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October 1996
Volume 60 |
Number 10
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| Increasing the
Value of Anesthesiologists: Opportunities for Perioperative
Managers |
Karl E. Becker, Jr., M.D.
Robert E. Johnstone, M.D., Chair
Ad Hoc Committee on Value-Based Anesthesia Care
Anesthesiology is changing. We are evolving from anesthesia administration
in the operating room to outpatient, pain management and perioperative
medicine practices. The economic marketplace is also changing,
from fee-for-service and indemnity insurance to complex systems
involving managed care organizations. Many anesthesiologists experience
this as frustrating negotiations for shares of shrinking clinical
payments. We must recognize these issues, commit to providing
more than just technical care and show the importance of our managerial
contributions to the patient and to the health care process.
Value-based anesthesia management includes safe clinical practices.
Recognizing and developing additional practices are important.
For the next few years, there will be many opportunities for anesthesiologists
as process controllers, information managers, outcome monitors,
clinical practice researchers and care delivery innovators. To
ensure our future roles in anesthesiology, we can upgrade our
skills and increase our involvement in all these development and
management areas.
Our Perioperative Advantage
No one has a better understanding of the perioperative process
than anesthesiologists. As perioperative physicians, we can understand
and evaluate all the steps that a patient takes in the process
of preparing for surgery, having an operation and convalescing.
We need to know how subprocesses (like getting payer preapproval
for a procedure or investigating underlying medical problems)
impact upon the efficiency, quality and cost of the care process.
Anesthesiologists will then be prepared to lead or assist in process
management and redesign so that efficiencies, cost savings, and
enhanced quality, safety and customer satisfaction can be realized.
Management of the perioperative process requires goal-setting,
continuous reassessment and new initiatives. To manage well, information
that is timely, accurate and relevant is imperative. Good information
(i.e., that which is useful for making decisions) can make managers
incredibly effective. To become health delivery managers, anesthesiologists
must also become information managers. We can imagine perioperative
information systems that enable anesthesiologists to chart and
manage patient care electronically with specific entries also
traveling to vendors, schedulers and payers. The vendor, for instance,
could use information supplied by the care provider to monitor,
maintain and resupply inventories of disposable equipment. Subsets
of data from the same electronic medical record could be used
for cost analysis prior to negotiating contracts.
Closer to patient care is our opportunity for optimizing and
standardizing many perioperative practices and convalescence care.
A current emphasis of medical research and care management is
measuring outcomes. The guiding aspiration of patient care is
the desire to do the right thing, the best way, to get the best
outcome. There are, however, many different ways we care for identical
clinical problems. These differences might manifest as divergent
plans of care among providers or as dissimilar processes among
institutions within the same health care network. The best clinical
path is often unclear. Anesthesiologists are well-positioned to
design studies, collect data and prove scientifically the values
of therapeutic strategies and care plans based on their outcomes.
Anesthesiologists will find the best perioperative paths. They
will then also have sufficient information to educate the public,
other providers and payers about our results and value.
Achieving Optimal Value
What exactly is value? Value, in mathematical terms, is simply
quality divided by cost. Thus, as costs rise, as they have in
medicine, quality must increase an equal amount if the value of
a service is to stay the same. Value, as determined by patients
and others, depends on vantage point and how the quality and costs
are perceived. Quality in anesthesia practice has two essential
elements: quality of medical care and quality of service. In today's
market, quality of medical care is a given and is demanded by
all. Quality of service relates not only to patient-specific concerns
such as decreased operating room turnover times and improved overall
outcomes, but also to organizational concerns such as cooperation
with one's group or hospital to reduce intensive care unit time
or pharmacy cost. Optimal values are achieved by jointly maximizing
quality (the positive aspects of health, function and satisfaction)
while minimizing cost (the negative aspects of mortality, morbidity
and expense). Anesthesiologists as perioperative managers can
find these optimal values.
Given the need for ensuring and providing value in perioperative
care, anesthesiologists are already assessing, expanding and redirecting
the profession. The Ad Hoc Committee on Value-Based Anesthesia
Care and many long-standing ASA committees, including the Committee
on Economics and the Committee on Quality Improvement and Practice
Management, are working in liaison with outside organizations
to properly position our specialty for the future. We are learning
the importance of market forces, work force constitution and government
payment policies in the delivery of care; recognizing the empowerment
of generalists and the integration of physicians, hospitals and
health maintenance organizations; and incorporating cost-containment,
pain management and perioperative medicine in our practices.
When applying value-based anesthesia principles to the perioperative
period and using information management techniques, anesthesiologists
need to look at many areas, including:
- Preoperative laboratory testing -- How much is needed?
- Outpatient versus inpatient surgery -- Outpatient surgery
is often cheaper and faster.
- Local/regional versus general anesthesia -- Recovery
and outcomes may be better with regional anesthesia; costs are
often less.
- Selection of anesthetic agents -- Is there really a
difference in outcome?
- Low-flow anesthesia -- Is there any reason not to use
low-flows?
- Choice of muscle relaxants -- Many selections with
marked cost differences are available; is there a difference
in outcome?
- Choice of narcotics -- Marked differences in cost appear
with little difference in outcome.
- Antiemetic therapy -- Many studies show little difference
in outcome with different antiemetics.
- Recovery requirements -- These can greatly affect costs
and satisfaction.
Perioperative anesthesia involves much more than just the selection
and interpretation of laboratory tests. It entails detailed interviews
with patients, review of their medical histories and determinations
of their suitability for surgery and anesthesia. Recognition of
the value of perioperative anesthesia and its contribution to
our total work was the primary reason that the AMA/ Specialty
Society Relative Value Update Committee recommended a 22.76-percent
increase in anesthesia work value to the Health Care Financing
Administration.
Another area for providing value and opportunity is pain management.
The American public, insurers, the government and even health
maintenance organizations are recognizing the need to have effective
pain management for the postoperative period and for chronic conditions.
Anesthesiologists with their technical expertise and knowledge
of clinical pharmacology and physiology are actively engaged in
this area. Pain management is now a recognized subspecialty of
anesthesiology; the number of pain clinics and anesthesiologists
devoted to pain management grows daily. Yet the supply of pain
management specialists is not sufficient for the demands, as the
large number of advertisements for physicians in this area indicates.
Valuable Opportunities
As the population of the United States ages over the next few
decades, the number of surgeries is projected to grow by 21 percent.[1]
Many of these surgeries will be longer and more extensive and
will require more invasive anesthesia and intensive postoperative
care. Anesthesiologists will continue to have opportunities for
employment in surgical anesthesia and intensive care as the population
ages, especially when augmented by the broader, coordinating role
of perioperative manager.
The value of anesthesiologists in providing care can perhaps
best be appreciated by noting that the number of anesthesiologists
has grown approximately sixfold from 1954, while over the same
time, the mortality rate for surgery has fallen sixfold. Similarly,
improved patient outcomes, as measured by a decrease in perioperative
mortality rate, was positively associated with an increased number
of Board-certified anesthesiologists.[2]
Development of good information systems should allow further documentation
of the value of anesthesiologists.
Clearly, anesthesiologists have many opportunities. Anesthesiologists
have the knowledge, expertise and clinical position to take advantage
of the ongoing changes in the marketplace, envision the future
and continue to provide value for the health care system. The
need to act has never been more acute. If anesthesiologists do
nothing but react to marketplace forces by cutting costs and staff,
narrowing their clinical focus and just "providing care,"
value will not be enhanced or even maintained. Someone else will
make all the decisions, and the specialty will shrink in importance,
prestige and relevance.
But if we are proactive, if we strive to increase value for all,
if we continue to expand our horizons outside the operating room,
and if we develop our information systems and management skills,
we will have the opportunity to enhance the importance of our
specialty and ensure our own survival and worth.
References:
1. Abt Associates Inc. Estimation of Physician
Work Force Requirements in Anesthesiology. Park Ridge, IL:
American Society of Anesthesiologists; 1994.
2. Silber JH, Williams SV, Krakauer H, et
al. Hospital and patient characteristics associated with death
after surgery. A study of adverse outcomes and failure to rescue.
Med Care. 1992; 30:615-627.
Karl E. Becker, Jr., M.D., is Professor
and Chair, Department of Anesthesiology, University of Kansas
School of Medicine, Wichita, Kansas.
E-mail the author.
Robert E. Johnstone, M.D., is Professor
and Chair, Department of Anesthesiology, West Virginia University,
Morgantown, West Virginia.
E-mail the author.
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