Tuesday, February 24, 2015

Anesthesia Has Become A Zero Sum Game

Anesthesiologists are under siege. Compensation is being attacked by payers from the insurance industry and federal government. CRNA's are rapidly encroaching on the livelihood of anesthesiologists. Why do you think the American Society of Anesthesiologists is trying so hard to promote the term "physician anesthesiologist"? If there were plenty of anesthesia jobs around, we wouldn't care about the nurses scrapping for our throwaway cases. But there aren't an infinite amount of jobs available. It has become a zero sum game where somebody who has a job is keeping somebody else unemployed. It's eat or be eaten.

In order to enlarge the trough from which we're all feeding, the ASA is attempting the popularize the concept of the Perioperative Surgical Home. In a nutshell, it's designed to keep anesthesiologists involved with patient care, from the moment a case is scheduled, through the preoperative workup and operation, then guide the patient to a successful postop and discharge with a thirty day followup. This new role has been coined the tongue-twister "perioperativist". It is modeled after the concept of the Patient Centered Medical Home advocated by Obamacare where the internist takes charge of a patient who is admitted for a medical issue, guiding the care and the consultations that the patient may require while in the hospital.

Some studies, conducted by anesthesiologists of course, have hinted at improved cost savings when surgical patients are taken under the anesthesiologists' wings. The PSH program at the University of California, Irvine Medical Center reduced the cost of a total knee replacement from a nationwide average of $16,267 to UCI's $9,952. Much of the cost savings was derived from being able to discharge the patient three days postop versus the national average of four days. The UCI PSH also had fewer readmissions after discharge.

Oschner Hospital also started a PSH program. Last year, their length of stay after a total hip dropped from 3.5 days in 2013 to 2.1 days in 2014. This allowed the hospital to admit additional patients, giving it an extra income of $201,931.

However, we already have doctors who see surgical patients before and after their procedures. They are called hospitalists. Surgeons have been relying on them for years to optimize their patients prior to surgery. There have been calls for anesthesiologists and hospitalists to work together and complement each other's abilities for the good of the patient. That's sounds just a wee pollyannish to me. Let's face it, the payers are not going to give more money just because there are now TWO doctors taking care of the patient perioperatively. Ultimately the same check that is being issued for one procedure will have to be shared between more interests. Right now, the medical team, usually chosen by the surgeon, makes sure a patient is ready for surgery. Are they going to abdicate their traditional roles and give up that lucrative consult just because a new doctor waltzes in with some less than impartial studies about cost savings? I find that highly unlikely.

I would expect that the hospitalists are going to come out with some studies of their own showing how they are the better perioperativists for a patient. They will find some way to show that anesthesiologists really aren't qualified to take care of all the medical issues a patient has without seeking multiple consults for specialists. Then they will trumpet their findings to the feds and the insurance industry so that they will maintain their position as the real perioperativists. If the ASA thought fighting the AANA was hard, wait until they have to duke it out with other physicians.

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