For many gastroenterology practices across the United States, in-house sedation has become an important ancillary service, enabling practices to generate revenue and control quality. But the provision of propofol sedation remains politically touchy; there are concerns about violating Stark and anti-kickback laws, and certain aspects may render the full ownership of anesthesia services difficult for some practices.
In the latest in our series on ancillary services, Gastroenterology & Endoscopy News asked our panel about the ins and outs of having in-house anesthesia services.
EXPERT ROUNDTABLE PANEL
GEN: Do you provide anesthesia services in your practice? If so, what type of model do you use?
Dr. Weber: TDDC does indeed provide anesthesia services. We own a single-member LLC subsidiary that provides anesthesia services using certified registered nurse anesthetists [CRNAs] on a contracted 1099 basis.
Dr. Roman: We’re open to considering in-house anesthesia, but at this time SDG is a selective anesthesia use practice for our ASCs. Most patients receive moderate sedation, although we do have set days to provide anesthesia in our ASCs for patients who do not require care in the hospital. We have a panel of anesthesiologists who provide monitored anesthesia care [MAC] for these patients and bill separately for their services.
Dr. Overholt: We provide CRNA-administered anesthesia services in our three GI ASCs.
Dr. Leavitt: We provide anesthesia services using a CRNA model. All of our CRNAs are employed by the practice and we have one anesthesiologist for our multiple centers.
Dr. Mergener: We use the same model commonly used in the United States: a subsidiary wholly owned by the physician-owners of our practice. That company employs CRNAs to administer the anesthesia in our practice.
GEN: The current guidelines from the American Society for Gastrointestinal Endoscopy on sedation and anesthesia in GI endoscopy do not endorse the routine use of propofol in average-risk patients [Gastrointest Endosc 2008;68:815-826]. What is your reaction to this stance, and what is your experience with providing propofol sedation to your patients?
Dr. Weber: Propofol is the preferred and expected form of sedation by all of our patients and providers. We believe this drug results in a safer, more standardized and overall better sedation for everyone, and results in excellent patient and physician satisfaction.
Dr. Roman: We believe that the majority of patients do well with moderate sedation, if given appropriately. We hired four new MDs in the past year, and they all trained with or were already using moderate sedation. It is unusual for patients in our community to specifically request MAC. Younger MDs, however, do have a lower threshold for choosing MAC over moderate sedation, depending on patient characteristics.
Dr. Overholt: My opinion is that the 2008 statement on anesthesia guidelines is outdated. One has only to look at the marketplace to see that propofol anesthesia is now administered in the majority of GI endoscopic procedures. Physician and patient preference drives this.
My personal experience supports the movement toward propofol anesthesia. Patients prefer the painless procedure under propofol and the quick recovery with essentially no side effects. Staff prefer the quiet environment, the quick recovery, no nausea and vomiting, and happy patients. Physicians prefer the quick sedation and recovery with propofol, the fact that they can have early discussions of procedural findings due to a quick return of mental recall and, importantly, the safety of propofol anesthesia.
Dr. Leavitt: The ASGE guidelines are out-of-date, and they are in the process of finishing new ones that will be much more supportive of what the majority of people do now. Though the standard of care varies from one region of the country to another, for the most part propofol is the standard of care at this point.
Dr. Mergener: I think, to some degree, the guidelines from our professional societies have been motivated by the concern over the added cost of propofol sedation. But an honest discussion about the overall cost of endoscopy needs to consider all cost components. The main cost driver is the facility fee and whether or not you perform this procedure at an ASC or in the hospital, where facility fees can be five to six times higher. Every component of the service can add to cost, but as long as the end price is reasonable and the service I provide, including propofol, is the optimal service I can give the patient, then that is my goal.
In my personal experience, propofol has been very beneficial medically. We now see increasing numbers of patients who are difficult to sedate with conscious sedation due to use of narcotics, antidepressants and anxiolytics, which can make conscious sedation drugs less effective. I would not dispute that propofol results in a modest cost increase, but it also brings a significant benefit to the patient, the provider and the ambulatory facility, so it’s well worth it.
GEN: There is some concern about the legality of some of the anesthesia models used in GI practices. What can a practice that wants to incorporate anesthesia services do to mitigate regulatory risk?
Dr. Weber: Get good legal advice prior to setting up anesthesia services.
Dr. Leavitt: Use a very experienced health care attorney to set it up and bless it. We have anesthesia services as part of the practice and all of our CRNAs are W2 employees. Our practice’s administrative functions manage billing and collecting.
Dr. Roman: That’s not applicable to us at present, but I would also not consider this a deterrent if approached cautiously.
Dr. Overholt: We have tried all anesthesia models. At each step of the way, we obtained expert legal advice about the legality of the method. Each model was considered legal at the time we tried it. But as the [regulatory] environment changed, so did the legal opinions—and so did our models. My best advice is first, obtain expert legal opinions from an expert health care attorney, or even several attorneys, experienced in the field of anesthesia and ASCs. Second, ask other experienced physicians who have been in the field for a number of years about their model and its legality. Then make your decision.
Dr. Mergener: Obtain input from a health care lawyer familiar with these matters to make sure the anesthesia model you’ve chosen meets all necessary legal and regulatory requirements. Once the service is up and running, stay up-to-date on rules and regulations. They can always change with new laws and mandates introduced on the state or federal level.
GEN: If you have in-house anesthesia, do you have any intention of selling, or bringing in a business partner? Why would you do so or not?
Dr. Weber: TDDC provides anesthesia in-house to control the work environment and the cost while providing safety and quality care to our patients. We do not need outside money nor do we desire outside supervision of this process.
Dr. Overholt: Over the last 15 years, we have tried all anesthesia delivery systems: contracted MD/CRNA services, owning the anesthesia company separate from the practice and providing CRNA services. Finally, close to two years ago, we sold controlling interest to a corporate partner that now provides all anesthesia services. We sold to take some capital off the table; reduce our risk against further cuts or adverse changes in anesthesia; eliminate our risk for Stark-like regulations or legislation prohibiting physician ownership of anesthesia services; and eliminate management, personnel and regulatory hassles. It has been an excellent business decision.
Dr. Leavitt: We don’t, at this point, have plans to bring on a business partner and we’re definitely not selling. I don’t think that fits the whole idea here, which is to be able to own, coordinate and control the spend. If we’re going to do value-based purchasing, bundling or any other type of alternate payment, we want to be in control of every bit of spend. If you sell, you don’t control the cost of anesthesia anymore.
Dr. Mergener: We do not currently have any intention of selling. Owning the anesthesia services allows us to control the cost and also the quality—we decide whom to hire and we train the CRNAs. But I can see why colleagues in small or mid-sized practices may benefit from selling the entire ancillary or a portion of it. For instance, they may need a strong management partner to help them bill for anesthesia services, which works differently from billing for endoscopy services. It’s a different set of billing codes combined with time codes, so it can be a bit tricky. A management partner can also help with recruiting and training CRNAs. We’re not planning to sell because we have the size and scale that allows us to do everything internally.
GEN: It’s unclear from published research on patient preference for and satisfaction with different types of sedation that any approach is superior. Anecdotally, in your practice, have you found that patients prefer one type of sedation over another?
Dr. Weber: Absolutely. The patients definitely prefer propofol to conscious sedation. They get sedated quickly and safely. They are extremely comfortable and completely unaware of anything during the exam. Then they awaken almost immediately after the procedure so that they can receive and understand post-exam instructions and information from their physician. They also report being able to function nearly normally the rest of the day, without losing time to fatigue and forgetfulness from the residual effects of conscious sedation.
Dr. Roman: How we present the options for sedation and anesthesia to patients is important. In our experience, patients do well with moderate sedation and have little or no recall of the procedures. From a quality perspective, using moderate sedation predominantly, our adenoma detection rate is close to 50%, and fewer than one in 500 procedures are incomplete. From a market perspective, we believe that selective anesthesia is attractive to integrative health care networks seeking lower-cost endoscopy services. We have been able to garner referrals in our market due to what’s perceived as responsible delivery of care, meaning we’re not adding cost.
Dr. Overholt: Our patients greatly prefer propofol over midazolam/fentanyl and do not want to go back to the old way of sedation. Our physicians feel the same way.
Dr. Leavitt: I would say that most patients don’t know the difference. They were amnestic when we used midazolam as they are with propofol, and most people found both forms of sedation equally satisfactory. With propofol, patients wake up faster and the amnestic period is shorter, so some people may prefer it. But the group that most prefers it is the physicians. Since patients wake up faster, the turnover is faster; and it’s nice to have another professional in there with the patient. It’s less stressful for the endoscopist because you’re not monitoring the patient and doing the endoscopy and administering anesthesia.
Dr. Mergener: I’m well aware of the published research. I think some of the limitations of this research is that the responses you get very much depend on the way you word the questions. I’m somewhat surprised that these studies have not shown a clearer patient preference for propofol. In our practice, patients who have experienced both kinds of sedation very strongly favor propofol because it’s shorter-acting, they’re more wide awake afterward and it provides more complete sedation during the procedure.