5 Challenges for Anesthesia in 2013

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Here American Society of Anesthesiologists President-Elect Jane C.K. Fitch, MD, weighs in on several immediate challenges for the practice of anesthesiology in the upcoming year.

Dr. Fitch is a professor and chair of the department of anesthesiology at the University of Oklahoma. She has also been actively involved in ASA since the 1990s and has worked with numerous governmental committees.

Here are her five anesthesia challenges for 2013.

1. Drug shortages. Although drug shortages have been hindering anesthesiologists since the late 1990s, they have increased in frequency and severity in the last two years. About 90 percent of members surveyed by ASA have had problems with various drugs being in short supply, Dr. Fitch says.

This becomes not only problematic for physicians who have to resort to second-choice drugs for procedures, but also for patients who have to endure the consequences. Some of these alternative drugs mean longer wake-up times or more post-operative nausea and vomiting. Dr. Fitch has also seen procedures delayed or postponed because critical drugs were unavailable.

Though the end is hardly in sight, ASA is working to partner with the FDA and come up with recommendations and solutions for shortages. The FDA has increased the number of individuals working to solve the problem, she says, and early warning systems and plans for managing short supplies are in the works.

"We have to figure out how to work with the government and with other agencies and turn it around so there is a minimal impact to patients and a minimal impact to physicians," she says.

2. Evolving the specialty. Healthcare reforms continue to be necessary to maintain and improve quality of care, and anesthesiologists will need to evolve to fit the industry's changing needs.

Dr. Fitch and ASA are proposing the perioperative surgical home model of care, which features anesthesiologists as expert perioperative consultants. These physician specialists would take a leadership role overseeing the entire patient continuum of care, from pre-surgical screening to recovery and home or hospice transition.

"We as a specialty are emerging out of a very narrow focus of just dealing with when you put someone to sleep and wake them up to a broader perspective of care delivery," she says. "We are perfectly suited as a specialty to do that."

Proponents of this perioperative model, including Dr. Fitch, want to further enhance the anesthesiology education and training to prepare residents for a leadership role and make sure they are equipped to treat all aspects of care, including post-operative pain medicine.

"We are the perfect folks to be the symphony conductor in the orchestra of taking care of patients," she says.

Anesthesiologists should continue to partner with their surgical and medical colleagues at hospitals and at the national level as they prepare for this perioperative role.  

3. Nurse anesthesia supervision. Several issues have come to national attention with the distinction of roles between anesthesiologists and certified registered nurse anesthetists. Court cases in several states — including a recent decision in New Jersey — have debated whether or not nurse anesthetists need supervision to administer anesthesia. The New Jersey Superior Court ruled in favor of requiring anesthesiologist supervision for nurse anesthetists in hospitals.

While CRNAs play a critical role in the provision of anesthesia services, Dr. Fitch says, they still require the supervision of a physician to safely carry out this comprehensive task.

Before becoming an anesthesiologist, Dr. Fitch worked as an intensive care unit nurse and a nurse anesthetist. She knows first-hand what the training and education for both professions entail.

"Because of the nature of our practice being critical care and acute care medicine, where seconds matter, there is no more important role than to have a physician supervising nurses in anesthesia care," she says.

Both jobs are demanding and both professions are in short supply, but it takes both the care providers working together to meet patient needs and demands. Patients are safest when physician extenders have supervision, Dr. Fitch says. The trend in healthcare is moving toward team-based care, not away from team-based care.

Complications from anesthesia often stem from underlying medical conditions. An anesthesiologist or surgeon has more underlying medical and surgical knowledge than a nurse anesthetist, she says.

"The physician, whether the anesthesiologist or surgeon, is there to provide a safety net of coverage for the patient," she says.

4. Nurse anesthetist chronic pain management. The Centers for Medicare and Medicaid Services recently ruled in favor of allowing payment for nurse anesthetists to practice chronic pain medicine. ASA does not support this decision, and Dr. Fitch says. This practice will be a challenge in the next year.

"If you look at their curriculum, they have zero requirements for any chronic pain medicine education and training during their program," she says. "It is not in the best interest of patient safety to have them perform services and be paid when it's not part of their education and training."

All anesthesiologists, however, have at least three months of pain medicine training during their residency, she says. Those interested in a career in chronic pain medicine do an additional one or two years of training in a pain medicine fellowship program.

Chronic pain patients are some of the most medically complex. Chronic pain is largely not related to a surgical procedure, but rather to an underlying and often undiagnosed illness. Some causes of pain are life threatening, while others require long periods of management. To treat this pain, a practitioner must be able to diagnosis the problem and be able to treat the complications that could occur from various treatments.

"It's different from the involvement of a nurse anesthetist taking care of pain after a surgical procedure," Dr. Fitch says.

ASA will continue to oppose the CMS decision and press for pain medicine physicians alone to be reimbursed for chronic pain care.

5. The fiscal cliff. The looming "fiscal cliff" is on the minds of many Americans, but if the Medicare sequestration takes effect, anesthesiologists will bear more brunt than most. Both the physicians and their patients will be deeply impacted by the mandated spending reduction.

While all specialties will be affected, anesthesia already receives substantially less money from Medicare payments than all other physicians.

When most physicians send a bill to Medicare, they receive 70 to 80 percent of what a commercial bill would pay, Dr. Fitch says. By comparison, anesthesiologists receive about 33 percent of what the commercial pay would be.

"Anytime we talk about Medicare cuts, we sustain a disproportionate cut from other specialties since we are already at a much lower rate of Medicare payment for those services," she says.  

If a compromised federal budget is not passed by the end of the year, anesthesiologists will have to find ways to compensate for the decreased payments or urge CMS to keep their rates steady so all specialty reimbursements can be on par.

More Articles on Anesthesia:
What Does the Future Hold for Ambulatory Anesthesia? Q&A With SAMBA's Dr. Michael Walsh
CMS Braces for 27% Mandated Sustainable Growth Rate Cut in 2013
Proposed Legislation Could Ease Anesthesia Participation in Meaningful Use


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