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December 1998
Volume 62 |
Number 12
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| Anesthesia Practice
Management: How to Assess and Promote Value |
Ronald A. Gabel, M.D.,
Chair
Ad Hoc Committee on Value-Based Anesthesia Care
The Ad Hoc Committee on Value-Based Anesthesia Care recently
completed the development and production of a new manual with
the above title. As an introduction to this manual, the first
chapter is reprinted here.
CHAPTER 1:
How to Define "Value-Based Anesthesia Care"
By Ronald A. Gabel, M.D.
The concept of value-based anesthesia care came into existence
because, during the past decade, U.S. health care costs have risen
too fast and too high. The federal government and the national
business community appear to believe that competition among health
care providers is the most acceptable and most effective method
for solving the problem of excessive health care costs. Therefore,
anesthesiologists, in order to be able to compete successfully
in the rapidly evolving competitive marketplace, must seek ways
to constrain costs of anesthesia care. However, because quality
is an essential attribute of patient care, we must develop strategies
for constraining costs without compromising quality. That is what
this manual is all about.
Cost and Value
One of the major historical problems with U.S. health care economics
has been an insufficient linkage between the cost and the value
of health care. The traditional assumption has been that more
health care is better. All too frequently, decisions on health
care management have been made without an explicit probing of
the value systems of patients. Because physicians have not traditionally
considered cost when making medical decisions, the issue of whether
the value of a given medical intervention is worth the cost rarely
came up. Note that the word value is used here to mean
"worth to the individual patient." Patient preferences are an
essential component of value-based medical care.
Rather than simply trying to reduce health care costs, physicians
should be seeking ways to increase the value of health care. The
economic sense of value is employed here: the ratio
of output-to-input. Input is defined in terms of dollars spent,
output in terms of improved health status of patients. Value in
health care is commonly defined as the ratio of quality-to-cost.
Therefore, in order to understand value, one must first understand
quality. Two important aspects of quality - clinical outcomes
and customer satisfaction - are discussed in Chapters 2 and 3
as essential components of value.
The term "value-based" assumes a double meaning, depending on
whether the sociologic definition ("worth to the individual patient")
or the economic definition of value is used ("ratio of improved
health status-to-dollars spent"). In the first context, physicians
must understand what is important to their patients in order to
provide high quality care. In the second context, physicians must
be attuned to the costs of health care interventions in order
to provide high quality care.
Depending on the way "value-based" is interpreted, either individual
patients (sociologic meaning of value) or patients in the aggregate
(economic meaning of value) are the theoretical beneficiaries
of value-based medical care. Owing to the competitive nature of
today's health care environment, anesthesiologists themselves
are also beneficiaries of value-based anesthesia care, because
job security is increasingly dependent on anesthesiologists' assuring
that the value of anesthesia services is consistent not only with
the needs of patients but also with the expectations of hospitals
and managed care organizations.
To understand value and to implement value-based anesthesia
care, one must understand cost, the denominator of the value equations
("quality/cost" and "improved health status/cost"). Therefore,
Chapter 4 focuses on how to analyze costs. Chapter 5 then pulls
quality and cost together by discussing how to analyze value and
implement change. Then Chapter 6 discusses value-based services
of the perioperative physician.
Practice guidelines have become a widely accepted method for
making accessible to individual physicians the collective judgments
of groups of experts, based on the best available scientific evidence.
The goal of practice guidelines in value-based anesthesia care
is to provide anesthesiologists with a method for optimizing the
balance between quality anesthesia care and costs. Important principles
for developing guidelines are covered in Chapter 7.
Ethics of Value-Based Anesthesia Care
A major cornerstone of medical ethics is the principle that
physicians are always obligated to place the best interests of
their patients above all else. Physicians are usually confident
that the therapy they provide patients will improve the condition
being treated. Other equally beneficial treatments, however, are
often available. Some alternatives may be less expensive. The
competitive environment is beginning to require that physicians
use their collective judgments to come up with the most economical
approach to given medical conditions, rather than permitting individual
physicians to use as wide a range of options as was previously
considered acceptable. The ultimate goal is to make health care
affordable for a nation that has collectively decided that the
only way to assure high-quality health care for its people is
to reduce its costs.
There should be no ethical dilemma in providing value-based
anesthesia care. If patients' best interests are at the heart
of practice guidelines, then anesthesiologists are working within
a highly ethical framework by following practice guidelines. Individual
patients should receive appropriate care, while patients in the
aggregate should receive better care, because the total revenues
available for health care should be spent more wisely. Therefore,
quality health care should become available to populations that
currently cannot afford it.
Of course, society has a considerable amount of work to do to
assure that savings are translated into improved health care for
populations that do not currently have access to its high quality.
That aspect of society's problem is beyond our control. However,
society has made clear through mandating a competitive environment
what anesthesiologists must do in order to survive professionally.
Purpose of This Manual
The purpose of this "how-to" manual is to provide some insights
into how the above principles can be applied to an anesthesia practice.
Making the necessary changes may require modification of some well-entrenched
concepts. Before society imposed on us a requirement to consider
the costs of anesthesia care, we focused almost exclusively on the
immediate clinical needs of our patients. Now we must meet the challenge
of constraining the costs of anesthesia care while continuing to
seek optimal outcomes for our patients. Now we must seek to increase
the value of the anesthesia care we provide.
| Manual on Value-Based Care Now Available
The ASA Ad Hoc Committee on Value-Based Anesthesia
Care has prepared a seven-chapter manual titled "Anesthesia
Practice Management: How to Assess and Promote Value"
for the benefit of ASA members. Chapter titles and
authors are:
- How to Define "Value-Based Anesthesia Care"
Ronald A. Gabel, M.D.
- How to Define Quality - Clinical Outcomes
Kenneth J. Tuman, M.D., and Thomas
D. Mazer, M.D.
- How to Define Quality - Customer Service
Robert E. Johnstone, M.D., and
Stephen T. Robinson, M.D.
- How to Analyze Costs
Karl E. Becker, Jr., M.D.
- How to Analyze Value and Implement Change
Thomas D. Mazer, M.D., and Kenneth
J. Tuman, M.D.
- How to Justify Value-Based Services of the
Perioperative Physician
Thomas L. Higgins, M.D., and
Thomas D. Younker, M.D.
- How to Write Clinical Guidelines for Value-Based
Anesthesia Care
David A. Lubarsky, M.D.
The manual is available to ASA members free of charge
upon request by contacting the ASA Publications Department
at (847) 825-5586 or <publications@ASAhq.org>.
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Ronald A. Gabel, M.D., is Professor of
Anesthesiology, University of Rochester Medical Center, Rochester,
New York.
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