ASA April 2003 Newsletter

Practice management issues are a growing concern for anesthesiologists. Beset by reluctant payers, costly insurers, a short supply of clinicians, new government regulations and constant change, anesthesiologists want up-to-date information and advice. One source is the Committee on Practice Management (COPM), now in its fourth year of existence.

In a recent survey, 91 percent of anesthesiologists rated “practice management publications and seminars” as “extremely important” or “important.” The highest rated among 23 types of information and service provided by the Society was “information on the economic impact of impending health care changes.” Providing such information is a charge of the committee.

History
In 1998, ASA President John B. Neeld, Jr., M.D., recognized the growing importance of business in the practice of anesthesiology and formed the COPM. It grew from the Committee on Quality Improvement and Practice Management (QIPM) and replaced the four-year old Committee on Value-Based Anesthesia, which had tracked the rise and fall of managed care in the U.S. health care system. Anesthesiologists knew that the delivery and financing of health care were still linked, but they needed a more broadly constituted committee to respond to their economic, regulatory and marketplace concerns.

ASA has long helped anesthesiologists with aspects of their practices beyond the scientific. The Committee on Economics, for instance, oversees the Relative Value Unit (RVU) system and Current Procedural Terminology™ (CPT) codes that most anesthesiologists and payers use. The Committee on Quality Management and Departmental Administration (QMDA), formerly the QIPM and before that, the Committee on Peer Review, represents the interests of anesthesiologists in the Joint Commission on Accreditation of Healthcare Organizations and other groups that set standards. The QMDA advises anesthesiologists how to organize hospital departments and quality improvement programs and functions in close cooperation with the COPM.

The COPM focuses on the business effects of government regulations, marketplace relationships of anesthesiology groups, applications of current economic and organizational principles to anesthesia practices and the education of anesthesiologists to succeed in the business world. Because the institutional and marketplace relationships of anesthesiology groups are linked, several anesthesiologists serve on both the COPM and QMDA committees.

What Is Practice Management?
One can define practice management as the structure behind the people who administer anesthesia, including the information, styles, organizations and contracting that groups need to deliver their care. Practice management supports the safe, efficient and compliant delivery of anesthesia care to patients; it applies organizational theories, business principles, ethics and the law to achieve predictable quality and satisfaction. Practice management concerns the business of delivering anesthesia care in everything other than the bioscience.

Practice management can be divided into four areas: economic, marketplace, professional and workplace. Table 1 lists some considerations within each of these areas.

Table 1: Practice Management Areas
I. Economic	II. Marketplace	III. Professional	IV. Workplace
Contracting	Marketing	Performance incentives	Group organization
Billing and collecting	Growth and mergers	Scope of practice	Surgical suite direction
Compliance plans	Outcomes assessment	Credentialing and privileging	Perioperative relationships
Cost containment	Managed care organizations	Privacy assurance	Duties and schedules
Budgeting	Negotiations	Quality improvement	Productivity measurements
Division of income	Satisfaction surveys	Fitness for work	Liability reduction
Employment benefits		Citizenship	Creating a culture

Anesthesiology residents now learn anesthesiology practice management as well as science and administration techniques. Program accreditation standards require a practice management curriculum that includes operating room management, types of practice, job acquisition, financial planning, contract negotiations, billing arrangements and issues of professional liability. The curriculum also must address systems-based practices with emphasis on the larger context and system of health care and how to effectively call on system resources to provide care. To ensure a proper perspective for these economic issues, training requirements also include professionalism.

Practicing anesthesiologists find that they must frequently update the financial and management information they use because market conditions change unexpectedly. These changes differ from the scientific side of anesthesiology where anatomic, physiologic and pharmacologic facts and relationships, once understood, remain unchanged. Thus, anesthesiologists understand the monitored anesthesia care value of isoflurane and how a ventilation-to-perfusion mismatch causes hypoxemia similarly today as it did 20 years ago. The RVU values for common CPT codes, however, and the break-even values for contracting anesthesia services, have changed numerous times over these 20 years. Anesthesia science thus involves the discovery of biologic facts, while practice management involves both the discovery of economic facts and the negotiation of business relationships, sometimes with adversaries.

Committee Activities
COPM members have diverse expertise in the business of anesthesiology. Members include academic and private practitioners, practice administrators and consultants. Some committee members have experience leading large practices, such as John M. Zerwas, M.D., of Greater Houston Anesthesiology, Eric W. Mason, M.D., of Critical Health Systems of North Carolina, and Jeffrey L. Apfelbaum, M.D., of the University of Chicago. Others practice solo. Committee members have negotiated with major payers, withstood strikes, survived hospital reorganizations, merged with other groups, responded to antitrust suits and adapted to changing regulations and markets. They constitute an excellent resource for the Society.

The COPM helps to organize the annual ASA Conference on Practice Management, usually held the first weekend in February. The conference provides national experts, including business leaders, lawyers and anesthesiologists, who cover the topics most pertinent and challenging to current practices. Recent talks included: “Measuring Individual Productivity,” “Creative Scheduling for Anesthesiologists: Physician Retention in a Tight Market,” “HIPAA Privacy: What You Need to Know, What You Need to Do,” “How to Battle the Blues — A Case Study,” “Hospital Stipends: The Business-like Approach” and “Newsletters Can Increase Productivity.” Reflecting the quality of past conferences and the current interest of anesthesiologists in practice management issues, the conference on January 31-February 2, 2003, in San Antonio, Texas, sold out again this year with 360 attendees. The 2004 conference, scheduled for February 5-7 in Fort Lauderdale, Florida, will accommodate a slightly larger attendance.

The committee supports surveys of practice demographics, productivity benchmarks and payer contracts, and it interprets these surveys and other information to benefit ASA members and leaders. The demand for anesthesia marketplace data currently exceeds what is available, so the committee is working with the Committee on Information Management and others to improve the collection of this information.

Where Can I Learn More About Practice Management?
The COPM supports the Society’s efforts to inform and help anesthesiologists with their practices. The ASA Web site contains a robust practice management section, accessible from the ASA home page. This section includes an archive of the monthly “Practice Management” NEWSLETTER columns by ASA Assistant Director of Governmental Affairs (Regulatory) Karin Bierstein, plus electronic anesthesia newsletters, monographs on compliance and other issues as well as handbooks from the annual practice management conferences. I particularly recommend the ASA publication, “Starting Out: A Practice Management Primer for Anesthesiology Residents” as a good overview of the area. It offers 95 pages, organized into 11 chapters, that deal with such issues as “Credentialing and Medical Staff Relations,” “Business, Tax and Retirement Planning for the Self-Employed” and “Contracting Issues.” Table 2 lists some items found in the Practice Management section of the ASA Web site.

Table 2: Available on ASA Practice Management Web site

• e-PM Letter

• ASA Comment Letters to CMS

• Publications on Practice Management

• ASA NEWSLETTER “Practice Management” Columns

• HIPAA EDI Practice Management System Directory

• Frequently Asked Questions

• Timely Alerts

• What’s New

Committee members are involved in panel discussions most years at the Annual Meeting. The committee distributes a list of speakers on business topics to anesthesiology training programs and other interested organizations. The committee also oversees a Certificate in Business Administration program, a “mini-M.B.A.” course for anesthesiologists interested in improving their business knowledge. This popular program is described in detail on page 7.

As government agencies increasingly regulate the health care marketplace with stiff penalties for noncompliance, and as financial transactions grow more complex, anesthesiologists recognize a need for help. Since most anesthesiologists have no formal business training, they are looking to ASA for current economic information and best business practices. Although no one can predict the future of our health care system, given the many conflicting pressures on it, we can safely predict that change will continue, and anesthesiologists will need to understand and adapt to these changes. The COPM will help.

Robert E. Johnstone, M.D., is Professor and Chair, Department of Anesthesiology, West Virginia University, Morgantown, West Virginia. He is ASA Director for West Virginia.

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