| |
December 2001
Volume 65 |
Number 12
|
| |
|
| Toward Fair and
Reasonable Fees in Obstetrical Anesthesia |
Alexander A. Hannenberg, M.D., Chair
Committee on Economics
The sweeping and welcome changes in the coding and reporting
of obstetrical anesthesia services are described by James P. McMichael,
M.D., on page 23 of this issue. As he points out, a major impetus
for these changes was to prevent the diverse and unique accounting
for time during labor analgesia from undervaluing anesthesia care
for related surgical interventions in the parturient. Thus, the
new codes for obstetrical anesthesia in 2002 do not eliminate
the often bewildering variety of methods for billing and reimbursing
the time component of labor analgesia that are in use throughout
the nation, but seek to limit their application to neuraxial analgesia
for labor.
The ASA Committee on Economics, aware of the wide variation in
billing practices for labor analgesia services, added a statement
to the 1999 Relative Value Guide (RVG) that reads:
“Unlike operative anesthesia services, there is no single,
widely accepted method of accounting for time for neuraxial
labor analgesia.
Professional charges and reimbursement policies should reasonably
reflect the intensity and time involved in performing and monitoring
any neuraxial labor analgesic.
Methods to determine professional charges consistent with these
principles include:
- Basic units plus patient contact time (insertion, management
of adverse events, delivery, removal) plus one unit hourly.
- Basic units plus time units (insertion through delivery),
subject to a reasonable cap.
- Single fee
- Incremental time-based fees (e.g., 0<2 hrs., 2-6 hrs.,
>6 hrs.)”
This statement and the examples included reflect the committee’s
desire to go “on record” by recognizing that the anesthesiologist’s
care of the laboring patient differs in important ways from the
continuous monitoring of the surgical patient and that billing
and reimbursement methods need to reflect these differences. We
continue to receive disturbing reports of charges for labor analgesia
based on unlimited accrual of four or five time units hourly,
producing very high charges that easily exceed the global obstetrical
charge for pre-, intra- and postpartum care.
Each of the methods described in the RVG statement has its adherents
among anesthesiologists and payers. Some wish to avoid the documentation
burden of recording each minute spent in contact with the patient
and choose a single fee unrelated to duration of labor analgesia.
Others have billing (or claims processing) systems that more easily
accommodate standard operating room anesthesia time calculations
but impose a “cap” or “ceiling” on the units
billed or paid. Other methods producing a reasonable charge and
a reasonable payment are equally acceptable and may be preferable
under local circumstances.
The “reasonableness” of the resulting charges and payments
needs to be considered at both the “micro” and “macro”
levels. At the “micro” level, the anesthesiologist must
be rendering a bill that is fair, defensible and which the physician
would not be ashamed to show to the patient as well as to surgical,
medical or obstetrical colleagues. At the “macro” level,
the payment must be sufficient to support the ready availability
of pain relief for parturients, an “optimal goal” embraced
by ASA and the American College of Obstetricians and Gynecologists.
Recently obstetrical anesthesiologists at Duke University published
an analysis of the costs of providing labor analgesia in a large
academic medical center’s maternity unit. Bell et al. demonstrated
a very dramatic shortfall in third-party payments relative to
the personnel costs of providing this care.1 Another
very important finding in this study was the significant difference
in the costs when calculated on the basis of the intermittent
staffing demands for individual patient needs versus the cost
to the anesthesiology department of providing ready availability
of personnel to provide labor analgesia. In this study, the “macro”
costs were more than double the “micro” costs. Especially
in a practice environment stretched for anesthesia providers,
the availability of labor analgesia services depends most heavily
on the adequacy of funding for the global staffing of the service.
The Duke findings are very important, but we must recognize that
this study reflected the particular staffing and employment practices
in a large academic medical center, which certainly differ from
the typical setting in which obstetrical anesthesia is practiced
in the United States In an accompanying editorial, Chestnut correctly
pointed out that the Duke model likely underestimated the actual
costs of this service. 2
The 1997 report by Hawkins et al. on obstetrical anesthesia services,
3 along with a similar, earlier survey published
in 1982, 4 provides important information on
prevailing practices and trends that make possible informed speculation
about a more typical practice model. By extrapolating the data
and trends reported in these surveys, one can develop a picture
of a typical obstetrical anesthesia practice to assess the “reasonableness”
and viability of billing and payment standards. On the basis of
the data and trends evident in the studies cited, one may speculate
that, in 2002, a typical obstetrical unit might have nearly 1,000
deliveries, reflecting the trend toward consolidation of units
and closure of smaller hospitals. The comparison of 1981 and 1992
survey data demonstrates a significant growth in the use of epidural
labor analgesia in units of all sizes. For the purposes of our
2002 model, we will assume that 40 to 50 percent of laboring women
receive labor analgesia. Thus our “typical” service
will provide between 400 and 500 labor epidurals annually, or
between one and two daily. Nature is random, and half of these
are likely to be required between 8 p.m. and 8 a.m. Making this
service available 24 hours a day, seven days a week poses special
problems. Among the challenges to the anesthesiologist providing
labor analgesia in such a typically sized unit are:
• Nearly all of these procedures are unscheduled.
• The service must be available not only “24/7”
but on short notice (15-30 minutes).
• For the duration of the labor epidural, the anesthesiologist
is precluded from personally providing anesthesia for surgical
procedures and, in many instances, may also be precluded from
medically directing nonphysician providers in order to remain
“readily available” to the labor patient.
• The anesthesiologist providing the service during nighttime
hours may be unable to provide anesthesia services during the
following day because of sleep deprivation and compromised attentiveness.
Based on these considerations, one could ask what constitutes
fair compensation for a physician spending the night in the hospital
and sacrificing the following day’s practice: In our “typical”
obstetrical unit, this characterizes at least 50 percent of the
labor anesthetics rendered. The answer to this question should,
in part, guide the development of the reasonable fee for labor
analgesia. This model is much more important in making rational
payment policy than those based on the very largest or very smallest
maternity units. It recognizes “opportunity cost,” a
well-established concept in valuing physician services that is
highly pertinent in determining fair value in obstetrical anesthesia.
In this context, it is clear that payment policies accruing time
units only during “face to face” contact fail to recognize
much of the true value of the anesthesia care. Most importantly,
success in addressing these considerations will ultimately determine
whether these important services are offered.
It should not be surprising that one of the most common justifications
for hospital financial support of anesthesia practices is the
necessity of making epidural analgesia available when direct patient
care revenue from the service is inadequate to support the necessary
personnel costs. The role of hospital administration in subsidizing
the availability of uncommonly used but critical services is not
limited to anesthesiology and may be an important element in reaching
the goal of widespread availability of labor analgesia.
Given the complexity of the considerations outlined here, it
seems abundantly clear that more than one methodology may be useful
for valuing anesthesia services in obstetrics. Balancing the need
to be reasonable on both the “micro” and “macro”
levels is a challenge for everyone providing and reimbursing anesthesia
care for childbirth. Developing a formula for “fair and reasonable”
payment for this care requires good faith and sound judgment from
anesthesiologists, hospitals and payers alike.
References:
1. Bell ED, Penning DH, et al. How much labor
is in a labor epidural? Anesthesiology. 2000; 92:851-858.
2. Chestnut DH. How do we measure (the cost of)
pain relief? Anesthesiology. 2000; 92:643-645.
3. Hawkins JL, Gibbs CP, et al. Obstetric anesthesia
work force study, 1981 versus 1992. Anesthesiology. 1997; 87:135-143.
4. Gibbs CP, Krischer J, et al. Obstetric anesthesia:
A national survey. Anesthesiology. 1986; 65:298-306.
| |
|
Alexander
A. Hannenberg, M.D., is Associate Chair, Department of Anesthesiology,
Newton Wellesley Hospital, Newton, Massachusetts. |
|
return to top
|