Volume 3, Issue 9 S A M B A T A L K S - PAGE 1 February, 2004

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Do you have a problem case or situation in ambulatory anesthesia about which you would like some advice? Would you like to reply to questions others have raised about ambulatory anesthesia issues? Do you have any comments or opinions regarding any topic related to ambulatory anesthesia which you would like to share with other professionals? If you answered "yes" to any of the above, then "Join the Discussion" here.

To enter the Discussion with a question, reply, or other comment, please contact us. Your question/reply/comment will be published in this section of the next available issue of SAMBA TALKS. Please include your name (or initials), city, and state, if you would like these published.

Questions and responses from previous months are available on the Web site. If you have any comments regarding the previous questions, please submit them to SAMBA Discussion, and they will be published here next month.

?? - LAST MONTH'S QUESTIONS WITH REPLIES - ?? - TOP

QUESTION 1:

I received a letter from an insurance carrier, citing that my group's "heavy use of single injection post-operative nerve blocks for pain control....are not medically necessary". The reviewer noted: "Heavy use of single injection post-operative nerve blocks for pain control." The exact commentary follows: "This practice, while within the current standard of care, is controversial. While pain control is clearly medically necessary, it is usually satisfactorily provided with oral narcotics, ketorolac, and NSAIDS. Post-op nerve blocks can, at best, provide only a few hours of relief, and then other means for pain control must be utilized (e.g. Vicodin, etc.).  A better technique involves surgical insertion of a tiny catheter connected to a slow continuous infusion pump. These are quickly inserted (<1 minute) by the surgeon and provide relief for days to weeks....and have lower risk (inserted under direct vision by surgeon=no nerve trauma), and probably cost less....These blocks are not medically necessary". Does anyone have any comments regarding this?

-- Anonymous

REPLY 1:

If they state that this is standard of care, how can they claim it is not medically necessary? Also, the carrier needs some education on nerve blocks - they last more than a few hours with long acting agents. We frequently use blocks so that we can send the patient home instead of admitting for pain control/IV narcotics. The idea that surgeons can do this cheaper is not valid, because implanting a catheter will result in another fee- it won't be covered under the global fee for the procedure. Most importantly, there is little data showing head to head comparisons on blocks vs. indwelling catheters. There is also a cost in the elastomeric or other pumps ($200-300) that would be required for the catheter technique. Furthermore, there is considerable debate over the safety of sending patients home with these devices. While it may be OK, there is not a preponderance of evidence and there are increased risks (infection, broken catheters, etc.). So, in the absence of data showing that the indwelling catheter technique is better and the complete lack of savings in cost over a block, and admission that this is standard of care, there is no basis for saying that it is not medically necessary.

-- From Alan P. Marco, M.D., M.M.M., Toledo, Ohio

REPLY 2:

Having been a practitioner of regional anesthesia for outpatients since 1996, I find this degree of misinformation and undeserved authority by a claim reviewer/third party payer to be at the core of the potentially greatest problem in the health care system in the United States.

It is true that single-injection nerve blocks provide short-duration analgesia. This "short duration" can range from 6-8 hours (e.g., mepivacaine) to 12-16 hours (ropivacaine without additives) to 18-24 hours (ropivacaine with additives such as clonidine and buprenorphine). All of these time intervals allow patients to self-administer 1-2 doses of postoperative oral opioids (and other non-opioid analgesics, e.g., COX-2 inhibitors, which insurers also commonly refuse to pay for) before blocks resolve. Lower net doses of perioperative opioids are associated with less PONV and fewer unplanned hospital admissions (not to mention less somnolence, respiratory depression, constipation, urinary retention, and pruritis).

Centers that routinely perform peripheral nerve blocks in an effort to provide meaningful pain relief do so because their surgeons and patients want them. Most importantly, peripheral blocks have been demonstrated to be more effective and provide better patient-reported outcomes than using strictly opioid-based postoperative analgesia. Regional anesthesia practitioners routinely serve as consultants to the surgeon to provide optimal analgesic care to patients. Pain is not only an unpleasant symptom, but it is also a symptom that is associated with stress. In this respect, regional anesthesia techniques have been clearly demonstrated to be the techniques of choice to prevent the development of the postoperative stress syndrome. The potential predilection of patients with inadequately treated surgical pain to develop chronic pain syndromes cannot be underestimated.

The main reasons that more people are not using regional blocks routinely is that (i) many anesthesiologists are not appropriately trained in the performance of these techniques, and (ii) perhaps surgeons are unwilling to have updated pain management practices for their patients when anesthesiologists are indeed trained in regional techniques. Third parties refusing to pay for a value-adding service (as listed in the original question) should not be a rate-limiting step. Quality of care in medicine is as important as the care itself. It is outrageous that an insurance company can claim that having inadequate pain control (with oral opioids and NSAIDS) while being afflicted with GI (PONV, hemorrhage) and renal side effects, along with itching, urinary retention, constipation, and respiratory depression is equal to having a single-injection block for postoperative pain relief.

Wound / intra-articular catheters represent a technique potentially providing longer lasting pain relief. However, (i) the pain associated with a number of orthopedic procedures is of short duration and do not justify a long lasting technique, (ii) wound / intra-articular infusions of local anesthetics have been shown to be less effective than continuous nerve block techniques, and (iii) the use of wound / intra-articular infusions is associated with an increased risk of joint infections, which represent a rare but catastrophic complication.

Furthermore, for a third-party payer to declare that the risk for nerve damage from peripheral nerve blocks is prohibitive, as justification for withholding payment for the charge-modified anesthesiologists' billing, indeed calls into question the ethics of such third party payers. Third party payment systems' decision makers who adopt such a patient-unfriendly mindset (or policy) may wish to pray that neither they nor their family members get sick or injured, lest the insurance policy they so carefully crafted to minimize expenditures restricts the quality of care they or their loved ones receive.

-- From Brian A. Williams, M.D., M.B.A., Pittsburgh, PA, Jacques E. Chelly, M.D., Ph.D., M.B.A., Pittsburgh, PA, and John P. Williams, M.D., Pittsburgh, PA

QUESTION 2:

The ambulatory surgery center my group covers has a policy that all surgical patients have a current history and physical prior to their procedure. Some of the podiatrists at the center have requested that the histories and physicals on their patients be performed by the anesthesiologists rather than sending them to a primary care doc. Would we be offering a valuable and convenient service to these patients or opening Pandora's Box in terms of added medical legal liability?

-- From John Martucci, M.D., Downer's Grove, IL

REPLY 1:

Yes.

The big question is why would you want to do this? A surgical H&P has to include a description of the surgical site and indications for surgery. As an anesthesiologist I'm not interested in writing that note! I'm not sure that you can get paid for both this note and not have it be part of the Pre-Op note that you need to write. Lastly, if you start acting as the primary care doc on this, you assume responsibility for following up on any abnormalities identified.

Why not get a brief note from the patient's PCP- even a recent clinic not would suffice. The facility may be able to declare that the note from the anesthesiologist qualifies as an H&P as well as the pre-anesthesia note, but I would still be careful that this declaration does not attach an unwanted duty to follow-up on the patient.

-- From Alan P. Marco, M.D., M.M.M., Toledo, Ohio

REPLY 2:

There may be significant conflict of interest/legal issues with Medicare in that one cannot supervise an anesthetic/ perform an anesthetic as well as perform the Primary History and Physical.  I was in private practice briefly approx one year ago.  The Medicare laws were reasons cited to stop performing the preoperative H&P as well as the anesthetic.  Our podiatric colleagues will just have to send their patients for H&Ps to the primary physician or the ASC will have to have another individual available that will not have anesthetic duties as the primary concern.

-- From Andrew Herlich, D.M.D., M.D., Philadelphia, PA

REPLY 3:

In Michigan , we performed the H&Ps as a service to our non-physician colleagues and their patients. One does have to dust off the old physical diagnosis skills from med school and internship, but it's like riding a bike. Do make sure that you bill for the service.

-- From Thomas W. Cutter, M.D., M.A.Ed., Chicago , IL

 

?? -- THIS MONTH'S QUESTIONS -- ?? - TOP

QUESTION 1:

We do a significant number of cosmetic surgeries at our ambulatory surgery center.  Some of these operations last well over six hours.  We are currently considering limiting the length of surgery that can be performed without an automatic overnight admission for observation.  Are there any guidelines or recommendations currently available to assist in this decision process?

-- From C.C., M.D., Tampa , FL

QUESTION 2:

A 28 y/o male is s/p MVA 14 days ago. He was treated then for pneumothorax. How long after a pneumothorax should an elective procedure be done? {I have polled anesthesiologists and thoracic surgeons at my old home (Mass General) and here in Phoenix. The consensus seems to be three weeks.}

-- From Joshua A. Bloomstone, M.D., Phoenix , AZ

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