Wednesday, September 22, 2021

Doctors Are Not As Essential As They Think They Are


Remember at the height of the pandemic last year when people were hanging outside their windows applauding healthcare workers for their selfless sacrifices to treat Covid patients? That was quite an ego boost and seemed to signal that people finally realized how essential doctors and other medical workers are to the well being of a nation and the world. But now, when it's time to match the rhetoric of appreciation with cold hard cash, all the applause is silenced.

The federal government is on schedule to cut Medicare reimbursements to doctors close to ten percent next year. The complicated formula for this involves the expiration of bonus hero pay of 3.75% enacted last year. Then there is another 5.75% cut to meet budget neutrality rules that were put into law back in 2011. Altogether, that plus other scheduled pay cuts add up to a nearly 10% reduction in Medicare reimbursement next year. This is happening even though doctors are already making less than plumbers. (Many readers have pointed out that Medicare actually pays doctors around $80-90 per hours rather than $45 that I wrote previously. Well, $90 per hour after years of higher education and hundreds of thousands of dollars in student loans still stinks. After you take out taxes, it's closer to $45 than you think).

How pernicious are these annual drip drop reductions in physician pay? Since 2007, GI doctors have seen their Medicare reimbursements drop 6%. Cardiac surgeons are down 8%. And cardiologists are lower by 22%. What other professional field has seen their pay actually go down over the last 15 years? 

Meanwhile, the cost of running a medical business keep rising. Staffing salaries are higher. Utilities are higher. Insurance is higher. Taxes are higher. Yet doctors are expected to pay all that with less income coming in. 

You want to know who the government considers the real essential workers? All you have to do is follow the money. The Biden administration announced they are increasing federal workers' pay over two percent next year. That may not sound like much but it's still better than the cuts doctors are facing. On top of that, the federal workers also get a brand new paid holiday to enjoy their new money, Juneteenth. Could you imagine the uproar if the government unilaterally cut their workers' pay ten percent and they had no say in its implementation? The entire federal government would shut down within 24 hours as they all go on strike and stay home.

Yet doctors continue to act as martyrs and just accept the reductions in reimbursements year after year. This makes it necessary for them to run faster than ever just to stay in place. Or more commonly, most doctors now don't run independent practices anymore. Many have gladly sacrificed their independence by working for large medical corporations. Independent doctors just don't have the resources and time to be fighting behemoth entities like insurance companies and the government. 

You would think the five trillion dollar budget supplement that Congress is haggling over could include more money to treat the country's population. Unfortunately clean energy and immigration reform for illegal aliens seem to take precedence over caring for sick people in America. They do it because they know they can and we doctors won't put up much of a fight just as we have not done so for the last fifty years.

Saturday, September 18, 2021

Nimbex Is Dead. Long Live Sugammadex



I've been a lifelong fan of cisatracurium (Nimbex). It has been my neuromuscular blocker of choice ever since residency. Why do I love it so much? Let me count the ways.

I've found that Nimbex is very predictable in its metabolism. I've been burned badly before when I used another agent like rocuronium on a patient with renal insufficiency and the patient had incomplete reversal at the end of the case that necessitated reintubation. Not good for the patient or your reputation as an anesthesiologist.

Thanks to its Hoffman elimination, I don't have to worry about a patient's kidney or liver function. The drug just metabolizes at a very steady and predictable manner. This is particularly important when a patient may have an unknown issue with their renal or hepatic functions and suddenly you're wondering why the patient isn't waking up. Nimbex is also very easy to reverse. Neostigmine easily takes care of the drug and the patient emerges quickly. 

Sure you can't use Nimbex for rapid sequence induction but that's okay. Most cases don't require RSI anyway. Due to Nimbex's property of predictable reversal, I've stuck with it long after many of my colleagues switched to roc. But now that's all changed thanks to the miracle of sugammadex.

Sugammadex (Bridion) is a drug invented specifically to reverse the paralysis induced by rocuronium. But it also works with other aminosteroid compounds like vecuronium. I feel it has revolutionized NMB reversal the way propofol transformed the induction of anesthesia.

First of all, Bridion works very fast. I'm always amazed by how quickly a patient starts moving after it is given, even if there is still a fair amount of inhalational agents on board.

Rocuronium no longer needs to be carefully titrated in order for it to be reversible at the end of the case. This is especially relevant in procedures that finish rapidly like in ENT. Those cases always present the conundrum of the need for deep paralysis followed by a quick emergence. There's no greater predicament for the anesthesiologist than staring down at a patient with zero muscle twitches and an impatient surgeon wanting to get his next case started ASAP. Prior to sugammadex there was no way to reverse a deeply paralyzed patient effectively.

One can give roc to anybody with sugammadex. Before, I was always leery of using Bridion in dialysis patients because there was always a small chance that the reversal agent would wear off before the body has cleared the NMB. I have yet to see that happen. It's just as easy to wake up a patient with renal failure as a patient with normal kidney functions.

With all these advantages, rocuronium and sugammadex have become the combo of choice in our department. Nimbex use has practically disappeared. Bridion is in such high demand that our pharmacy is complaining about the high cost of the drug. Whereas one 200 mg vial of sugammadex costs about $100, one vial of neostigmine costs $10, and that can be used with multiple patients. Our sugammadex costs are now disrupting our pharmacy's budget because people are using it so often. In addition, the anesthesiologists frequently use more than one vial per patient as some are now becoming too lazy to titrate their NMBs properly.

Are there costs that are saved because we use so much sugammadex? One has to consider the cost benefit analysis for a weak patient in PACU that requires reintubation. What are the costs of prolonged OR use because the patient took a longer time than anticipated to wake up? What is the cost of the psychological trauma in a patient who is gasping for breath because he is too weak to breathe? Or the patient who is too weak to protect his own airway when extubated too early and she aspirates, requiring hospitalization for pneumonia? All these should be taken into consideration when calculating the cost of using sugammadex.

Are there downsides to sugammadex? I've already mentioned the exorbitant price of the drug. That hopefully will come down in a few years when the drug goes off patent and generics flood the market.

Worse than that though is that I think sugammadex makes anesthesiologists lazy and they lose an essential skill. It's a real art to titrate paralytic agents properly so it can be reversed quickly at the end of a case. It's not something that can be taught in a book since each patient is unique in their ability to metabolize NMBs and every surgical case is different. With sugammadex, it doesn't matter at all. This is particularly detrimental to the anesthesia residents. It is just as easy to wake up a patient with zero twitches as one with four twitches. There is no learning there. Just give more sugammadex! But they didn't learn anything about the art of controlling anesthesia.

This is all part of the long standing trend of making anesthesia ever faster and easier to use. From halothane to desflurane. Pentathol to propofol. Pancuronium to rocuronium. If we're not careful, anesthesia could become too easy to administer. There are plenty of people who would love to get anesthesiologists out of their procedure rooms. From gastroenterologists to cardiologists, having one less physician in the room would be a dream come true. If anybody ever makes reversal agent for propofol, anesthesiologists would soon be unemployed.

Thursday, September 16, 2021

How Much Do CRNAs Make And Why I'm Totally Jealous

US Bureau of Labor Statistics

The U.S. Bureau of Labor Statistics has released the numbers for the average salaries of CRNAs. You better sit down for this. They are quite astonishing. Remember when nurse anesthetists first broke into six figure incomes and everybody thought that was amazing? Well now they are doing much much better. According to the federal government, the average CRNA income was $189,190. However many CRNAs are doing even better than that. The nurses in Oregon are doing the best, with annual incomes of $236,540. As a matter of fact, CRNAs from eleven states earn over $200,000 per year. 

Why should I be jealous of this when the average income for anesthesiologists is twice as much? Medscape's annual physician compensation survey this year showed that anesthesiologists reported earning over $370,000 per year. I shouldn't be upset that somebody makes half my income, right?

Remember that CRNAs also have work schedules that resemble any other nurses in the hospital. They have a set schedule during the day that are practically inviolable. If they have a 12 hour shift, by golly they are only working 12 hours that day. We've had an instance where the case reached a critical period and because it happened right at the end of their shift, the anesthetist simply walked away from the patient and boogied their way to the parking lot. The anesthesiologist was the one who stayed behind to finish the case and make sure the patient was satisfactorily taken to the recovery room.

The anesthetists also have guaranteed morning and afternoon breaks along with a luxurious lunch break. We've had CRNAs literally quit because they didn't get their required lunch break one day. I've had days where I'm lucky to get a two minute run to the bathroom between cases. Getting a daily 30 minute lunch break is the stuff of fevered dreams.

CRNAs also don't work as many hours. Like other nurses, they work three days a week. Ours also don't take any calls or work any weekends. So with all that free time they can work at other locations and double their salaries if they so choose.

I've been told by CRNAs that not all of them have such schedules. Many of them work in remote or dangerous places unlike anesthesiologists who prefer to congregate in nicer locations. Some also take calls and work long unpredictable hours like anesthesiologists. But I suspect those work conditions are fairly uncommon and they always have the option of moving to a different job with all the perks.

So yes I'm jealous of the CRNAs. I know many anesthesiologists who would gladly take half their incomes for a work schedule that includes guaranteed breaks, guaranteed hours, three day work weeks, no calls or weekends, and the most important thing, little liability for any incident. I would say that's a fair trade. Wouldn't you agree?

Sunday, September 5, 2021

Medicare Pays Anesthesiologists Less Than Plumbers


American doctors may be among the highest paid physicians in the world, but that wouldn't include anesthesiologist who receive their patient reimbursements through government healthcare. 

In an interview in Becker's ASC Review, Dr. Scott Harper, Assistant Professor of the Department of Anesthesiology and Perioperative Medicine at the University of Alabama Birmingham, noted that Medicare pays anesthesiologists the equivalent of $45 an hour for their services. That's less than what your local plumber charges you to come in and look at your clogged toilet.

With new federal laws prohibiting doctors from balance billing, which is charging patients for the balance of a medical bill not fully paid for by insurance, the problem is only getting worse. Insurance companies have no incentive to reimburse doctors fairly because they don't have to deal with irate customers who have to pay out of pocket anymore. Now these companies are canceling contracts and lowering thier reimbursement rates, getting closer to Medicare rates.

Anesthesiologists already have to put with Medicare payments that are only about one third of private insurance reimbursements. Medicaid, which is government insurance for the poor and indigent, pays even less. The wide expansion of stingy Medicaid is how the Affordable Care Act aka Obamacare is able to insure millions more people, on the backs of doctors and hospitals. 

If the private insurance payments keep going lower, anesthesia private practice will be a thing of the past. We will all become hospital employees like emergency medicine or pathologists. Only hospitals will have the leverage to negotiate fair contracts with these behemoth insurance corporations. Individual anesthesiologists will not be able to sustain a viable business model with payments that rival the plumbing profession because plumbers don't have to pay back six figure student loans and five figure malpractice insurance premiums as part of their business expenses.