Recent statistical reports indicate that the medical field is experiencing a shortage of both primary care and specialty physicians, increasing the likelihood of a widespread serious physician shortage in the United States.  A physician shortage, as calculated by the AAMC, is a calculation of the gap between physician supply and demand. According to the Association of American Medical Colleges’ Center for Workforce Studies, the physician shortage is expected to approach 104,900 physicians by 2030. By physician category, the AAMC predicts a shortage of between 7,300 and 41,300 for primary care physicians, as compared to a shortage of between 33,500 and 61,800 for non-primary physicians.^[1] The latter category includes physicians categorized under specialty services, under which anesthesiology is housed. Note that the AAMC projections are variable to account for a variety of elastic conditions implicit in physician supply and demand calculation. The lower end of the spectrum provides estimates for an optimistic calculation, referencing several policy approaches to ameliorate the physician shortage. However, the higher end of the range represents a final sum based on inaction on the part of healthcare providers, anesthesia management services, and medical educators alike.

A multipronged approach is necessary to avoid a serious physician shortage in 2030, particularly in specialized fields such as anesthesia services. In sum, a multipronged approach may be comprised of the intersection between innovative medical technologies, modernized medical education policies, and optimized collaborative delivery practices. Innovative medical technologies will provide an incentive for physicians to enter a specialized field by minimizing time spent on administrative services. For example, many novel medical database applications streamline the documentation process, allowing physicians to focus on diagnostic and therapeutic work above clerical tasks. In addition, a push for modernized medical education policies will encourage students to pursue 

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careers, specifically in anesthesiology and other specialty fields. These policies may be advocated via support for post-medical school training at the federal level; an increased emphasis on medical specialization in the medical school curriculum; or other such policy levers that add incentives for medical students to specialize and thus reduce the projected physician shortage. Finally, the optimization of collaborative delivery practices will minimize physician shortage by effectively applying assets towards medical cases. In practice, this will require maximizing the use of Certified Registered Nurse Anesthetists (CRNAs) in anesthesiology practices, as well as a reconfiguration of other key members of the medical team. In this way, anesthesiologists will be supported throughout the duration of each medical cases, ensuring the longevity of physicians in the field.

Taken together, the above multipronged approach is one potential mechanism to address serious physician shortage. However, anesthesiologists, anesthesia management companies, and medical educators must share knowledge to develop further techniques to address a physician shortage in anesthesia, thus minimizing the threat of a serious and impactful shortage in the United States.

Telehealth Increases Access to Healthcare

A new study found that direct-to-consumer telehealth often initiates new use of medical services and may increase medical spending instead of decreasing it. The use of telehealth, in which a patient has access to a physician via telephone or videoconferencing, is projected to increase access to health care while reducing costs and saving time.

The Rand Corp. analyzed 2011 to 2013 claims information for 300,000 beneficiaries of a health plan provided by CalPERS, a large California public employee benefit organization, which began offering telehealth services to selected members in 2012. They examined the per episode cost of telehealth and physical visits for acute respiratory infections and estimated what fraction of telehealth visits represented substitution versus new utilization.

One of their key findings was that the cost of telehealth visits was 50 percent lower than a visit to the physician’s office and less than five percent of the cost of an emergency department (ED) visit. Although there were cost savings, these were outweighed by the increase in spending from new utilization. Net annual spending on acute respiratory infection actually increased by $45 for every telehealth patient due to new use of medical services. Only 12 percent of all telehealth visits were substitutions for visits to other providers, while the other 88 percent represented new utilization.

The researchers suggest that innovative policies could help telehealth services reach their cost-saving potential. Insurers who want to increase direct-to-consumer telehealth services may consider raising copays for telehealth and encouraging frequent ED users to utilize telehealth services instead.

Although these new findings seem to overturn the common belief that telehealth is cost-saving, the authors acknowledge that their study was subject to several limitations that may mean that their results are not universally generalizable. First, the patient population studied had generous commercial insurance, and utilization patterns among the uninsured and those with government insurance may differ. Secondly, the overall uptake of telehealth in the population was low, so it is difficult to predict how utilization might change when telehealth becomes more popular. Finally, telehealth utilization may vary among conditions, and the breakdown of spending per episode may change when other conditions are considered.

Overall, these findings begin to shed light on the question of whether telehealth tends to substitute or supplement in-person care. At this time, it appears that telehealth services are primarily increasing overall access to care without replacing physical visits to a meaningful extent.

 Anesthesia management company

Expansion of Rural Hospitals’ Medicare Reimbursement Plan

In an effort to relieve rural hospitals’ eternal battle with insufficient funding, the Center for Medicare and Medicaid Services (CMS) is expanding its alternative reimbursement plan for another 5 years for Medicare-covered treatment costs for rural hospitals. Already starved of in-demand and expensive physicians such as specialized surgeons, radiologists, and anesthesiologists, many hospitals are struggling to provide optimal care with their available resources under their shoestring budgets or deficient incomes caused by insufficient reimbursement from both Medicare and private insurers.

           

Larger, urban hospitals can sometimes rely on extra reimbursement from private insurers to cover occasional discrepancies between treatment costs and governmental payments. However for rural hospitals that provide care to lower-income, small populations, there is a lack of a competitive market for insurance that drives down prices and raises reimbursements. These hospitals then grow dependent on full Medicare reimbursement to meet operating costs, and if these costs are not met by revenue streams, private and governmental, these hospitals, the only source of care for millions of rural Americans, are forced to close—as evidenced by the 78 closures since 2010.

           

In response to this closure epidemic, CMS is inviting qualifying rural hospitals to apply to join its payment plan designed specifically for mid-sized rural hospitals—the Rural Community Hospital Demonstration. Under this reimbursement plan, the hospitals will receive reimbursement for inpatient treatments costs for Medicare-covered patients after the patient is discharged from the hospital as long as the procedure was completed at a reasonable speed and cost. The current standard method for Medicare payment is that each year hospitals are required to estimate treatment costs for different procedures and illnesses and submit them to CMS. Then based on those early predictions, CMS reimburses the hospitals for the treatments they performed for Medicare patients. Because of rising healthcare costs, outdated technology in these hospitals, and naturally arising treatment complications, these annual predictions are sometimes insufficient to cover costs, which can be devastating to a small hospital’s budget.

           

That is why the CMS is campaigning for rural hospitals to join its alternative plan. To qualify, the hospitals must have 51 beds or less but also be larger than a Critical Access Hospital. Also, they must provide 24-hour emergency care, and be situated in a designated rural area. Applications for hospitals to switch plans close May 17th with priority given to hospitals in states with the lowest 20 population densities. With more hospitals ensuring that their budgets are always met by joining this plan, more rural Americans will continue to receive the care that they need.

Trends Shaping the Future of the ASC Industry

More now than in the past, the soaring cost of hospital care is leading physicians and patients to look for different venues for medical treatment. The average cost of a hospital stay in 2010 was $9,700, whereas for Americans ages 65 to 84 that number soared to $12,300. It is not surprising that an increasing number of patients are choosing to undergo procedures in Ambulatory Surgery Centers (ASCs), rather than in typical hospital settings. Colonoscopies, for example, one of the more common services provided by ASCs, cost patients on average a co-payment of just $76. A similar operation in a hospital, meanwhile, can cost the patient $186. While ASCs offer many benefits, there are a few key trends transforming the ASC industry which physicians, from surgeons to CRNAs to anesthesiologists, and their patients should be acquainted with. 

Since the first Ambulatory Surgery Center was established in 1970, ASCs in the United States have collected less reimbursement from Medicare than hospitals have for carrying out identical procedures. ASCs collect on average only 49% of the fees earned by hospitals and hospital-affiliated centers. For example, an ASC will receive a payment of only $980 for conducting a cataract surgery, whereas a hospital which performs the same operation will earn $1,760. This could change in the near future, however. Government health officials are working to eliminate the payment disparity between hospitals and ASCs in order to foster the growth of the ASC industry. The ASC Access and Quality Act of 2017, introduced in the House of Representatives in March of 2017, seeks to ensure fair compensation for ASCs. Moreover, the newly appointed chief of the Department of Health and Human Services, Secretary Tom Price, has a track record of supporting ASCs. He once owned an ASC himself, and worked as an orthopedic surgeon before he was elected to Congress. In his new role he may try to promote ASCs as a high-quality and cost-effective health care option for patients

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            ASCs are well-known for their autonomy, but a recent trend in the medical industry could change this. Hospitals have ownership stakes in just 21 percent of ASCs, and fully own only 3 percent of ASCs, whereas 90 percent of ASCs are owned in full or in part by surgeons and physicians. Over the last few years, however, prominent insurers and hospitals have made efforts to purchase ASCs in order to extend their presence in the healthcare market. ASCs are known for being small, local businesses – almost 70% of ASCs employ 20 people or fewer. If insurers and hospitals continue to buy ASCs this could change, however. ASCs could become more profitable as a result of these mergers, though, as they would have access to more capital and be able to procure supplies at lower costs. The future of ASCs in the United States is not certain, but these developments provide clues as to how the industry will likely change in coming years.

Optimizing the Anesthesia RFP Process (Request for Proposal)

Hospitals looking to change their anesthesia service providers will likely need to create a request for proposal document (RFP) to send to new potential vendors. RFPs can be time-consuming for both the buyer and the vendor, so it is in both parties’ best interests to make the process as straightforward as possible. While this may seem like a daunting task, there are a couple tactics that can be implemented to optimize the anesthesia RFP process and to create the best match between the vendor and hospital.

1. Hospitals should know what their needs are and convey them clearly.

A hospital will likely choose to change vendors based on concerns regarding the cost and/or service of the current vendor. The hospital should identify where the current vendor is falling short and gear a portion of the RFP to understanding how other vendors approach those areas. In general, RFPs are most effective when they are specific and allow for standardized comparisons of vendor responses during the evaluation portion of the selection process. Some hospitals will allow vendors to contribute to the RFP, a tactic that reduces the time spent by the buyer, but potentially biases the RFP towards a specific vendor and reduces its specificity to the hospital’s needs. In the interest of developing a fair and representative RFP, the hospital should handle the RFP creation process independently. However, the vendors do not need to be completely blind in the selection process; according to the TechRepublic, providing the evaluation criteria of the hospital may help vendors provide responses better geared towards the hospital’s priorities.

2. Representatives from the teams affected by the change should be included in the discussion.

Changing health service vendors not only affects the business end of the hospital but also the health care aspect. As a result, it is important to include a diverse group of stakeholders in the conversation prior to and during the vendor change. Different teams within the hospital will have different requirements for the anesthesia service. According to the Becker’s Health IT and CIO Review, addressing the stakeholders’ concerns early on in the vendor selection process will ease the implementation and transition phases. Additionally, while the current vendor should not be included in the RFP drafting process, the hospital should have a discussion with that vendor regarding their performance months before collecting RFP responses to avoid pressure to renew services.

3. Make sure that vendors follow through with their claims.

The hospital should make sure to hold the vendor to the specific standards and claims described in the vendor’s response to the RFP. If additional promises were made by the vendor before the selection committee, they must be added to the written contract or they may not be viewed as commitments by the vendor. The hospital also should request a list of references from the top candidatesand follow up with them; in some cases, a site visit could be beneficial in understanding how the service is being implemented in other locations.

New HIPAA Rules Involving Electronic Communication

The Health Insurance Portability and Accountability Act, enacted in 1996, was established to protect patients’ health information and set regulations on how health records are accessed. Healthcare providers now are required to provide electronic access to each patient’s health information. With the rise of electronic communication, many healthcare providers have started to use email and text (SMS) messaging to communicate with patients more quickly and easily. With the increased dependence on electronic communication, many people are concerned with how HIPAA applies to electronic communication.

As a result of the rapid pace of electronic communication development, many people have been confused on how the HIPAA Security Rule applies to modern electronic communication such as emails and text (SMS) messaging. The new HIPAA rules now tell healthcare providers to “[i]mplement technical security measures to guard against unauthorized access to [electronic protected health information (ePHI)] that is being transmitted over an electronic communications network”. To prevent unauthorized access to ePHI, healthcare providers must confirm that there is secure transmission of patient health information.

Healthcare providers can offer secure access to healthcare information online through encrypted messages and emails or using a password protected patient login. Unencrypted messages may be read on a public Wi-Fi network so encryption provides protection in the event that a message is intercepted. Patient portals that require patient login provides password protection of patients’ health information. These methods allow healthcare providers to share health information with their patients in a protected and convenient way.

While the new HIPAA regulations do not specifically prohibit text (SMS) messaging as a way to communicate patient health information, most text message communication is not encrypted or password protected and is therefore not compliant with HIPAA. In order to be HIPAA compliant, healthcare providers must first confirm that the text (SMS) messaging feature that is being used meets, or is exempt from, the safety regulations imposed by HIPAA. Otherwise, text (SMS) messaging without proper safety measures is not permitted.

Healthcare providers may be able to communicate health information via unsecure email and text (SMS) messaging if the email and text (SMS) message communication is from the patient to the healthcare provider. HIPAA states that its rules “[do] not apply to the patient. A patient may send health information to you using email or texting that is not secure. That health information becomes protected by the HIPAA Rules when you receive it”.  Therefore, healthcare providers must be aware that they should alert the patient of the risks of using unencrypted email or text message communication. The patient can choose to decide whether they would like to continue using this form of electronic communication, and the healthcare provider can continue using email or text (SMS) messaging, as long as it is acceptable for the patient.

HIPAA rules not only apply to communication between patient and healthcare providers, it also applies to communication between providers, employees, and third parties such as insurance companies. If the communication does not include the patient, all forms of electronic communication of patient health information must be encrypted or have a password protected system such as a user login.

The evolving healthcare environment affects every healthcare provider, including anesthesiologists. After the introduction of new regulations such as the changes in HIPAA, anesthesiologists should contact their employer, or the anesthesia management company they work for, in order to reevaluate their plan to provide the best anesthesia service for patients and ensure a sustainable business model. All healthcare providers must stay up to date on any new revisions to the HIPAA regulations. As people continue to rely heavily on electronic communication, it is essential for healthcare providers to continue discussing both how to best meet the needs of their patients and how to best protect their health information.

Pre-surgical Services

Pre-surgical services are a vital component to providing quality healthcare. While pre-surgical services vary across healthcare providers, specialties, and procedures, many guidelines remain similar.Generally, healthcare providers will require a pre-admission appointment up to a month in advance where a healthcare provider will conduct a pre-surgical assessment, go over any specific instructions, and conduct any required testing before the procedure (3, 5). In addition to providing diagnostic testing, many healthcare providers use the opportunity for a pre-admission appointment to include pre-operative teaching and care planning to help ensure a satisfying surgical experience for the patient and patient’s family (4).

For those undergoing a surgery involving anesthesia, a medical professional will begin by taking a patient’s medical history and conduct a physical to ensure that the patient may undergo the procedure safely (1). Prior to the procedure, patients will be given the appropriate information regarding the procedure, including any special instructions regarding intake of food and liquids. Patients will also receive instructions on any necessary medications pre- and post-operation. In some instances, the anesthesiologist will consult with patients prior to the day of the procedure. Anesthesia providers will “review your health history, medications, allergies and past experiences with anesthesia, and recommend the best plan for your care” (1).

Communication between physicians and patients prior to surgery is important in ensuring a safe and positive surgical experience for patients. Many patients prior to undergoing surgery may be concerned about the risks associated with anesthesia. While the overall risk of anesthesia-related complications is extremely low, it is the responsibility of the healthcare professionals to assess the risks of the procedure and anesthesia services, decide on the optimal procedure to minimize any possible risks, and communicate and consult with the patient throughout the process (1). Additionally, there are many other factors to consider during any pre-surgical meetings. For example, patients should know that they should always inform their physician if there are any changes to their health, such as a cold, that might impact surgical care so that the healthcare team can decide whether there needs to be any changes to the procedure. According to a study published by The Journal of the American Society of Anesthesiologists, “a communication gap already exists between patients and physicians on the topic of [complementary and alternative medicine]”, indicating that anesthesiologists and other physicians must continue to work on improving communication during pre-surgical care (2).

To improve a patient’s surgical experience, physicians can work on clearly communicating information regarding the surgery, including the diagnosis, surgical process, and anesthesia to patients during any pre-surgical appointments (7). A study shows that patients who report more knowledge of the surgical procedure and anesthesia also had lower pre-procedural anxiety levels. Physicians can also find “reliable, valid information on patient pre-surgical risk factors, process of care during surgery, and 30-day morbidity and mortality rates […] for all major surgical procedures,” which can help physicians assess risk of surgery (6).  All healthcare professionals involved in surgery should stay up to date on any research regarding pre-surgical services in order to provide quality care and ensure the best outcomes.