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The American Society of Anesthesiologists is an educational, research and scientific association of physicians organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient.


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June 1, 2013 Volume 77, Number 6
Practice Management: The Perioperative Surgical Home Model Mike Schweitzer, M.D., M.B.A., Chair

Brenda Fahy, M.D.

Marc Leib, M.D., J.D.

Richard Rosenquist, M.D. Committee on Future Models of Anesthesia Practice

Sharon Merrick, M.S., CCS-P

ASA formed the Committee on Future Models of Anesthesia Practice (CFMAP) approximately two years ago. One purpose of this committee is to evaluate how the rapidly changing health care system could affect anesthesiologists and develop strategies for our members to effectively deal with those possible changes.

The proposed system changes include Accountable Care Organizations, Shared Savings programs and various forms of enterprise contracting. Most of the proposed changes include models for bundling most or all of the services provided to patients by multiple providers across one or more care settings into a single payment. From a payer standpoint, this is not only efficient, but significantly reduces the financial risks associated with an episode of care that can span an extended period of time, involve multiple providers (surgeon, anesthesiologist, intensivists, multiple specialists, physical and occupational therapists, etc.) and several care settings (hospitals, rehab centers, skilled nursing facilities and home health care).

The goal of most bundled payment systems is to provide quality care for patients by improving efficiency and reduce the costs of these services compared to the total costs when the individual services are paid separately. Anesthesiologists will need to demonstrate to the enterprise receiving the bundled payments the added value they provide beyond surgical anesthesia care to individual patients.

One value-added component in most discussions of future health care systems is the Patient-Centered Medical Home (PCMH), which will coordinate ambulatory care by a number of physicians and other providers. Anesthesiologists have little to contribute to the PCMH as currently envisioned. Therefore, ASA is currently developing the Perioperative Surgical Home (PSH) model of care as a counterpart to the PCMH. The PSH model is a patient-centered and physician-led multidisciplinary and team-based system of coordinated care that guides the patient throughout the entire surgical experience, from decision for the need for surgery to discharge from a medical facility and beyond. The goal is to create a better patient experience and make surgical care safer, efficient and aligned in order to promote a better medical outcome at a lower cost.

In order to better identify the value-added services that anesthesiologists can provide in settings participating in one or more bundled payment programs, such as an ACO or hospital contracting on bundled payment rates for an array of surgical services, ASA and CFMAP are engaged in developing and defining the PSH, a model of care that is analogous to the PCMH. In the PSH, patients scheduled for surgery are managed by a coordinated team from preoperative assessment through the post-discharge period.

Improved coordination and management of surgical patients has been shown to increase quality, reduce complications, increase the efficiency and cost-effectiveness of perioperative care, and improve the patient’s perception of the surgical experience. The health care team is incentivized to improve the perioperative process through a single payment that covers both facility and physicians for the episode of care. Through our work with every procedural service and patients of every age and co-morbidity, anesthesiologists are uniquely qualified to lead the PSH.

The PSH team will contribute to the continuous improvement in surgical care by refining both the process and structural elements of the surgical pathway, directly developing or modifying facility protocols, and improving systems that impact perioperative management. Some examples include development of transfusion and anticoagulation guidelines, pain management focused on earlier patient mobilization and discharge, and cross-disciplinary education of the surgical team on process improvement.

The PSH model can target shared savings and incentive payments for quality achievements based on:

  • Early patient engagement: Engaging patients early is beneficial to both the patient and health care enterprise by creating open communications, supporting and educating patients to make decisions and participate in the process of undergoing surgery as either an inpatient or outpatient, and reducing unrealistic expectations.
  • Reduced preoperative testing: Unnecessary and/or duplicative testing results in significantly increased costs with no benefit to patients, physicians or health care facilities. By coordinating preoperative testing and ensuring that only those tests that are necessary based on the patient’s individual medical conditions, the PSH will achieve cost savings without negatively impacting patient care.
  • Intraoperative efficiency: Reducing delays, increasing surgical facility throughput and optimizing equipment and devices utilized, the PSH team can help achieve more efficient care without sacrificing quality.
  • Clinical outcomes: Better care coordination and increased standardization while still allowing for patient variability have been shown to result in better clinical outcomes.
  • Cost reduction: Just as the PCMH results in cost savings across ambulatory care settings, the PSH will result in cost reductions in both inpatient and outpatient surgical settings.
  • Post-procedural care initiatives: Having the PSH team coordinate post-procedural care will result in improvements in the incidence of postoperative nausea and vomiting, reductions in the severity and duration of postoperative pain, achieving patient mobility sooner and, for patients undergoing inpatient surgical procedures, the likelihood of earlier discharge from the hospital setting.
  • Reduce post-procedural complications: The PSH team approach to patient care will likely result in few post-procedural complications. In addition, when such complications do occur, they are likely to be recognized sooner and treated more efficiently. All of this will result in lower overall costs associated with post-procedural complications.
  • Care coordination and transition planning: Early discharge planning, especially for patients undergoing inpatient procedures, will result in decreased hospital length of stay and, therefore, decreased costs, allowing earlier appropriate transfers to more appropriate care settings such as rehabilitation centers, skilled nursing facilities or, with the proper support, the patient’s own home.

  • All of the above will result in savings to the health care enterprise, providing care to patients under the newer payment models. These savings should be shared among the various providers responsible for the cost reductions, not retained solely by the entity receiving the bundled payment. By providing the value-added services that result in these savings, the PSH team not only can demonstrate its value but also share in the benefits for providing those services.

    The evolution of anesthesia practices toward the PSH model will likely follow many different paths. However, to be recognized by outside entities, including payers, it may be necessary for PSH entities to meet objective criteria for certification. ASA may wish to consider developing processes and guidelines for certification. These could be similar to the certification of ACOs, PCMHs and Centers of Excellence, each of which have various organizations that provide recognition through certification.

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