Medicare Conversion Factors
The 2004 national average Medicare conversion factor (CF) is $17.50, up from $17.05 in 2003. CFs for the various Medicare localities are adjusted for geographic cost differences and appear here. The increase reflects organized medicine’s success in persuading Congress to substitute a 1.5-percent increase in Medicare payments for the 4.5-percent decrease that would have gone into effect had it not been for the Medicare reform legislation passed in December.

The increase in the national anesthesia CF, 2.6 percent, also reflects a change in the formula used by the Centers for Medicare & Medicaid Services (CMS). The CF is based on three components: physician work, practice expenses and professional liability expenses. The anesthesia CF received a 0.9-percent boost on top of the 1.5-percent statutory increase because the proportion of the professional liability expense component grew, and the payment for professional liability expenses also grew, based on new cost data for all specialties.

Changes in the CFs for the individual localities vary. The Medicare reform bill raised the Geographic Practice Cost Indices for 29 of the 92 localities by setting a floor of 1.0. The floor for one of those localities, Alaska, was established at 1.67, accounting for the significant increase in the Alaska CF. Finally, the new law provided a 5-percent adjustment to payment for physicians working in “physician scarcity” areas of the country.

JCAHO Publishes Universal Protocol™ for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery

On December 2, 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) published a new Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™. The protocol, which is available here, was the result of a “summit conference” last May sponsored by JCAHO and several other entities. More than 30 organizations, including ASA, represented by then First Vice-President Eugene P. Sinclair, M.D., participated in the conference. More than 40 organizations have officially endorsed the Universal Protocol.

Dr. Sinclair reviewed the incidence and causes of wrong-site surgery in his article “Not an Urban Myth” on page 2 of this issue of the NEWSLETTER. JCAHO also noted in its press release accompanying the issuance of the Universal Protocol that it has continued to receive five to eight new reports of wrong-site surgery per month. The need to formulate a specific and unambiguous protocol was clear.

The Universal Protocol will become mandatory on July 1, 2004. It calls for a three-step process for preventing patient, procedure or surgical site errors. First, the preoperative verification process begins with the decision for surgery. It involves ensuring that all relevant records and documents have been reviewed and checked for consistency and that there is no missing or contradictory information before starting the procedure. The JCAHO Protocol Guidelines suggest use of a preoperative verification checklist.

Second, the operating physician must mark the site for procedures involving laterality, digits or other “multiple structures” or multiple levels, e.g., spinal surgery. The implementation guidelines use the verb “should,” implying that there may be circumstances when another member of the surgical team can do the marking. The guidelines are quite prescriptive, specifying among other things:

The patient brochure published by JCAHO advises that if the site cannot be marked before the patient is sedated, a family member or friend should oversee the marking.

The third step is a “time-out” immediately before starting the procedure during which the entire surgical team should agree through “active communication,” i.e., verbal responses to questions by a designated team member, on the identity of the patient, the nature of the procedure and the surgical site. Many anesthesiologists began participating in time-outs some time ago and are accepting of this mechanism.

The implementation guidelines require documentation of the time-out and recommend a checklist, including at a minimum:

The patient brochure published by JCAHO enlists patients in establishing the use of the time-out by telling them to “ask your doctor if he or she plans to take a ‘time-out’ with the surgical team just before beginning your surgery.”

In California, state law has placed the primary responsibility for avoiding wrong-site surgery on anesthesiologists, which is now inconsistent with the JCAHO Universal Protocol. In some other states, there has been confusion over who is responsible. JCAHO appears to have mooted the debate. Anesthesiologists who have understandably resisted principal accountability for ensuring that the surgeon makes no site, patient or procedure errors will benefit from the Universal Protocol, as will patients.


Source Material:
• The 2004 Physician Fee Schedule appears at 69 Fed. Reg. 1084 (January 7, 2004) <www.access.gpo.gov/su_docs/aces/fr-cont.html>.

• JCAHO Universal Protocol™, Implementation Guidelines and surgical patient brochure “Help prevent errors in your care” are available at <www.jcaho.org/accredited+organizations/patient+safety/universal+protocol/wss_universal+protocol.htm>.