Author: Emil Engels, MD, MBA, CPC, FASA

Las Vegas—The Eiffel Tower, named after Gustave Eiffel, was built to welcome travelers to the World’s Fair of 1889. Its construction was opposed by many important figures in the arts, who criticized it on artistic grounds and felt it was incongruent with other structures in Paris. Since then, the Eiffel Tower has become one of the most recognized structures in the world and a much-visited cultural icon. This year’s ASA Practice Management Meeting was held in the shadow of the Eiffel Tower, albeit a replica in Las Vegas. A recurring theme of the meeting was understanding disruption, embracing change and “Defining the Future.”

This year’s meeting drew 1,128 anesthesiologists, residents, practice managers, coders and business leaders. Now in its 24th year, the conference is an excellent opportunity to network, learn about the business side of anesthesiology and develop strategies to run a successful practice.

Alexander Choi, MD, MPH, FASA, who is the chairman of the ASA Committee on Practice Management, said the meeting “offers attendees important and timely information that equips both physicians and administrators with the tools necessary to advance their practice.” The lectures, summarized below, did indeed provide valuable information.

Provider burnout in health care has become an all-too-common problem. Wayne M. Sotile, PhD, an expert in life coaching, physician resilience and work-life balance, gave the keynote lecture, titled “The Key to Resilient Medical Organizations.” He introduced his comments with a quote from Sigmund Freud: “Life is about love and work.” He then asked the audience, “Are you happy? And who are you to the ones you love and work with?”

The pace of change in health care is dramatic, and providers must deal with increasing demands, less control, government regulation and the burden of using electronic health records. Sotile mentioned a survey that showed 56% of anesthesiologists are affected by burnout. He said, “Work is fun when you’re doing good work.” Unfortunately, a fear of burnout leads to work ambivalence, which reduces engagement. This causes lower-quality care and a reduced sense of fulfillment. The resulting negative feelings can carry over from work to home, harming one’s personal life.
  • Does your work match your values?
  • Can you do it to the best of your abilities?
  • Do you enjoy working with the people you work with and serve?
  • Do your family members and close friends admire you for what you do?

Sotile’s comments were timely and helpful for anesthesiologists trying to deal with burnout.

Stan Stead, MD, used vignettes from the HBO series “Game of Thrones” to describe the changes coming to health care in the future. In a talk that was both educational and entertaining, Dr. Stead began with the quote, “Valar Morghulis” (All men must die).

He painted a bleak picture on health care spending, describing trends that are clearly unsustainable. Medicare enrollment grows at 3% annually; health care expenditures (now 18.5% of the growth domestic product) continue to rise; and spending exceeds $12,000 per person per year. In 2017, the health care sector became the largest source of jobs (exceeding retail) and continued to grow, adding 318,000 jobs in 2018.

Dr. Stead said, “There is no new money—you must focus on decreasing spending per patient.” What value can you add? It’s no longer fee-for-service; it is fee-for-value. Initiatives such as the ASA’s Perioperative Surgical Home will allow groups to deliver that value.

Again, quoting from “Game of Thrones,” Dr. Stead said, “Chaos is a ladder.” Change is an opportunity to innovate. Increasingly, health care innovation is powered by artificial intelligence (AI). IBM’s Watson Care Manager actively manages 147,000 patients. Amazon and Microsoft are entering the AI health care space. Another area of change relates to price transparency. Price transparency is now a federal issue, and Medicare requires hospitals to publish a chargemaster. Prescription drug price transparency is becoming more prevalent, and Dr. Stead envisions a large disruptor like Amazon entering the prescription drug space. Consolidation continues, but now companies in different sectors are joining forces, such as Aetna and CVS. Apple may buy Epic. Patients can shop for radiology facilities, comparing price, quality and amenities (e.g., availability of parking).

Dr. Stead used a quote that captures the strategies needed to thrive in today’s health care environment. “The brave men did not kill the dragons; they rode them.” He concluded a memorable and clever lecture by stating, “We need to add value; that’s the real magic.”

Medicare Access and CHIP Reauthorization Act (MACRA)—Regulatory Update

Sharon Merrick, MS, CCS-P, and Matthew Popovich, PhD, updated attendees on regulatory changes affecting the practice of anesthesia. Popovich discussed the “Patient over Paperwork Initiative,” which is designed to reduce the administrative burden on physicians. He also described the “Meaningful Measures” initiative, which promotes alignment of measures across the health care spectrum and focuses on outcome measures. Unfortunately, this initiative has had the unintended consequence of limiting the availability of measures for anesthesiologists, which the ASA hopes to address. Popovich also presented information on the American College of Emergency Physicians’ sedation policy, the Association of periOperative Registered Nurses’ attire policy, and a series of frequently asked questions about the Joint Commission.

Merrick talked about how the conversion factor is determined, a process that includes a positive update specified in MACRA. The Bipartisan Budget Act of 2018 reduced this increase, and there is also a budget neutrality adjustment applied. The net modest increase does not keep pace with the Medicare Economic Index.

She discussed “misvalued codes,” which are CPT codes that the Centers for Medicare & Medicaid Services (CMS) determines need reevaluation because of utilization and cost. The Relative Value Scale Update Committee of the American Medical Association surveys the codes in question. This process was used recently to change the value of the endoscopy and colonoscopy codes. Merrick encouraged individuals to fill out a survey on a procedure if requested.

CMS has proposed changes to Evaluation and Management (E/M) codes, but the implementation has been delayed until 2021. This will only affect office and outpatient services. E/M levels will be condensed from five levels to three, documentation will be simplified, and reimbursement amounts will change.

Finally, Merrick described changes to the Quality Payment Program (QPP). A “low covered services” (less than 200) exclusion has been added to the exclusionary criteria, exempting more providers from the QPP. Penalties and incentives change in the 2019 performance year to –7% and +21% of Medicare allowable charges (applied to 2021 payments). However, because the assignment of penalties and incentives is revenue-neutral, positive adjustments are likely to be small.

New in 2019 is the ability for facility-based providers to use a hospital’s Value-Based Purchasing score for the quality and cost categories of the Merit-Based Incentive Payment System (MIPS). No action is required on your part; CMS will determine your score automatically and compare it with your MIPS score. The higher value of the two will be chosen. Facility-based providers are defined as those who provide 75% of their services at inpatient hospitals, on-campus outpatient hospitals (as identified by a Place of Service code), or an emergency room. The ASA recommends continuing to report MIPS quality data this year until you determine your facility scores. In addition, you are still required to report Improvement Activities and participate in the Promoting Interoperability category (if eligible).

D.C. Update

Manuel Bonilla, MS, the chief advocacy officer of the ASA, provided a legislative update. The top priorities for the ASA last year included addressing the opioid epidemic, ameliorating drug shortages, preserving physician-led care (scope of practice), and holding patients harmless in out of network (“surprise”) billing while maintaining the ability of physicians to get paid fairly. The ASA’s Political Action Committee continues to be the largest such physician organization.

Bonilla also outlined the goals for 2019, which include the list above, along with some new areas of focus. As a leader in research, the ASA started a brain health initiative to focus on the effects of anesthetic drugs on the brain, particularly in people at the extremes of the age range.

Other issues include truth and transparency (avoiding terms like “nurse anesthesiologist” and “dental anesthesiologist”); an economic strategic planning initiative to address Medicare reimbursement and the use of the QZ modifier; and a new out-of-network bill at the federal level being developed by Sen. Bill Cassidy (R-La.).

ASA President’s Address

Linda Mason, MD, FASA, the president of the ASA, gave the organization’s State of the Union address. Anesthesiologists are the leaders in patient safety, she stressed.

Dr. Mason reiterated the ASA’s focus on the issues detailed in Bonilla’s regulatory/legislative review. Delivering value to its members is of the utmost importance to the society, she added.

In an effort to develop the next generation of physician leaders, the ASA has created the Executive Physician Leadership Program, designed in partnership with the Northwestern University Kellogg School of Management. Successful completion of this curriculum will advance leadership and health care strategy skills while earning continuing medical education credits and a certificate of completion.

Closing the Gap in Physician–Hospital Alignment

Richard Priore, ScD, MHA, FACHE, gave an excellent talk on value in health care. A former hospital CEO who now works in consulting, Priore presented the hospital’s perspective on alignment and value.

The United States spends more on health care than other developed countries, yet does not have the desired outcomes. Unwarranted variation drives cost. Providers are under pressure to cut costs and improve results. Health care is a business, and anesthesiologists need a sound business case for what they do. Hospital leaders struggle in aligning their mission with the business side to achieve it.

Government reimbursement cuts, commercial payor cuts, and increasing operating costs “keep the CEO up at night.” Priore suggested that groups need to pitch ideas whose impact is on quality and return on investment, making the business case. He concluded with a quote from Al Capone: “You can get much farther with a kind word and a gun than a kind word alone.”

Other Presentations

There were additional informative presentations. The “Fundamentals of Practice Management” track provided a series of lectures to attendees who were new to practice management. It offered basic but timely information on anesthesia operations, quality, metrics, leadership, regulations, billing and coding.

For the second year, the “Anesthesia Administrators and Executives Conference” provided presentations important to both physicians and anesthesia executives, as well as a very moving talk about the Las Vegas mass shooting in 2017 and anesthesiologists’ unique role in assisting during the crisis. New to this year’s conference was the “Touchpoint Series,” which replaced the traditional pre-conferences.

These sessions were innovative and highly interactive, and included topics on the Perioperative Surgical Home, operating room management, quality, the anesthesia value proposition, leadership, health system consolidation, asset protection and payor contract negotiations. Collectively, the presentations provided unique and engaging information that attendees could take home and immediately use to improve their practice.

The conference concluded on Sunday with two important panels. Will Latham, MBA, and Mark Weiss, JD, led a discussion titled “How to Maintain Autonomy While Building Market Share and Geographic Scope: Group-to-Group Mergers.” Latham and Weiss explained the merger process, including strategies for negotiation. Insights on why deals fall apart and common pitfalls will be valuable to anesthesiologists who are looking to merge or be acquired.

The final panel of the conference dealt with group culture, provider demographics and human resources issues. Judith Jurin Semo, JD, discussed “Positioning Your Group for Success: Strategies to Get the Naysayers on Board.”

Shena Scott, MBA, FACMPE, talked about the implications of changing practice demographics in “Understanding the Generations: Bridging the Gap.” Genie Blough, MBA, FACMPE, concluded by discussing “Increasing Engagement in a Diverse Workforce.” Race, gender, language, religion, economic conditions and generational differences can affect group dynamics and culture.


I found the ASA Practice Management meeting to be essential for anyone managing an anesthesia practice. Now, more than ever, it is important to understand the changing landscape in health care. The Practice Management meeting has something for everyone, whether you are an experienced anesthesiologist or a new resident beginning your career.

Next year’s meeting will be held again at the Paris Hotel in Las Vegas. Stroll down the faux streets of Paris, dine on a tasty crepe, and learn about the latest changes and trends in health care. Au revoir!