Economic Impact, Cost, and Reimbursement Issues

Chapter

Abstract

Healthcare delivery costs in the perioperative setting have increased due to varying factors. Regional anesthesia (RA) minimizes costs and would lead to cost benefits on evaluation. RA allows for airway avoidance and minimizes/eliminates general anesthesia requirements for perioperative patient care. Additionally, patients receiving RA have fewer effects from perioperative anesthetic agents than their general anesthesia cohorts.

Bypassing Phase I recovery leads to tangible savings that medical center leadership may tangibly notice. Older patients and those with comorbidities are able to have surgery on an outpatient basis, largely on the strengths of RA, leading to a fiscally viable healthcare delivery.

With the implementation of programs to enhance care and recovery via protocol-driven algorithms (ERAS and ERPs), RA plays a vital role in virtually all surgical encounters, enabling cost beneficial and safe patient care.

The anesthesiologists of today and tomorrow will play a vital role in the perioperative home and in executing the ERAS programs via a RA service. Fiscal responsibility is reflected by perioperative physician’s technical choices in care delivery. This cost-saving approach also allows for new avenues and revenue for the anesthesia service team. Key considerations are required in the implementation of a RA service and in the documentation of procedures performed for economic viability.

Armed with an analysis of evaluating the plethora of techniques and agents to provide safe and cost-effective care, the anesthesiologist with regional expertise and insight into the economics of healthcare will be poised to lead the operating room of tomorrow.

Keywords

Regional anesthesia Anesthesia-controlled times (ACT) Economics Peripheral nerve block Billing Ultrasound guidance Operating room management Fixed and variable costs Performance standards Perioperative efficiency 

References

  1. 1.
    Center for Medicaid and Medicare Services. NHE fact sheet [Internet]. Baltimore: Center for Medicaid and Medicare Services; 2016 [cited 2016 Jan 30]. https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html.
  2. 2.
    Fuchs VR. The gross domestic product and health care spending. N Engl J Med. 2013;369(2):107–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Sisko AM, Truffer CJ, Keehan SP, Poisal JA, Clemens MK, Madison AJ. National health spending projections: the estimated impact of reform through 2019. Health Aff (Millwood). 2010;29:1933–41.CrossRefGoogle Scholar
  4. 4.
    Shuber A, Guirguis M. The role of peripheral nerve block analgesia in advancing therapeutic effectiveness spanning the episode of care. Tech Reg Anesth Pain Manag. 2014;18(4):118–22.CrossRefGoogle Scholar
  5. 5.
    Alzahrani T, Eldawlatly A. The enigma of regional anesthesia in enhanced recovery after anesthesia protocols. Basic Res J Med Clin Sci. 2016;5(7):127–33.Google Scholar
  6. 6.
    Eldawatly A. Is enhanced recovery after anesthesia a synonym to enhanced recovery after surgery? Saudi J Anaesth. 2016;10:119–20.CrossRefGoogle Scholar
  7. 7.
    Sibia US, MacDonald JH, King PJ. Predictors of hospital length of stay in an enhanced recovery after surgery program for primary total hip arthroplasty. J Arthroplast. 2016;31(10):2119–23.CrossRefGoogle Scholar
  8. 8.
    Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff. 2008;27(3):759–69.CrossRefGoogle Scholar
  9. 9.
    Institute for Healthcare Improvement. IHI triple aim initiative [Internet]. Cambridge, MA; 2010 [cited 2016 Jan 31]. http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/Materials.aspx.
  10. 10.
    Healthcare Cost Institute. Health care cost and utilization report: 2011. Washington, DC: Health Care Cost Institute; 2012 [cited 2016 Feb 1]. http://www.healthcostinstitute.org/report/2012-health-care-cost-utilization-report/.
  11. 11.
    Sheldon GF, Ricketts TC, Charles A, King J, Fraher EP, Meyer A. The global health workforce shortage: role of surgeons and other providers. Adv Surg. 2008;42:63–85.CrossRefPubMedGoogle Scholar
  12. 12.
    Martin J, Cheng D. Role of the anesthesiologist in the wider governance of healthcare and health economics. Can J Anaesth. 2013;60:918–28.CrossRefPubMedGoogle Scholar
  13. 13.
    Macario A. What does one minute of operating room time cost? J Clin Anesth. 2010;22(4):233–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Oldman M, McCartney CJ, Leung A, Rawson R, Perlas A, Gadsen J, et al. A survey of orthopedic surgeons’ attitudes and knowledge regarding regional anesthesia. Anesth Analg. 2004;98:1486–90.CrossRefPubMedGoogle Scholar
  15. 15.
    Stahl JE, Sandberg WS, Daily B, et al. Reorganizing patient care and workflow in the operating room: a cost-effectiveness study. Surgery. 2006;139:717–28.CrossRefPubMedGoogle Scholar
  16. 16.
    Eappen S, Flanagan H, Lithman R, Bhattacharya N. The addition of a regional block team to the orthopedic operating rooms does not improve anesthesia-controlled times and turnover time in the setting of long turnover times. J Clin Anesth. 2007;19(2):85–91.CrossRefPubMedGoogle Scholar
  17. 17.
    Williams BA, Kentor ML, Williams JP, Figallo CM, Sigl JC, Anders JW, et al. Process analysis in outpatient knee surgery: effects of regional and general anesthesia on anesthesia-controlled time. Anesthesiology. 2000;93:529–38.CrossRefPubMedGoogle Scholar
  18. 18.
    Saporito A, Anselmi L, Borgeat A, Aguirre JA. Can the choice of the local anesthetic have an impact on ambulatory surgery perioperative costs? Chloroprocaine for popliteal block in outpatient foot surgery. J Clin Anesth. 2016;32:119–26.CrossRefPubMedGoogle Scholar
  19. 19.
    Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17(2):131–57.CrossRefPubMedGoogle Scholar
  20. 20.
    Carli F, Kehlet H, Baldini G, Steel A, McRae K, Slinger P, et al. Evidence basis for regional anesthesia in multidisciplinary fast-track surgical care pathways. Reg Anesth Pain Med. 2011;36(1):63–72.CrossRefPubMedGoogle Scholar
  21. 21.
    Hudson ME, Chelly JE, Williams BA. Economics: projecting costs and revenue for an interventional pain service in the ambulatory setting. Int Anesthesiol Clin. 2011;49(3):68–83.CrossRefPubMedGoogle Scholar
  22. 22.
    Foster BD, Terrell R, Montgomery SC, Wang JC, Petrigliano FA, McAllister DR. Hospital charges and practice patterns for general and regional anesthesia in arthroscopic anterior cruciate ligament repair. Orthop J Sports Med. 2013;1(5):1–5.Google Scholar
  23. 23.
    MacFarlane AJR, Govindarajulu AP, Chan VWS, Brull R. Does regional anesthesia improve outcome after total knee arthroplasty? Clin Orthop Relat Res. 2009;467:2379–402.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Richman JM, Liu SS, Courpas G, Wong R, Rowlingson AJ, McGready J, et al. Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg. 2006;102:248–57.CrossRefPubMedGoogle Scholar
  25. 25.
    Williams BA, Kentor ML. Fast-track ambulatory anesthesia: impact on nursing workload when analgesia and antiemetic prophylaxis are near optimal. Can J Anaesth. 2007;54:243–4.CrossRefPubMedGoogle Scholar
  26. 26.
    Mauermann WJ, Shilling AM, Zuo Z. A comparison of neuraxial block versus general anesthesia for elective total hip replacement: a meta-analysis. Anesth Analg. 2006;3(4):1018–25.CrossRefGoogle Scholar
  27. 27.
    Williams BA, DeRiso BM, Figallo CM, Anders JW, Engel LB, Sproul KA. Benchmarking the perioperative process: III. Effects of regional anesthesia clinical pathway techniques on process efficiency and recovery profiles in ambulatory orthopedic surgery. J Clin Anesth. 1998;10:570–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Heil JW, Ilfeld BM, Loland VJ, et al. Ultrasound-guided transversus abdominis plane catheters and ambulatory perineural infusions for outpatient inguinal hernia repair. Reg Anesth Pain Med. 2010;35(6):556–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Calle GA, Lopez CC, Sanchez E, et al. Transversus abdominis plane block after ambulatory total laparoscopic hysterectomy: randomized controlled trial. Acta Obstet Gynecol Scand. 2014;93(4):345–50.CrossRefPubMedGoogle Scholar
  30. 30.
    De Oliveira GS Jr, Castro-Alves LJ, Nader A, Kendall MC, McCarthy RJ. Transversus abdominis plane block to ameliorate postoperative pain outcomes after laparoscopic surgery: a meta-analysis of randomized controlled trials. Anesth Analg. 2014;118:454–63.CrossRefPubMedGoogle Scholar
  31. 31.
    Yamamoto H, Shido A, Sakura S, Saito Y. Monitored anesthesia care based on ultrasound-guided subcostal transversus abdominis plane block for continuous ambulatory peritoneal dialysis catheter surgery: case series. J Anesth. 2016;30(1):156–60.CrossRefPubMedGoogle Scholar
  32. 32.
    Sammour T, Zargar-Shoshtari K, Bhat A, et al. A programme of Enhanced Recovery After Surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J. 2010;123:61–70.PubMedGoogle Scholar
  33. 33.
    McIsaac DI, Cole ET, McCartney CJL. Impact of including regional anaesthesia in enhanced recovery protocols: a scoping review. Br J Anaesth. 2015;115(52):ii46–56.CrossRefPubMedGoogle Scholar
  34. 34.
    Dexter FD, Wachtel RE. Strategies for net cost reductions with the expanded role and expertise of anesthesiologists in the perioperative surgical home. Anesth Analg. 2014;118:1062–71.CrossRefPubMedGoogle Scholar
  35. 35.
    Williams BA, Kentor ML, Vogt MT, Vogt WB, Coley KC, Williams JP, et al. The economics of nerve block pain management after anterior cruciate ligament reconstruction: significant hospital cost savings via associated PACU bypass and same-day discharge. Anesthesiology. 2004;100:697–706.CrossRefPubMedGoogle Scholar
  36. 36.
    Sandu NS, Sidhu DS, Caplan LM. The cost comparison of infraclavicular brachial plexus block by nerve stimulation and ultrasound guidance. Anesth Analg. 2004;98:267–8.CrossRefGoogle Scholar
  37. 37.
    Saporito A, Sturni E, Borgeat A, Aguirre J. Continuous popliteal sciatic nerve block for outpatient foot surgery: incidence of unplanned visits and readmissions compared to inpatient management—a randomized, controlled trial. Anaesthesia. 2014;69:1197–205.CrossRefPubMedGoogle Scholar
  38. 38.
    Hadzic A, Karaca PE, Hobeika P, Unis G, Dermksian J, Yufa M, et al. Peripheral nerve blocks result in superior recovery profile compared with general anesthesia in outpatient knee arthroscopy. Anesth Analg. 2005;100:976–81.CrossRefPubMedGoogle Scholar
  39. 39.
    Gonano C, Kettner SC, Ernstbrunner M, Schebesta K, Chiari A, Marhofer P. Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery. Br J Anaesth. 2009;103(3):428–33.CrossRefPubMedGoogle Scholar
  40. 40.
    Ilfeld BM, Mariano ER, Williams BA, Woodward JN, Macario A. Hospitalization costs of total knee arthroplasty with a continuous femoral nerve block provided only in the hospital versus on an ambulatory basis: a retrospective, case control, cost-minimization analysis. Reg Anesth Pain Med. 2007;32:46–54.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Urquhart DM, Hanna FS, Brennan SL, Wluka AE, Leder K, Cameron PA, et al. Incidence and risk factors for deep surgical site infection after primary total hip arthroplasty: a systematic review. J Arthroplast. 2010;25(8):1216–22.CrossRefGoogle Scholar
  42. 42.
    Helwani MA, Avidan MS, Abdallah AB, Kaiser DJ, Clohisy JC, Hall BL, et al. Effects of regional versus general anesthesia on outcomes after total hip arthroplasty. J Bone Joint Surg Am. 2015;97:186–93.CrossRefPubMedGoogle Scholar
  43. 43.
    Rinehardt EK, Sivarajan M. Costs and wastes in anesthesia care. Curr Opin Anaesthesiol. 2012;25:221–5.CrossRefPubMedGoogle Scholar
  44. 44.
    Swenson JD, Davis JJ. Getting the best value for consumable supplies in regional anesthesia. Int Anesthesiol Clin. 2011;49:94–103.CrossRefPubMedGoogle Scholar
  45. 45.
    Swenson JD, Klingler KR, Pace NL, Davis JJ, Loose EC. Evaluation of a new needle guidance system for ultrasound: results of a prospective, randomized, blinded study. Reg Anesth Pain Med. 2016;41(3):356–61.CrossRefPubMedGoogle Scholar
  46. 46.
    Armstrong KP, Cherry RA. Brachial plexus anesthesia compared to general anesthesia when a block room is available. Can J Anaesth. 2004;51(1):41–4.CrossRefPubMedGoogle Scholar
  47. 47.
    Drolet P, Girard M. Regional anesthesia, block room and efficiency: putting things in perspective. Can J Anaesth. 2004;51:1–5.CrossRefPubMedGoogle Scholar
  48. 48.
    Kim TW, Mariano ER. Updated guide to billing for regional anesthesia (United States). Int Anesthesiol Clin. 2011;49(3):84–93.CrossRefPubMedGoogle Scholar
  49. 49.
    Mariano ER. Making it work: setting up a regional anesthesia program that provides value. Anesthesiol Clin. 2008;26:681–92.CrossRefPubMedGoogle Scholar
  50. 50.
    Gerancher JC, Viscusi ER, Liguori GA, McCartney CJ, Williams BA, Ilfeld BM, et al. Development of a standardized peripheral nerve block procedure note form. Reg Anesth Pain Med. 2005;30:67–71.CrossRefPubMedGoogle Scholar
  51. 51.
    American Medical Association. CPT 2017 Professional Edition. American Medical Association; 2017.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of AnesthesiologyAdvocate Illinois Masonic Medical CenterChicagoUSA
  2. 2.Department of Anesthesiology and Critical CareThe University of ChicagoChicagoUSA

Personalised recommendations