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The American Society of Anesthesiologists is an educational, research and scientific association of physicians organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient.


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July 1, 2013 Volume 77, Number 7
Bending the Advocacy Curve: Advocacy in an Accountable Care World David M. Broussard, M.D., M.B.A. Committee on Governmental Affairs

“The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn.”
– Alvin Toffler

The health care world is changing. Often, surviving dramatic change requires learning new skills and techniques that did not exist prior to the disruption. Recent trips to the ASA PRACTICE MANAGEMENT conference and the meeting of the Committee on Governmental Affairs have made clear to me that the advocacy skills required to ensure quality anesthesiologist-led care for future generations of patients are evolving. A major role of the Governmental Affairs committee is to ensure that this educational process occurs among our membership. I will discuss three significant challenges here, including: 1) defining the Perioperative Surgical Home (PSH) model; 2) advocating locally for your share of the payment “bundle”; and 3) the importance of engaging our patients.

I have heard a few members express concern over the term “Perioperative Surgical Home.” When I inquire deeper, the major hang-up seems to center around the word “perioperative.” Several feel that this word does not resonate with the public outside of medicine and have struggled to define it for that public. As with so many complex things, breaking the word “perioperative” down into its component parts is helpful. You may also find that developing specific scripts that can be used repeatedly helps make the concept come across in a more succinct way to your audience, and thus stick. Most of us are already comfortable with using pre-developed scripts in our interactions with patients, for example, when obtaining an anesthetic consent.

One script I have used to help describe the PSH model is: “In the perioperative surgical home, anesthesiologists guide patients through their entire surgical experience. This is much more than what we traditionally think of, where the anesthesiologist keeps patients asleep or otherwise pain-free during surgery. In the PSH, your Anesthesiologist plays a substantially greater proactive role before surgery, for example, making sure that patients only get the tests needed for safety, making care more affordable. After surgery, he or she follows the patient to make sure pain is controlled and recovery proceeds at an optimal pace, helping avoid complications.”

In my own experiences over the past couple years, I have found advocating for the PSH to be like almost anything else, in that it became much easier with repetition. There is one important caveat in using scripts – delivery is key! Enthusiasm and sincerity go a long way in making the concept credible to your audience.

The second challenge I will address is advocating within your hospital for a fair share of the payment “bundle.” Several members have forwarded concerns regarding how to best position themselves for a fair “slice of the pie” within the newer bundled payment programs. The reality is that, up to now, many of these programs have been run as something of a hybrid between fee-for-service and truly bundled payments. This has been necessary since most hospitals don’t have contracts with all Medicare providers working in their facilities. The spending for a given organization’s episodes will be compared to historical data (minus some discount), and those faring better than the target will earn additional payments, while those performing worse will have to repay the overage.

Because of this transitional “hybrid” arrangement, the goal for this early round of internal bundled payment advocacy should focus on being involved and exhibiting expertise. In the words of ASA Immediate Past President Jerry Cohen, M.D., we need to be involved as the experts in perioperative care “so much so that administrators… will wake up in a cold sweat in the middle of the night wondering, ‘Are my anesthesiologists happy?’” If you have not already been involved, then chances are there is some form of program under way in your facility without your knowledge (in February, the Center for Medicare and Medicaid Innovation announced that more than 450 groups were selected to participate in their Bundled Payments for Care Improvement initiative). The time to catch up is now. Make certain that you get key members of your department involved in these programs today, offering value-added perioperative services. With regard to exhibiting expertise, the best source for a primer is within our very own society newsletter. In the May 2011 ASA NEWSLETTER, the article “Episode-Based (Bundled) Payments for Anesthesiology” by Stanley W. Stead, M.D., M.B.A. and Sharon Merrick, M.S., CCS-P, ASA’s Director of Payment and Practice Management, is the definitive source for information on calculating costs and other facets of successfully launching related programs. In addition to the abundant print resources, this year’s PRACTICE MANAGEMENT conference featured invaluable information for members related to developing substantive expertise with bundled payments. If you were not able to attend this year’s conference in Las Vegas, much of the content will soon be available online for CME.

The third advocacy challenge brought to the forefront by accountable care is related to patient satisfaction. Medicare has announced that a full 30 percent of bonus payments will be based on patient satisfaction outcomes going forward. Patient satisfaction is multidimensional and represents a powerful advocacy opportunity for our profession with the public every day. A passionate, satisfied patient is a compelling voice for the profession with the government, with third-party payers and with the community at large.

One popular memory aide shown to improve patient satisfaction is the acronym AIDET®.1 AIDET stands for Acknowledge, Introduce, Duration, Explanation and Thank You. Acknowledging patients means making eye-contact, smiling and using their names along with some recognition that you were prepared for them to be in the O.R. with you that day. The Introduction is important and you should provide clarity to the patient about your role in directing the care team in the O.R. Duration means keeping the patient and family as informed as you can about progress toward surgery starting times as well as recovery times. The Explanation means telling them what to expect (from their perspective) followed by the obvious… Thanking the patient for trusting you with providing their care. Several health care organizations have reported not only improved patient satisfaction, but even improved collections when implementing this tool.

The advocacy challenges brought on by accountable care represent opportunities to make care more affordable and enhance the surgical experience of our patients. The “storm” of health care reform appears threatening to some. The time is now to seize these opportunities so that we can favorably bend the advocacy curve for the benefit of all.

“Unless someone like you cares a whole awful lot, nothing is going to get better. It’s not.”
– Dr. Seuss, The Lorax

David M. Broussard, M.D., M.B.A. is System Vice Chair and Program Director, Adult Cardiothoracic Anesthesiology, Ochsner Health System, New Orleans. He is ASA Director from Louisiana.

1. AIDET® is a registered trademark of Studer Group. Used with permission.

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