Anesthesiology and the Perioperative Surgical Home

  • Feaster, William, MD
| Oct 29, 2015

Is the Perioperative Surgical Home (PSH) a viable option for anesthesiology?

During the ASA Annual Meeting, attendees were treated to a spirited debate about this topic, with Zeev Kain, MD, MBA, arguing in support and Lee Fleisher, MD, arguing in opposition.

Dr. Kain started the discussion with a review of future health care financing and the shift to new value-based payment methodologies, specifically bundled payments for procedures such as joint replacements. But if anesthesiologists just stay in the OR and leave compensation decisions up to the surgeons, our services would be significantly undercompensated, he argued. 

kain-fleischerAnesthesiologists need to be part of the discussion of how to create more value in the care we deliver to surgical patients, Dr. Kain continued. Several national pilots are exploring how the PSH can achieve that value. Under the PSH model, anesthesiologists become involved in every aspect of the patient’s care from the moment surgery is scheduled, and they play a vital role during the preoperative period, surgery, recovery, postoperative, and post-discharge care. 

However, there are some legitimate concerns about PSH implementation, Dr. Kain said. The majority of anesthesiologists in practice today haven’t been trained to provide comprehensive patient care outside of the OR, beyond basic residency rotations in the PACU and ICU. In fact, many of us chose to practice anesthesia to avoid internal medicine or becoming a hospitalist, which this model now encourages. 

There are also financial concerns, Dr. Kain acknowledged. Today’s fee-for-service payment model provides little incentive for anesthesiologists to leave the OR in order to provide broader care to patients. 

Dr. Fleisher didn’t disagree, and underscored the need for anesthesiologists to work as a team with surgeons, internists, hospitalists, and others to take a multidisciplinary approach to surgical care. But he stressed that strategies must focus on the patient, not the anesthesiologist. If we deliver added value to the patient, others will notice and include us in the care team, he claimed.

The debate concluded with a look at the challenging relationship between the American College of Surgeons (ACS) and the ASA in supporting and implementing the PSH model. The ACS advocates for centers of excellence for geriatric surgery with partners like insurers, geriatricians, anesthesiologists and others, while orthopedic surgeons seem more amenable to the PSH concept. 

As we consider how anesthesiologists in a small hospital should engage in a PSH, simply being at the table during discussions about bundled payments would be a good start, the speakers agreed. More tools to help implement a PSH are in development from the ASA, but what matters most are the relationships and interactions with the surgeons, and the respect for the value we as physician anesthesiologists already add to the patient’s care.

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