This Just In

Salary Survey
From Clerks to CRNAs, What ASC Employees Make
CRNAs and nursing directors saw the biggest percentage jumps in their salaries from 2001 to 2002, according to the national ASC salary data from the Federated Ambulatory Surgery Association (FASA).

The average CRNA salary at an ASC went up more than $14,000 in the last year, from $87,727 to $101,825, a 16 percent increase. The average nursing director salary rose more than $6,000, from $53,702 to $59,812, an 11 percent increase. Anesthesiologists also fared well, their average salary rising about $8,000 to an average of $204,850, a 4.4 percent increase. The percentage increases were not quite as dramatic in other areas, but every position took home more last year than in 2001. Here's the breakdown.

Surgeon Shortage?
Applicant Pool for Surgery Residency Programs Shrinking
Once the most competitive and highly coveted positions by medical students, surgery residencies are being passed over for residencies in subspecialties that afford a more controllable lifestyle and more competitive salaries.

The percentage of medical students interested in a residency in surgery has decreased from 12.1% in 1981 to 6.1% in 2001, according to data from the Association of Medical Colleges (AAMC). For the first time, surgery residency programs have vacant positions - AAMC projects that only 76.6% will be filled by 2005. Here's why.

• Demographics. The very process of becoming a general surgeon in the rigid and inflexible environment of many residency programs is excessively difficult for medical students who are older or wish to raise families.
• Debt. Mean salaries of medical graduates are decreasing at a time when 83% are in considerable debt. Their average debt is $95,000, for which repayment must begin immediately; average salaries of first-year house staff are lower than $36,000. Surgery residencies can last 5 to 10 years, compounding the indebtedness issue.

Umbilicoplasty
A New Body Part Going Under the Knife
Navel reconstruction - or "umbilicoplasty," as the pros call it - is giving breast implants and liposuction a run for their money. Last spring plastic surgeons began reporting a curious spike in the number of women requesting the ideal umbilicus. With the midriff at the height of fashion, the navel is now the center of what's considered sexy. A study found that attractive navels are small and vertical in orientation, or have a T shape - a thin vertical hollow capped by "a superior hood or shelf.''

Washington Giveth, Washington Taketh Away?
ASC Medicare Payments Come Under Fire From MedPAC
While ambulatory surgery centers continue to work with CMS to re-base ASC payment rates, another bureaucratic arm of the Federal government is questioning whether ASC payment growth has been excessive. The result could be a Medicare reimbursement freeze for your ASC. It is also possible that some of the highest reimbursements could be capped at the hospital rate.

The Medicare Payment Advisory Commission (MedPAC), an independent board that advises Congress on Medicare policy payment issues, may recommend budgetary changes designed to freeze or cap ASC payments in its final report to Congress.

"MedPAC staffers mischaracterized information about Medicare payment updates, which unfortunately led the Commissioners toward a consensus position to recommend that Congress freeze Medicare payments for ASCs in 2004," says Eric Zimmerman, Esq., legal counsel for AAASC.

Specifically, MedPAC is looking at two levels. First, there is the issue of annual inflationary adjustments. The law calls for an annual adjustment equal to the Consumer Price Index (CPI), but as a provision of the Balanced Budget Act of 1996, the rate was reduced to the CPI minus two percent. Congress recently allowed the provision to lapse, restoring the full inflationary adjustment for 2003.

At the November 7 MedPAC meeting, it was erroneously stated to the commissioners that ASCs enjoyed full inflationary increases every year since 1986. After groups such as FASA and AAASC pointed out that ASCs actually received miniscule inflationary adjustments from 1997 to 2002, MedPAC staffers issued an amended statement for the December 12 meeting.

Says FASA president Kathy Bryant, "To pick out 281 codes without looking at the bigger reimbursement picture does not provide a clear understanding of the problem with the ASC payment system which, in a nutshell, is that the existing rates do not reflect real-life costs for ASCs."

Several MedPAC Commissioners at the December meeting expressed interest in recommending that Congress freeze ASC payments in 2004, says Mr. Zimmerman. Some also advocated a recommendation to cap Medicare payments for ASCs at hospital outpatient service levels, so that an ASC could not be paid more than a hospital for any given service.

Pushing the Envelope?
Many Anesthesiologists Believe Ambulatory Surgery Tests the Limits of Patient Safety
Many anesthesia providers believe that facilities often push the safety limits of outpatient surgery. At least that's what an Internet survey of anesthesiologists conducted by the Society of Ambulatory Anesthesia (SAMBA) reveals.

Twenty-one of the 53 respondents (40 percent) said they agree or strongly agree with the statement that their practice "pushes the envelope of patient safety" by performing outpatient surgery on patients with serious pre-existing morbidities. Meanwhile, 35 percent (18 respondents) agreed or strongly agreed that making complex or lengthy procedures into outpatient cases is testing safety boundaries.

SAMBA president Barbara Gold, MD, notes that "pushing the envelope" need not have a negative connotation. Such practices can be "beneficial and innovative" so long as the cases are taken outpatient as a result of medical consensus between the surgeon and anesthesiologist and not because of "system issues" such as reimbursement and staffing.

However, some providers fear that system concerns bear direct pressure to take risks they would not recommend. Twenty percent of the survey respondents said that they felt the strongest pressure from administrators, while the largest percentage (43%) said surgeons apply the strongest pressure.

For example, Alexander Liu, MD, of Van Nuys, Calif., notes that anesthesiologists' knowledge of techniques for treating obese patients makes it possible to treat an increasing number of their surgical cases on an outpatient basis, but the circumstances need to be reviewed carefully on a case-by-case basis.

Unfortunately, there are times when an anesthesiologist's concerns over doing outpatient surgery on an obese patient with significant systemic illnesses get brushed aside. He cites one case involving a colleague in which the surgeon pressured him into treating an especially problematic case, even noting that the patient could be admitted if necessary. Says Dr. Liu, "If there's any doubt that you can uphold the principle of 'above all, do no harm,' it shouldn't be an outpatient case. "

Eventually, several anesthesiologists huddled and together, they devised a complex multi-faceted regional anesthesia approach that worked for the patient. The entire surgical team sweated it out the whole way and no one, including the surgeon, was anxious for a repeat performance. Says Dr. Liu. "The case took much longer than normal, tied up extra staff, left everyone fatigued afterwards and, most importantly, doing the case outpatient was not what was medically best for the patient, even though they brought him through surgery successfully."

Medical Malpractice Insurance
Gloom and Doom: As Premiums Skyrocket and Insurers Flee, Surgeons Are Left in a Lurch
How bad has the medical malpractice insurance crisis gotten? Well, assuming your surgeons can get coverage at all, more and more of them can no longer afford it. Consider:

• West Virginia surgeons staged a New Years Day job stoppage to protest the astronomical cost of medical malpractice insurance.
• Two major malpractice insurers, the St. Paul Companies and TIG Specialty Insurance Solutions, are no longer writing medical liability policies.

"When states and many HMOs require a doctor to have malpractice insurance and the coverage either isn't available or it's so expensive that you can't afford to practice, there are going to be a lot fewer doctors in all specialties to see patients," says Arthur Palamara, MD, vice president of the Florida Medical Association.

The medical community was rocked by the announcement last year that the St. Paul Companies, the nation's second largest malpractice insurer, was exiting the business. Providers and facilities in several states had to scramble to line up liability coverage. On Jan 1, 2003, TIG Specialty Insurance Solutions, a major malpractice insurance carrier favored by CRNAs, bowed out of the business. TIG will deal with its program underwriters on a business-as-usual basis for six months, says American Association of Nurse Anesthetists (AANA) director of insurance services John Fetcho. AANA underwriters can amend, cancel or write new TIG policies for CRNAs until June 30, 2003.

• Practitioners of pediatric anesthesia have become one of the nation's most sought-after sub-specialists, according to Cejka and Company, a national health care search firm. The firms report that anesthesiologists with expertise in pediatric cases cost between $200,000 and $275,000 to recruit. The high salaries are attributed to very short supply in the sub-specialty, coupled with greatly rising demand from patients and facilities alike...
• Olympus America has acquired the exclusive rights to supply hysteroscopy and video endoscopy equipment for use by Conceptus in the training of U.S. surgeons on Essure, the permanent birth control procedure being hailed as a non-incisional alternative to tubal ligation...
• The regulation of office-based surgery remains a controversial topic. The American College of Surgeons (ACS) and the American Medical Association (AMA) are convening a task force to develop safety guidelines for office suite surgery. The task force will develop specific safety requirements for twilight sedation, deep sedation, and general anesthesia procedures, with the ultimate goal being the creation of standardized models for which state regulation can be based. Presently, office surgery is not regulated by many states...
• Tumescent liposuction performed by dermatologic surgeons is safe, with no deaths and a serious adverse event rate of 0.68 per 1,000 cases, according to a seven-year retrospective study conducted by the Department of Dermatology at the Wake Forest University School of Medicine...
• Still confused about HIPAA? You may be able to find clarifications on the Web. CMS has posted a HIPAA FAQ to address common questions about the more problematic aspects of the massive statute. Go to writeOutLink('www.hhs.gov/ocr/hipaa/privacy.htm','y')...
• As of Jan. 1, your facility will no longer be able to receive private accreditation-readiness consulting from JCAHO surveyors.