Physician-Owner Tax
New Jersey Set to Tax ASCs
Physician-owned ASCs in New Jersey will soon be hit with a tax to fund hospital charity care. A bill imposing an annual tax ranging from $10,500 to as much as $200,000 has been approved as part of the state's annual budget.

The tax doesn't apply to facilities licensed to a general hospital as an off-site ambulatory center. In addition to outpatient surgery services, the tax affects facilities providing MRIs, CAT scans and extracorporeal shock wave lithotripsy. Highlights:

• Payments, in four installments, begin Oct. 1.
• Assessments will be based on facilities' gross receipts. Facilities grossing at least $300,000 will have to pay a tax equal to 3.5 percent of their gross receipts or $200,000, whichever is less. Facilities with annual gross receipts less than $300,000 are exempt.
• Facilities subject to the tax must submit an annual report to the state by Sept. 15 that includes case volumes, charges and gross revenues by payer type, beginning with calendar year 2003 data. Facilities could be fined up to $500 for each day of non-compliance if they don't submit the information.
• The state, which will notify facilities if they are subject to the tax by Aug. 15, may audit reports and levy retroactive assessments if it finds the submitted data inaccurate.
• If a facility performs one or more of the services included in the bill without a license from the department on or after July 1, it will be liable for double the assessment, plus fines.

The news isn't good for physician-owned ASCs, says Mark Manigan, Esq., a partner in the healthcare group at Wolf Block Brach Eichler in Roseland, N.J. "An ASC could lose money on the year but still owe the tax, because it's based on gross, not net revenue," he says. "ASC owners could be required to pay out of pocket."

- Stephanie Wasek

ASA Publishes Equipment Guidelines
Is Your Anesthesia Machine Obsolete?
Anesthesia machines don't become obsolete merely because of age, according to the American Society of Anesthesiologists' guidelines for determining if the gas-delivery system you use is obsolete. Some things to watch out for:

• Lack of such essential safety features as an oxygen-supply pressure-failure alarm and fail-safe emergency delivery mechanism, a pin-index safety system for attaching cylinders, and non-interchangeable, gas-specific connections on the pipeline inlets.
• Lack of desirable safety features, such as an airway pressure alarm.
• Features that don't reflect standards of care, including measured-flow vaporizers and scavenging system connections that are the same diameter as a breathing system connection.
• Lack of maintenance on a decertified model that the manufacturer and its subsidiaries no longer service.
• An obsolete machine that no longer meets practice needs. The machine might be in good working order, but it's not compatible with vaporizers for newer volatile inhalation agents.

- Bill Meltzer

Antiemetic Prophylaxis
Study: Cheaper PONV Prevention Drugs As Effective as More Expensive Drugs
The first head-to-head comparison of common antiemetic strategies found that drugs costing a few dollars work just as well as more expensive medications in preventing PONV. The study, published in a recent New England Journal of Medicine, looked at 64 possible combinations of six different nausea and vomiting treatments. Twenty-eight participating hospitals in seven countries used every possible combination to learn which treatments worked best on 5,199 patients diagnosed as moderate to high PONV risks.

Three of the treatments researchers examined are antiemetic drugs - the generic steroid dexamethasone, the serotonin antagonist ondansetron (Zofran) and the tranquilizer droperidol (Inapsine and others). Droperidol costs facilities about $1, dexamethasone $2 or less and ondansetron roughly $15. Individually, researchers found the three drugs to be about equally effective.

Droperidol for many years was the foundation for any protocol against PONV, but it's no longer a front-line treatment. In December 2001, the FDA issued a black box warning for droperidol, related to deaths associated with cardiac rhythm abnormalities. Specifically, the warning states that "? (this drug) should be reserved for use in the treatment of patients who fail to show an acceptable response to other adequate treatments ?" and suggests you monitor a patient for several hours after you administer the drug.

Dexamethasone doses for PONV prophylaxis are usually about 5mg given via IV administration early during the anesthetic. Dosed at this level - and administered in only a single dose - there appears to be no significant side effects of the type commonly associated with high-dose or chronic steroid use, says anesthesiologist Paul Ting, MD, a co-medical director of Virginia Ambulatory Surgery Center and an assistant professor of anesthesiology at the University of Virginia, who has extensively researched PONV-related issues. However, "this drug has no role in treating established nausea and/or vomiting. For that purpose, the serotonin antagonists likely remain the most efficacious choice for single-agent treatments," says Dr. Ting.

In the NEJM study, researchers also studied the effects of two anesthetic techniques - using TIVA rather than gas and using nitrogen rather than nitrous oxide as the inhalation agent blended with a primary volatile inhalation agent (such as desflurane [Suprane] or sevoflurane [Ultane]). They also added remifentanil (Ultiva and others) administration into the mix.

More than half (52 percent) of study patients receiving no anti-emetic drugs became ill after surgery. This dropped to 37 percent of those who received one of the three antiemetics, 28 percent of those receiving two and 22 percent of those who got all three.

Propofol-based TIVA brought a 19 percent drop compared with use of gas, and nitrogen rather than nitrous oxide a 12 percent reduction. A painkiller change to remifentanil instead of longer-lasting opioids made no significant difference.

- Bill Meltzer

Inside The Numbers
Unannounced Surveys

• 1%: Hospital non-compliance rate for pre-op patient verification during regular JCAHO accreditation surveys.
• 5%: Hospital non-compliance rate for pre-op patient verification during random unannounced JCAHO surveys.
• 9%: Hospital non-compliance rate for OR time-out before surgery during regular JCAHO accreditation surveys.
• 23%: Hospital non-compliance rate for OR time-out before surgery during random unannounced JCAHO surveys.
• 7%: Hospital non-compliance rate for surgical-site marking during regular JCAHO accreditation surveys.
• 36%: Hospital non-compliance rate for surgical-site marking during random unannounced JCAHO surveys.

Source: Joint Commission on Accreditation of Healthcare Organizations (surveys conducted from January 2003 through September 2003).