As residents, we spend most of our training immersed in hands-on clinical experience, learning the different methods of administering anesthesia to be able to care for patients with varying needs. California’s 11 anesthesia residency programs, among the best in the country, each year produce outstanding, clinically expert physician anesthesiologists.
Yet once we leave residency, we quickly learn that there is much more to the practice of anesthesia than what happens in the operating room.
We are faced with learning about billing, compliance, and the organizational structure of our practice. Unfortunately, these are topics that most residents know little about, because the amount of education dedicated to the practice management side of being a physician anesthesiologist varies with the residency program.
Fortunately, the ASA understands residents’ need for practice management education, and with the generous support of the CSA, I was able to attend the 2017 ASA Practice Management Conference in Dallas, Texas. This year’s theme, “Critical Changes, Critical Strategies”, provided residents from across the country with important lessons about the ever-changing landscape of anesthesia practice management.
We discussed how the practice of anesthesiology is on the verge of dramatic change, perhaps even a revolution. The current fee-for-service payment model in the United States is essentially on life support waiting for a DNR order. It is unsustainable, incentivizes volume of care over quality, and has little to do with actual patient outcomes. Beginning this year, MACRA, a CMS-established compensation formula, will either increase or cut payments based on the quality of care physicians provide.
Bundled payment programs, such as the Comprehensive Care for Joint Replacement (CJR), are already in effect at some hospitals. CJR pays a fixed amount for an “episode of care”, defined as all care related to a joint replacement, placing the risk back on the hospital. If a patient experiences a complication, needs readmission, or requires a revision surgery during that episode, there is no additional compensation. That throws the ball into our court, and motivates the hospital to do everything it can to deliver quality care and prevent complications.
Technological advances are also changing the practice of anesthesia. Sure, there are issues with our EHRs, but they give physicians access to a vast amount of data, or “big data” as we call it. This allows us to analyze and streamline processes to identify patients that are at risk for certain complications, so that we can help to prevent them.
We already have Tele-ICU—is Tele-Anesthesia next? The technology is being developed at a rapid pace, and let’s face it, the physician-only model of care that’s so prevalent on the West Coast probably isn’t sustainable in the long-term given the current political and economic trends.
These are all exciting changes that will allow us to expand our skills, responsibilities, and opportunities—but only if we choose to embrace the change, not fight it.
After all, we are the ones who work to continually improve the safe use of anesthesia. Statistically speaking, physician anesthesiologists are doing well at intraoperative care, and the OR has become the safest room in the hospital. Although crisis management and protocol-driven personalized care are still challenges to be solved, other issues have a strong impact on patient outcomes, such as those surrounding perioperative care.
Complications happen not only in the OR, where we are fully equipped to deal with just about anything, but also when the patient is on the floor managed by a single night nurse and an overworked intern. Some of the complications in that setting could be avoided by instituting a program that uses data to identify and manage risks in an appropriate and systematic manner before surgery. That concept is exactly what quality initiatives would do. Yet in the pure fee-for-service system, the cost of this work wouldn't necessarily be reimbursed—but that too is changing.
Change can be both frightening and exciting. In fact, it’s what initially attracted me to our field in the first place. As physicians, we must always first and foremost be clinically competent, but equally important, we must be able to adapt to new changes. Change is what allows us to learn how to lead, manage, and optimize new systems. After attending the ASA Practice Management meeting, I believe we should dedicate time and effort to learning how to adapt to the changing field of anesthesiology as early as residency.
Dr. Figura is a CA-1 resident at UCLA’s Department of Anesthesiology and Perioperative Medicine