Embracing the Unknown – Nothing to Fear…

  • Chamberlin, Keith, MD, MBA, FASA
| Feb 02, 2014

Anesthesiology, like all medical specialties, is undergoing cataclysmic changes. The good news: our physician-led research in patient safety makes us the internationally recognized leaders in all of medicine. The other good news: we now have an opportunity to take our specialty to new heights of safety and quality care for our patients, and gain renewed respect and appreciation from patients, surgeons, and health care organizations for what we do.

So goes my interpretation of the ASA Practice Management Conference recently in Dallas, Texas. The overarching theme for the conference was "show them your value"— with data, collaboration, and enthusiasm, as we create new models of cooperative care within the surgical continuum for our patients. SURGEONS told us they welcomed the collaboration, as they preached the message of the physician-led team approach. And we are now showing surgeons and others outcome data to support the question of the appropriateness of a planned procedure for a specific patient. Yes, we have actual data showing outcomes based on patient condition, type of surgery, social situation, and everything else we look at when preoperatively evaluating the whole patient. (Data to support our universal question of “WHY are we doing this??”)

It was quite clear the current method of practice (autonomous, fee-for-service, isolated in the OR) is going away in the near future. It will be replaced by collaborative, coordinated care among teams of physician anesthesiologists, surgeons, nurses, dietitians, physical therapists, transition-of-care nurses, and more. We will see more global or bundled payments and eventually some form of capitation. We will be moving (and already are) from volume to value, from fee-for-service to payment for quality. And while this concept is not new and you have read about it in this blog previously, I was impressed with how far the concepts have progressed. The orchestra is gathering and, with a little effort, the anesthesiologist can be and SHOULD be the conductor. Patients will benefit, the system will benefit, and we can continue getting paid what we are worth. Yes, really. Getting paid for value.

As the medico-economic tsunami approaches, here are four concepts you should know and understand:

Triple Aim: Developed by the Institute for Healthcare Improvement, this term defines the quest for better health for the population, a better patient experience, and lower cost of care. These three goals are at the core of all new health care initiatives.

Accountable Care Organizations (ACOs): The future organizational structure for CMS payments, as outlined in the Affordable Care Act (ACA). Described in many non-flattering ways (HMO on steroids—which it is not), the ACO holds promise for anesthesiologists.

Disruptive Innovation: Made popular by Clayton Christensen in his book "The Innovator's Dilemma": this is where a technology, service or product provides a new, yet similar product at lower cost and albeit a lower quality. It establishes a foothold and grows, because it is affordable for those whose alternative would be NOTHING, and eventually the new technology supplants the current model. The "well, it is good enough" alternative becomes the standard, and then eventually “the new” has to improve because the next “new” disruptive innovation will be chasing it. The opposite of this is "sustaining innovation", which takes current markets and processes and evolves them to a higher value. Sustaining technical product innovations for anesthesiology have been pulse oximetry, capnography, and advanced nerve blocks via ultrasound, to name a few.

What about “service” product innovations? Now we have one: The Perioperative Surgical Home.

Perioperative Surgical Home (PSH): The largest funded ASA initiative and creation, this new model of care describes an anesthesiologist-led collaboration involving the entire perioperative team. The PSH delivers a totally integrated surgical experience that costs less, keeps patients happier, and takes better overall care of our community. This really is our sustaining innovation.

The PSH is actually a form of an Integrated Practice Unit (IPU), the entity described by Michael Porter (a business leader who writes extensively about changing health care, and is read and listened to by virtually all health care executives) in his October 2013 Harvard Business Review article, "The Strategy That Will Fix Health Care" .

In an IPU, personnel work together regularly as a team toward a common goal: maximizing the patients overall outcomes as efficiently as possible.

IPUs are organized around a disease process—not by department. For example, an IPU at Virginia Mason Hospital & Medical Center in Seattle focuses exclusively on back pain, and has achieved remarkable quality and cost results. Many different clinical practitioners and staff members are part of the IPU, but all are coordinated and focused on the primary problem.

Our IPU is the surgical home: focused on the surgical disease with multiple specialties organized and led by anesthesiologists to guide the patient from preoperative evaluation and preparation through intraoperative management, postoperative care, pain management, and discharge. This is where we can really show our skill as physician anesthesiologists.

There were many lectures about the PSH, there are now conferences devoted exclusively to the PSH, and the ASA has established a PSH Collaborative to collect data about results and processes. The PSH is here to stay. And while most of the PSH examples presented were from academic institutions and larger organizations, the PSH model is valuable and feasible in small private practice settings.

The PSH, as it develops in local settings, will make use of many of the concepts discussed at the Practice Management Conference:

The “New Pre-Op Clinic": More than preoperative testing, it is transforming into a collaborative discussion among anesthesiologists, surgeons, patients and their families, discussing the risks and predicted outcomes of the surgical procedure given the patient's specific medical AND social situation. Again, we now have data that we can use to answer the question, "Why are we doing this, and is the treatment plan appropriate for this particular patient?"

Advanced Intraoperative Care: We are gathering more data to demonstrate that the care we give intraoperatively affects 30-day mortality, chronic postoperative pain (CPOP, a recognized ICD-9 diagnosis), and now, possibly, cancer outcomes. Clinical pathways for specific procedures and diagnoses are being developed. 

Acute Pain Service (APS): This service is high on hospital "demand lists". Part of the hospital's payment modifier is based on the new federally-mandated Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) results. HCAHPS surveys are sent out to patients and ask a lot of questions, some of them specifically about how well the patient's pain was treated. While payment for this service can be challenging, physician anesthesiologists, in partnership with facilities, can make this work for patients, hospitals, and our specialty. We can get compensated for the value we bring when we show the value.

This year’s conference was one of solutions. Attendees left energized and with a purpose. We are the perioperative leaders. We do have a "Triple Aim" plan. And our patients will benefit, everyone in the system will benefit and our jobs will be even more rewarding. It turns out all we have to fear is fear itself (with a nod and thanks to FDR…)

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