On most days my concerns include which way the day’s attending physician likes to tape the endotracheal tube, what the newest nutrition room code is, and how I am going to safely get a “typical” UCLA patient with an ejection fraction of 10%, diabetes, liver disease, and peripheral vascular disease, on continuous renal replacement therapy through the day’s surgical procedure.
As I sat through the ASA’s recent Practice Management Conference in Dallas, Texas, I was initially overwhelmed by how much I don’t know about practice management in anesthesia. As a CA2 at UCLA with a father who is a physician anesthesiologist in private practice, I thought I had an understanding of what my future practice entailed. By the end of the conference it was clear that there is a lot to learn.
Howard Greenfield MD of Enhance Perioperative & Anesthesia Consulting commented on the traditional message of the three ‘A’s’ to bring to an anesthesia group “ability, availability, and affability.” This echoed much of my dad’s earlier counsel to me as I entered the specialty. The overwhelming message from the conference was clear: this is no longer enough. Physician anesthesiologists must demonstrate value beyond our intraoperative presence and provide data to support that our actions have an impact on perioperative morbidity and mortality.
I wondered whether my father’s mode of practice, (all physician, personally provided) would become antiquated. Both ASA President Jane Fitch MD’s opening comments and ASA Staff’s legislative update stated clearly: change is coming. As a profession, we need to be on the front lines positioning our groups to respond appropriately to changes. If we don’t, we likely will find ourselves in a reactionary situation that is suboptimal for our patients and ourselves.
Zeev Kain MD of UC Irvine described a two-pronged view of the transitions happening in health care: insurance changes and delivery system reform. The overall shift appears to be a movement away from payment-for-time to payment-for-quality. This is not to say fee-for-service is disappearing, but that steeply discounted payments and penalties for not demonstrating quality are here to stay. Stan Stead MD, ASA’s Vice President for Professional Affairs, noted, “You won’t be rewarded for better quality, but you’ll be penalized for less quality.” Dr. Richard Dutton MD chair of the Anesthesia Quality Institute, reminded us “what isn’t measured can’t be improved” and if we “control the data, we control the future.” In light of these transitions, the conference sought to answer CEO of EmCare Michael Hicks MD’s question, “What value do you bring and how do you make money doing that?” His answer: “Focus on the work, not the worker.”
The Perioperative Surgical Home (PSH) model is an example that focuses on achieving an integrated surgical experience to improve patient satisfaction and outcomes, as well as reduce costs and inefficiencies. The PM Conference speakers believe that physician anesthesiologists are the natural leaders to facilitate and guide the PSH process. Much of the shift to the PSH is likely to be led by large academic centers. Resident involvement in and understanding of the PSH model will be crucial as we enter private practice groups that are making these transitions. As residents, we must ask ourselves, are our programs properly preparing us to be part of a PSH-type team? Are we getting enough training in managing the anesthesia care team, care coordination with other specialties and across disciplines within medicine, nursing, and outpatient care? Do we have the statistical and data presentation skills to be effective advocates for our patients?
Unfortunately, these topics are not on most residents’ minds. Current lunchtime conversations among my classmates revolve around recent cases or recounts of how much blood products were given on the latest liver transplant. Without the knowledge of how current academic and private practices operate, it’s hard to have meaningful discussions about changes to come or to even to know the right questions to ask about the ultimate impact of these changes on patients and our profession. Some believe that our professional expertise and performance must be recognized and that fair reimbursement will “work itself out.” Others will worry about it only when absolutely necessary— once we get “real jobs.” Both of these approaches may well be shortsighted.
As a resident physician in an anesthesiology program, one’s primary goal is the acquisition of knowledge and experience in order to provide superb anesthetic care to patients. However, anesthesia programs may currently fall short in preparing us to navigate outside the clinical setting. Residents must understand the business functions within an anesthesia group or department and payment–for-services models. Only then can we understand current and future models of care.
Anesthesia residents should, as part of our standard curriculum, be educated on current legislative and regulatory issues, and how anesthesia groups collect and analyze compliance, quality, and outcomes data. We should learn how electronic medical records (EMRs) can be used to extract and analyze this data and should have statistical skills and data presentation as part of our training. Data collection is a crucial aspect of a successful PSH and EMRs that exist in our programs will provide an opportunity to both teach data collection and statistical analysis, while also supplying residents’ concrete feedback about their patients’ outcomes and how they compare to their peers on specific metrics.
Involving residents in some aspects of a department’s operations will create the basic foundation to enable residents to provide the highest quality care at the most efficient cost. Perhaps most importantly, residency should teach residents how to be effective leaders in care coordination and management of the anesthesia care team. This should include the entire spectrum of perioperative care, from the preoperative clinic, to the supervision of other anesthesia providers, to the transition to postoperative ICU care and pain management. As residents enter the anesthesia workplace, leveraging these skills that place a premium on value will ensure our patients in the future a safe and satisfactory perioperative experience led by physician anesthesiologists.
I returned to UCLA excited about the future. This is an inflection point in anesthesiology and the change is particularly evident at academic centers. In addition to its own PSH, UCLA is developing a much-needed practice management curriculum, placing residents in a better position to become effective leaders and advocates with practical implementation skills to develop quality improvement and reporting models. Preparing residents for the evolving environment in health care is vital because, as a profession, we will define ourselves by how well we manage the surgical patient population through the entire perioperative continuum.