Global fees for managed care in ambulatory surgery

Managed care, especially health maintenance organizations (HMOs), has expanded rapidly in the United States, with nearly 52,300,000 enrollees. HMOs seek to provide health services in an efficient setting at the most reasonable price. To facilitate this objective, HMOs are shifting the financial risk from payors to the providers. Historically, ambulatory surgery was viewed as a significant cost savings compared with inpatient surgery, eliminating or reducing costly nursing care, boarding charges, medications, and therapies. As the incidence of ambulatory surgery utilization increased from approximately 20% of all surgery performed in the United States in 1982, to nearly 60% in 1993, consuming larger quantities of scarce health dollars, the emphasis shifted to reducing the charges for ambulatory surgery. Initial efforts to contain costs involved utilization management and discounted fee-for-service reimbursement methodologies. When this proved ineffective, a fixed fee per procedure was employed. Recently, full-risk capitation reimbursement has been applied to transfer financial risk and incentive to the provider to mitigate increasing health care costs. Surplus capacity and the consolidation of many covered lives or enrollees with fewer institutional payors (e.g., Blue Cross Blue Shield or Prudential) has made this transformation possible. The combination of these events has provided the HMOs with great leverage. The payors have more choices of providers than ever before, and they seek a safe ambulatory surgery environment at a low charge. In some areas of the country, facility and professional fees are being bundled to differentiate their product and attract more volume. Subcapitation of anesthesia services is being implemented or discussed in regions with very high HMO market penetration. This paper reviews the concept of bundling of services involving anesthesia in ambulatory surgery. It also seeks to provide a process that will assist anesthesiologists to achieve appropriate capitation reimbursement rates from HMOs.