November 4, 2019
In the evaluation of coverage and staffing requirements, the primary focus is always the number of operating rooms (ORs) and delivery (OB) suites in which most anesthesia providers typically practice. However, groups should be careful to analyze the staffing requirements of their non-OR anesthesia (NORA) episodes, as well. These include all those procedural services that happen outside the operating room suite, such as cardioversions, intubations, and services provided for EP lab, MRI and interventional radiology that the department is expected to shoehorn into the schedule. When the volume of such services is minimal, the scheduling of such cases is not a problem. As the volume increases, however, the manpower and staffing implications can be significant. These NORA services can be a moving target, which is why it is so important to track your NORA activity closely.
How Times Have Changed
Endoscopy used to be considered a part of NORA when it was rare that anesthesia was required for endoscopic procedures. As the role of anesthesia in endoscopy became more common, endoscopy came into its own. What used to be isolated procedures performed in a procedure room has now become a separate line of business for most practices. This evolution highlights a central aspect of NORA; it is a catchall out of which grow new potential lines of business—kind of like an anesthesia petri dish.
In many practices today, the Electrophysiology (EP) lab represents the fastest growing and most significant coverage requirement. As hospitals continue to invest in their cath labs to attract more heart cases, the EP lab can easily require one FTE (full-time equivalent) anesthesiologist or CRNA, depending on the payer mix.
The table below includes the top five NORA procedures from a sample of five large practices in five states—Florida, New Jersey, Illinois, Wisconsin and California—based on activity for the years 2015-2019.
Activity varies somewhat by facility, as indicated in the below graph, but overall NORA represents between two and three percent of the services for the five sample practices. This might not seem like a lot, but the impact of such services may be significant, especially if it requires additional staffing.
A New Management Matrix
Covering NORA cases adequately requires the management of three distinct sets of challenges. First, many NORA procedures are add-ons and not subject to the usual OR scheduling rules. Since they are generally short cases, the assumption is that the department can find someone to do an isolated case or two. Anesthesia providers generally try to accommodate the needs of their fellow physicians but certainly hope that the proceduralists will be flexible from a scheduling perspective.
The second challenge is that there is never just one NORA location. A single provider may bounce around from location to location to cover all the NORA cases. Traditional models of utilization monitoring by anesthetizing location do not work for NORA cases. The NORA productivity must be tracked by provider, not location, which can get complicated—especially if the provider in question spends part of his or her day in the operating room performing scheduled surgical cases.
The third challenge involves finding and utilizing a viable management system. There is a saying in business that you cannot manage what you do not measure. Very few practices have developed accurate and reliable tools for monitoring their NORA activity; for, to do so, requires a degree of refinement in the tracking of clinical activity that few practices have perfected. Capturing the anesthetizing location and type of service is a critical first step. For purposes of analysis, every NORA case or procedure must be readily identifiable. The data must then be viewed through a standard lens or compared to a reliable benchmark. Let us suppose that the target production level per day of an anesthesia provider is 60 ASA units. If one can consistently calculate the average number of NORA units generated per provider per day then one can easily assess the impact of NORA on the practice. Using billed ASA units is just one measure. One could also measure and compare minutes of anesthesia time or actual financial yield. The key to effective assessment, though, is that all data must be normalized to the same standard. Measuring activity per provider day has proven to be a very useful tool, especially for staffing purposes.
The management of anesthesia practices has evolved considerably over the past decade. One might say that we have gone from seat-of-the-pants management by ATM card to a more sophisticated stab at cost accounting. It used to only matter how much money was being collected, but now it is much more important to know what is being spent to provide the required services, as well as how it is being spent. We used to just look at the practice as a whole, but now we are more focused on the component parts. Drilling down to NORA is a good example of today’s practice management requirements and where the specialty is headed.
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