Dr. Chris Steel: Reframing the Perioperative Visit

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Dr. Chris Steel (00:15):

Thanks so much, Bob. I really appreciate it. And it's really been my pleasure to sit here and listen to everybody. I could have talked for hours with those panels. This is just fun stuff to talk about, so I really enjoyed it. Thanks for Medaxion as well, for ,putting this together. It's fun to talk about things we enjoy. So I want to start with, we're going to talk about pre-op clinics a little bit. I want to start by saying, I'm not completely tone deaf. I am not going to come up and say it's so hard to recruit CRNAs and anesthesiologists. So what y'all need to do is take them out of the OR and stick them in a clinic. We're not figuring out extra ways to use your labor, but we've got some opportunities I think we can talk about and things that we all deal with every single day in the OR and in hospitals.

(01:02)
My background anesthesiologist, I led the ASAs Perioperative Surgical Home Collaborative. I was in each of those and I was medical director for the last one. Now the ASAs formed a big group called the Committee on Periop Medicine. And so they're trying to herd, the a lot of cats. There's a lot of people involved in perioperative medicine, not just in anesthesia, but in other specialties. And so we're trying to improve that and seeing a rising tide lifting all boats. So we're going to talk about perioperative medicine clinics, compare the different models briefly, and then talk about how you can roll it out there. And later after the break, you're going to hear some of the nuts and bolts of details of how to bill and collect. And yes, you can bill and collect for these and something that I highly recommend, though I'm totally biased.

(01:52)
Always put the patient first, always start with that disclaimer. We're going to talk about how to bill for it and how to collect, but please know the patient's got to be the center of this, and that's why we do what we do. I'm glad you were all sitting down for this slide because probably you're all shocked to know that the pre-op journey is complex. So thank you. Deep breath. Ah, it is very complex. We've got to coordinate with the surgeons, anesthesiologists, specialists, and PCPs. And so it's a journey that is complex. We all know that. And it's getting more complex. Again, big surprise. People are getting older, sicker. They're harder and harder to get them optimized. And actually things we're talking about today, the locums and the turnover in the market, that makes it even harder because a lot of providers aren't comfortable with that specific system knowing, oh, we accept this cutoff value or this is how to jump through that hoop.

(02:51)
So in the end, you see more cancellations than you would if in situations where there's less locum and less turnover. So this is a problem that's getting harder and harder to deal with. And again, we're going to talk about some of the things you guys go through. Everybody that deals in anesthesia or any type of procedure is on this spectrum. Anesthesia pre-ops and optimization are either happening the day of the procedure. The patient shows up, you can take care of them. A lot of ASCs still do this. Then the progression is nurses do screenings and then they follow some kind of triage or protocols that's established either by the organization or the ASC. Then some people kind of progress to a traditional pre-op clinic where a provider may see the patient and dictate what happens. And then lastly, we're seeing these integrated perioperative medicine clinics.

(03:44)
And so with that, you can see that at the beginning when they show up, it's really just a nurse calling the patient and telling them when to show up. And that it works if all of your patients are very, very healthy and compliant and you're very consistent with the anesthesia care you deliver. I'm sure that's all of your organizations. I'm sure you've never seen an ASA3 patient. They do exist, but ASA 3s and fours are out there. And as you heard, the trend is for more and sicker and sicker people to be going to ASCs. So we're seeing ASCs rarely be able to pull this off and not have a really high rate of cancellations. The next progression in the complexity is setting up a bunch of protocols. These people get BMPs and EKGs and we're going to call and they're going to get it done.

(04:33)
And that will reduce some of the cancellations. But the next step is getting them to see a provider and customize that care specifically to them and really act as a quarterback for referrals. And then lastly, in the peri-op clinic, we're going to start trying to tie that together with what's happening before surgery, how to get them ready for surgery, but also how to keep them from getting readmitted after, and how does that tie into the whole system from a healthcare standpoint. So I'm going to drive into each of these four models and then kind of tell you how to get that going. But your day of surgery assessment, not going to spend a lot of time because a lot of organizations aren't doing this anymore, ASCs, but it is a low cost model. You're not spending a lot of time with people optimizing patients on the phone.

(05:20)
It's a low upfront cost model. The problem with this model is there's more cancellations when people show up and they didn't get proper labs or delays when they show up and you got to get the labs with point of care testing or test them and delay the case getting started. We all are fully aware of that. We've talked a little about AI in this presentation though, and I'll tell you, like they mentioned, it is getting in the peri-op world a little bit more. There are these AI products that are able to look through the EHR and the health information exchange from the state and really compile it and run them by basic anesthesia algorithms to help speed this up so that nurses can get a really good idea on these phone calls of what to do. So that is something that's being used more and more.

(06:05)
This is where most of the clients that we see either live in model two or three. A lot of smaller community hospitals, they have a call on every single patient that gets scheduled. They call and follow a big algorithm, all the labs, the EKG testing, if there's prehabilitation, they can be reasonably sophisticated in how this is done. And then that nurse will follow certain algorithms and say, "They need to go see this specialist and they need to do that. " Still very complex. The benefit to this is you're going to catch some of the patients who have abnormalities in relation to their electrolytes and some of their chest pain and other issues that you're going to prevent cancellations. The problem is these are not providers and a lot of times they're doing these via phone. And so you are going to still miss optimization opportunities.

(06:54)
When a patient shows up with high blood pressure, there's really not much that the nurse can do other than send them to the ER or something like that. And so it's really hard to intervene specifically to reduce your blood pressure, reduce heart rate. All the things that cancel cases can't really be intervened upon as well. And that's why a lot of people move to a pre-op clinic in model three. This is where patients will come in or telemedicine that's still available right now to be able to bill and collect for telemedicine. Providers will be able to take the patients. Now again, it's not all the patients. Typically, you'll have a screening algorithm that'll fast track some patients. Some of them will get a phone call, get their meds wrecked and get labs, but then the sickest of the sick will get in- person visit a lot of times or a telemedicine visit.

(07:41)
And this is the opportunity where you can specifically meet the patient. This is where the biggest mistake happens that I see a lot of times is these clinics are set up wrong. They're set up to where you're not able to bill and collect for these services. And so much of the work being done from a hospital administrator's heart, it hurts. All of it's being done and it's just a money pit. And that's the biggest issue I heard in the PSH is, how do we get this paid for? And they want the hospital to pay for more and more FTEs. And it's hard for administrators to say, "Yeah, just keep doing that. We're not going to get any money, but keep doing it. " So that's why I think it's really important to set this up in a way you can bill and collect. And again, we have an example, E&M and advanced care planning.

(08:22)
Those are things that can happen. E&M's kind of common sense. You're doing an evaluation at management. Advanced care planning's one that you'll hear about a little later that's talking about code status, really advanced directives and counseling people on their chronic illness. So those are things that really should happen weeks before surgery. So you're not surprising them with code status right before you put them to sleep. Probably not the most reassuring thing to do for a patient. Perioperative health clinic, lastly, this is one where you're going to integrate it not just with seeing them in the clinic. You're going to integrate this with your accountable care organization. You can do screenings and things where you're screening for depression. You're hitting all your ACO metrics that are needed. And you can put this in your clinic and you can capture. There's a lot of patients that don't see their PCP every year, but they may see their surgeon here for this.

(09:10)
And this might be your chance to close the care gap for them. Also, a lot of these people might not have cardiologists or PCPs. So it's an opportunity to feed them in the system and reduce leakage and really integrate this into the whole health system. So that's something we're seeing and a really good thing for HCC RAF scoring, for clinical documentation improvement and a lot of other things like that. If you're wanting to do this on your own, this is the methodology we use. We would recommend you start with a blueprint, the foundation. You engage your stakeholders because this matters for a lot. That's what we see the biggest problem is people jump right to the go live and getting ready and they haven't figured out how's this a win for your surgeons or your nurses or anesthesia or admin or your CFO. You got to bring them all together and get a common vision.

(09:57)
Then you can do your clinical workflows and revenue cycle. For go live, you get all that ready. You do the go live. And then it's a PDCA cycle. We talked about Toyota and other things. That's starting small, scaling up. That's what happens in phase three. And lastly, you're going to incorporate the other parts of the hospital, incorporate into your ACO and your population health and referrals and whatever the needs of that specific organization are.

(10:25)
When you can pull that off, the things you're going to get from a strategy standpoint, it's going to help you to align with other specialists, reduce leakage. You're going to be able to coordinate all these consults and fewer people are going to fall through the cracks. Documentation's better, like we said, HCC RAF scoring, clinical documentation improvement, and compliant billing. And after the break, you're going to be waiting with bated i breath to hear the finance part of which codes to bill and what, but that's where you'll hear more about that. E&M, advanced care planning, sometimes transitional care management. Those you can bill and collect actually more than what you're paying out for the provider to be doing that. And so again, instead of it being a money pit where you're not making anything, you're making enough pro fees to pay for itself, which is a good place to be.

(11:11)
And it helps admin to want to invest in this more because you're not just seeing indirect savings, you're seeing actual pro fee revenue. Really good thing. Again, bigger picture, being patient-centric, you're going to have a lower length of stay in readmissions, a better patient experience, decreased leakage. And lastly, I'll leave you with the Teams program. You're going to hear more about one of the presentations, but the CMS Teams program is mandatory for a lot of people. And this is a great way to standardize your spine, your heart, your total joints, your colon resections, things like that, that there's a lot of evidence for. You can really get teams under control when you've got everyone on the same page ahead of time. And Bellinger's going to talk more about that for y'all after the break. So as you see in the model here, interdisciplinary clinicians they're with the patient doing that.

(11:56)
Again, a lot of times we do see that's an APN or somebody working there. There are people that use APNs, sometimes physicians. It depends on your model and how to do it. But when you've got that person doing it and a way to bill and collect for it, it seems to be a great way to move this along. So that's about my time on that. I know I'm between y'all on a break, so I'm going to stop here and we'll take a break and I'll be around for that. Any questions? Okay. What a blessing.

Speaker 2 (12:31):

Any questions for Chris? You all go on a break, I guess.

Speaker 3 (12:38):

We have a question that we have provided.

Dr. Chris Steel (12:41):

Okay. We got

Speaker 3 (12:42):

... Oh, just as far as anything new, people are so focused on the 101 stuff. I'm just curious about what you've done to educate people on- Getting this new idea and ,overcoming initial pushback or rejection or we already have too much on our plate.

Dr. Chris Steel (13:02):

Yeah. The irony is the biggest problem we run into about 90% of the people, most people are doing pre-op clinics in big institutions already, and the vast majority of them are billing nothing for those services, which is shocking. The issue is it's not that much money for a hospital. As an administrator, we don't care for the administrators of the room. It's hard to care about pro fees. I mean, no offense to anesthesia and everybody, but it's such a fraction compared to a $50,000 DRG that it's hard to get their attention. So when you say you're leaving a million dollars on the table, they want the million, but then sometimes contracts are weird and they're like, "Well, I'm going to pay the providers because they get WRVU incentives." There's a lot of questions, but the problem is it's set up poorly. And so if you can make little changes to get it set up properly, you can bill.

(13:48)
So people are bought into perioperative medicine. A lot of people don't believe you can bill because they've asked their anesthesia billers, but this is not just about anesthesia. If you ask a family medicine biller, a clinic biller, they're going to be like, "We do E&M and ACP and TCM all day long." But it's looking through the anesthesia lens, it's challenging. Looking at a system lens, it's not. So that's what I see.

Speaker 2 (14:12):

Chris, in order to bill, do you have to set up a separate H&P?

Dr. Chris Steel (14:17):

It depends on how it's set up originally. If you're an anesthesia group, and again, I'm not a revenue cycle expert, but you'll probably hear more about it. If you're an anesthesia group, you can't provide ... The anesthesia H&P is obviously bundled into Medicare conditions or participation. So you can't do a pre-op visit and say, "Well, that's my anesthesia H&P." You won't be able to bill separately, but you can do a separate visit when you start getting RAC audited or if they look closely, it's nice to have a separate entity to do. And Bellinger would be the expert on that, but for anesthesia groups. But if it's being run collaborating with anesthesia, but being run by family medicine or by some other specialty outside of anesthesia and they're collaborating, it may look just like a normal clinic setup.

Speaker 2 (15:02):

I'm seeing a lot of places using hospitalists to do this. Is that what you're seeing?

Dr. Chris Steel (15:07):

Hospitalists, family medicine, internal medicine, anesthesia are kind of some of the big ones. And a lot of them are using mid-level providers, APNs that are there in the clinic to be able to do this optimization. They collaborate with anesthesia. And sometimes we're seeing co-medical directorships or medical directorships for a governance structure of doing it. The key is at that very beginning blueprint, set it up properly so everybody knows what they're getting into and the CFO can build it in a way that makes sense.

Speaker 3 (15:35):

Great. Thank you so much, Chris. Thank you.

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