Monday, February 4, 2013

Anesthesiologists Are Rewarded For Being Inefficient In The OR

This is the dirty little secret amongst anesthesiologists. While the entire nation is trying to streamline medicine and make it more cost effective and efficient, it is against the self interest of anesthesiologists to follow suit. The reason for this has to do with the way anesthesiologists are paid.

Anesthesia billing is unique compared to other fields of medicine. Surgeons and internists are paid based on the patient's diagnosis and procedure performed. For example a surgeon will get paid a set amount of money for performing a hernia repair or a lap chole. A cardiologist will be reimbursed a certain sum for treating an acute MI. And that's it, other than a few modifiers thrown in.

By contrast, anesthesiologists are paid based on procedure performed PLUS time spent with the patient. Every surgical procedure has an associated CPT code for insurance purposes. This CPT code is then converted into base units which is determined by Medicare and insurance carriers. The more complex the case, the higher the base units assigned. The number of base units is then multiplied by a conversion factor, which is in dollars, to determine how much money the anesthesiologist will get paid for that procedure. This conversion factor changes with geographic location, based on cost of living and the preponderant cost of providing that service in the area.

But that's not all. Anesthesiologists also get time units for the procedure. These are usually marked in 15 minute increments and start when the patient enters the operating room. Therefore a procedure that lasts one hour will get four units of time. If it goes to one hour and two minutes, the anesthesiologist can bill for five units of time. So when an anesthesiologist bills for a case, the formula is (base units + time units) x conversion factor=$$$.

Pretty sweet deal right? While a surgeon may spend three hours on a difficult hernia repair and still get the same amount of money as a twenty minute repair, to the anesthesiologist it's just more money in the bank. Cha Ching! Unfortunately this set up is also ripe for abuse. While it is difficult and fraudulent to change the diagnosis to get a higher base unit, the time unit reported can be slippery.

It is all too easy to extend the time units to increase your reimbursement. And it is all legitimate too. I know some anesthesiologists who have perfected this practice to a science. For instance, just because a patient enters the OR doesn't mean you have to start the anesthesia right away. Maybe you decide you don't draw up your drugs until the patient enters the room. This can easily add another ten to fifteen minutes to your time units. I'm shocked when nurses tell me about colleagues who take over twenty minutes to put a patient to sleep after entering the room. I can't imagine what they could possibly be doing for that long. I'm sure it is nerve racking for the already anxious patient too.

Emergence is even easier to add to your time units. It's very simple to say the patient just isn't ready to be awakened yet and nobody will doubt you. The anesthesiologist can say the patient doesn't have all his twitches back yet. Or the patient is just one of those people who takes more time to metabolize their anesthesia and thus slow to wake up. So while the nurses and surgeon are sitting around twiddling their thumbs waiting for the patient to regain consciousness, the anesthesiologist is sitting back and fattening his wallet.

I personally detest wasting time in the operating room. I have things to do and family to tend to when my cases are done for the day. But maybe some people just need to make more money for their Porsche payments, or their Caribbean cruise vacation coming up. Whatever the reason, the anesthesia time units will be difficult to eliminate as so many of us have come to finesse the system for our own personal gain.


  1. Thanks for the comments Dr. Z.

    But, do you think this practice will continue on with health care reform? With bundled payments on the way, it seems Anesthesiologists will receive a predetermined fee that has already been decided on prior to the start of the surgery... in which case, the practice of prolonging cases for personal gain will probably come to an end because billing will no longer be based on 15 minute intervals (I'm guessing). If anything, it seems bundled payments will be an incentive to power through cases as quickly as possible.

    Your thoughts? Thanks in advance.

  2. My feeling is that eventually all doctors will become salaried employees of a hospital or the government. Then the incentive to work harder will disappear. We will all drag our feet until 3:00 PM then see who can race out to the parking lot the fastest.