| |
May 1996
Volume 60 |
Number 5
|
| |
|
| Perioperative
Medicine: Walk the Walk or Face the Music? |
John P. Erickson, M.D.
Michael F. Roizen, M.D.
Anesthesiology as a specialty is being squeezed from all directions.
Technological developments and internal changes are already evolving
the specialty out of the physical confines of the operating room
(O.R.). This change can be viewed as potentially disastrous or
filled with opportunities for us to benefit patients and the specialty.
Anesthesiology may be in a circumstance similar to that of radiology
in 1975. At that time, the viewing room was filled mostly with
plain films plus a little computerized tomography (CT) and some
ultrasound. Now in 1996, much of the viewing room is filled with
magnetic resonance imaging, CT and films from interventional activities,
while ultrasound machines abound throughout the hospital. Radiology
has expanded the size of its "pie." More radiology is
done by more radiologists to generate more good for society.
The potential to increase the size of the anesthesiology "pie"
is neither easy nor guaranteed. We face numerous sizable and serious
problems en route. What is guaranteed is that change will occur,
whether the specialty obstructs, stands clear or participates.
The latter is favored. The technological revolution has laid the
groundwork for this opportunity; if the specialty ignores it,
the specialty may become less valued and less influential as a
force benefiting patients. But the times also allow us to seize
a role that can positively impact society.
The Evolution of Managed Care
Decreasing O.R. volume is the usual result of the third and fourth
stages of the evolution of managed care. Capitation rewards those
for doing fewer procedures. Capitation-at-risk encourages this
restriction even more. On the other hand, having a known payment
for a known population for a fixed time period will make it easier
to cut costs. Staffing and equipment needs will be more predictable,
and we will not be burdened with the current administrative load.
Pressure to cut costs influences both salaries and number of O.R.
personnel. Since labor is the dominant expense in running an O.R.,
savings here have high yield at the bottom line. Material costs
are lower in relative proportion but still sizable. These include
drugs, disposables, capital equipment, transfusions and postoperative
analgesia.
Perioperative medicine departments must deal with all costs like
small businesses in competitive environments, not large businesses
in regulated industries. Costs must be cut constantly and aggressively,
and more patient value of benefit to society must be delivered.
Anesthesiologists based solely in the O.R. currently do not fully
control their own destiny since most patients come to them indirectly.
With managed care owning access to patients, it directs patients
by allowing payment only at certain facilities or, with co-payment
disincentives, to out-of-network facilities. This set of incentives
directs patients to doctors and hospitals that give the payer
the best deal, meaning the lowest cost for a given quality. (Note
that quality is assumed to be equal if no demonstrated difference
exists.)
Few patients seek out, are directed to or are referred to specific
anesthesia groups. Recently, some groups have been approached
to match someone else's costs because their outcome was better,
the first case of equal price and better outcome changing patient
direction.1 We could have a greater part in this regard if physicians
are allowed to form select groups and bid directly for provision
of professional services for groups of patients.2 (Note that these
select groups will not necessarily include all physicians at a
hospital or health system but those with demonstrated best outcomes
for a given procedure.)
Already, physicians trained in anesthesiology are moving out of
the O.R. Typically providing episodic care rather than continuing
care, practitioners in our specialty now care for patients in
the intensive care unit (ICU), patients who have chronic pain
and those in need of postoperative pain or critical care management.
O.R.-related activities include preoperative preparation, O.R.-
and bed-control management, sedation and analgesia, the last two
not only with surgical patients.
As reimbursement changes, some activities may not cover the cost
of the anesthesiologist's time. Examples of this situation include
sedation for smaller cases both within and outside the hospital.
Can these under-reimbursed services be provided with equal safety
by one possessing the skills of an anesthetist without requiring
the full-time physical presence of an anesthesiologist? Or is
the medical/industrial/financial complex forcing us to compromise
on safety in the interest of decreasing the costs of production?
Labor analgesia is another relatively time-consuming activity.
Could this be provided satisfactorily in part by nursing, pharmacy
and single-shot opioid spinals instead of anesthesiologist-placed
continuous lumbar epidural analgesia?
Patient-controlled analgesia (PCA) is being moved from anesthesiology
departments to hospital services as it is no longer separately
reimbursed. Can PCA under this form of administration remain as
helpful to colleagues and as satisfactory and safe for patients?
Similar computer-driven pumps for patient-controlled sedation
may also decrease the need for the anesthesiologist's time in
certain situations without a decrease in the quality or amount
of care delivered.
O.R. anesthesia is largely hospital-based. It is logistically
easier for a hospital to deal with managed care entities when
one exclusive group provides its anesthesia services, a situation
sought by more and more hospitals. Both the hospitals and capitated
primary care doctors have noted the current oversupply of anesthesiologists
and are presently taking advantage of the competition. The resultant
actions may have consequences in the future if the oversupply
is temporary.
Papper made the point that anesthesia was a natural outgrowth
of the times; its discovery in the middle of the 19th century
was preconditioned by the change in technology and the change
in the social and philosophical concern with relieving individual
suffering that arose in the middle of the same time period.3 Is
the current technology revolution in biology, computing and telecommunication
with the rising influence of ethics preconditioning society for
the change to perioperative medicine? Let us examine what anesthesiology
is now and where it can go.
Our Specialty in Retrospect
Before 1980, preoperative evaluation consisted of ordering the
usual tests and seeing the patient the night before surgery on
the ward. Economic factors led to the explosive growth of outpatient
surgery, and preoperative evaluation moved to the preoperative
holding area.
By 1990, the risks and unnecessary costs of ordering the usual
tests as well as the benefits of contacting the patient prior
to his or her arrival in the holding area were clearly demonstrated.4
Anesthesiologists are the experts in preoperative evaluation,
partly because no one else medically manages the patient intraoperatively
and partly because the specialty has pioneered the study of what
is necessary for preoperative evaluation.
As ethical choices assume a larger presence in clinical medicine,
patient autonomy becomes a more frequent concern. Satisfaction,
information and education all nourish individual autonomy. Patient
education is an area into which preoperative evaluation is moving.
Our contact with the patient perioperatively may be used in numerous
ways beyond current practice. For one, we can reinforce the surgeon's
explanation. (How often are you asked a clearly surgical question
by the patient during the preoperative anesthesia visit?)
Each patient contact is one of more than 20 million potential
chances that we have each year to explain who the anesthesiologist
is and what is involved with anesthesia.5 Our contact has potential
benefits to the hospital and payers as far as bottom-line costs.
Examples include giving directions for the day of surgery, explaining
the insurance fine print, decreasing no-shows and late-shows,
and positively impacting postoperative expectations and pain management
requirements.
Another facet of perioperative medicine involves changing the
way that O.R.s function. We already are involved with hospital
committees because of our presence in the ICU, O.R. and postanesthetic
care unit (PACU). This involvement can be informal or formal;
at Duke University, for example, the health system pays an anesthesiologist
to be director of perioperative services. Such involvement contributes
to running the O.R. and PACU more effectively, building relationships
for future rocky times and observing what other departments and
administrators are thinking and planning.
The Evolution of Our Specialty
As technology advances, we will be involved in changing the way
patients flow into and out of the O.R. For example, propofol and
the new inhalation agents allow some patients to "recover"
after general anesthesia by being sent directly to the second-stage
recovery area and then to home. The PACU of today may not be required
for most patients in the future.
Surgicenters can take advantage of faster out-the-door times.
Combine this with lower costs because they do not have the regulatory
overhead of a fully licensed hospital, and you have potentially
enormous cost savings along with increased quality. Extending
the surgicenter paradigm further, today's inpatients may, in the
future, be managed by anesthesiologists in ambulatory recovery
centers.
A final example of broader social change leading to changes in
our specialty is capitation. No longer are facilities and physicians
financially benefited by poorer morbidity with subsequent longer
stays and more treatment required. With a fixed rate for each
patient, perioperative morbidity raises the costs without raising
the reimbursement. Lower wound infection and reoperation rates
and shorter hospital stays save enormous amounts in the way of
costs. In contrast, O.R. turnover, intraoperative speed and affability
with colleagues have limited financial advantage compared to better
outcomes.
Anesthesiologists may have a bigger part in tracking outcomes
and selecting surgeons who have the better results. "Our"
quality assurance may be more appropriately tracking what is now
considered the surgeons' quality assurance. Can we do this more
readily among surgeons than the surgeons can themselves? Surgical
outcomes are not "our" outcomes so we can be quite objective.
We deal with all surgical patients so comparison of data would
not require our seeking it out from each surgeon or payer individually.
Furthermore, we may be able to collect data more cost-effectively
than quality assurance administrators because we are physically
present in the O.R. every day. Administrators rarely come by the
actual patient care areas because they have many other duties
elsewhere in the hospital. This limited physical presence is a
disadvantage with respect to tracking outcomes.
Remember that patients come to doctors for diagnosis and treatment
because doctors are licensed and trained to practice medicine.
They come via managed care because that is how they can "get
to see" a doctor. Managed care has clout because it controls
the flow of patients for financial reasons - a lower cost to the
payer of the premium.
Cutting costs and improving outcomes are science- and technology-driven.
Payment and profit are politically and administratively driven.
It is not necessarily profitable to all managed care organizations
for science and technology to advance, such that groups of physicians
can provide more care at a lower cost, unless one managed care
organization gains a financial advantage over others. When the
health care system is presented with lower costs and better outcomes,
the contribution of managed care is reduced to mainly additional
overhead.
A word of warning: Anesthesiologists are invited by managed care
administrators to "help" with cost-cutting by decreasing
O.R. turnover, spending time in critical path development and
"cooperating" with the primary care physician. All of
these seem minor administrative tasks. What we really need to
be actively doing includes:
1. cutting costs (changing the patient flow);
2. providing better outcomes (science- and technology-driven);
and
3. attracting patients (providing both of the above more effectively
than others).
It is unlikely that managed care organizations as a group will
be interested in supporting perioperative medicine efforts toward
these ends. We must add value ourselves if we are to transform
the specialty in the future the way Papper and colleagues did
in the past.
Our Opportunities, Our Future
Many forces are changing the specialty of anesthesiology. Whether
this will be a disaster or a boon for society and the specialty
over the next 20 years depends on whether we adapt to deliver
more value to the patient and to society. To realize the opportunities,
the specialty must cut costs constantly and do more, as does a
small business in a competitive environment.
In spite of the numerous obstacles that stand in the way of realizing
the opportunities, our specialty has several major advantages.
Our position in the perioperative arena has been mentioned previously.
In addition, the same youthful demographics that exacerbate the
current supply/ demand imbalance also provide plenty of talent.
This talent pool may well be the specialty's most significant
asset as anesthesiology evolves in the future.
The times have forced a change; will we seize the opportunity
or try to hold back the future? We believe we must take the risks
of "walking the walk" of perioperative medicine, or
we will not have a chance to influence the future beneficially
for our specialty and our patients.
References:
1. Roizen MF. Letter to the editor. Barrons. March 25,
1996; 60.
2. Medicare's Rx. Barrons. November 6, 1995; 26-27.
3. Papper EM. Romance, Poetry, and Surgical Sleep - Literature
Influences Medicine. Westport, CT: Greenwood Press; 1995.
4. Roizen MF, Kaplan EB, Schreider BD, et al. The relative roles
of the history and physical examination, and laboratory testing
in preoperative evaluation for outpatient surgery: The "Starling"
curve of preoperative laboratory testing. Anesthesiology Clinics
of North America. March 1987; 5(1):15-34.
5. Wetchler BV. We need your involvement. ASA NEWSLETTER.
July 1995; 59(7):2.
return to top
Home >Newsletters
>May 1996Home >Test
|