Anesthesiology in 2014: Post-Op Pain Management, Ultrasound-Guided Regional Anesthesia & More

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Two anesthesiologists discuss what lies ahead in the anesthesiology field as well as offer advice for anesthesiologists for the year to come.

Question: What are some of the most exciting opportunities for anesthesiologists in 2014?Noback

Carl Noback, MD, Medical Director, Innovative Practice Strategies (Sarasota, Fla.). The Expert Institute: Some of the most exciting possibilities for anesthesiologists involve finding additional opportunities to provide physician-related services. These includes involvement in patient-centered surgical homes where anesthesiologists are able involved in preoperative and postoperative care of the patient in an outpatient setting rather than the more common limitation to the immediate perioperative period. Patient-centered surgical homes offer anesthesiologists the option to exercise some of their physician skills.
Also, anesthesiologists should look to get involved in ambulatory care for spine and total joint orthopedic procedures. The anesthesiologist can offer postoperative pain management through a variety of techniques for patients undergoing spinal procedures or total joint procedures.

Ensuring the patient has adequate pain management after a procedure helps improve outcomes and reduce costs and is necessary to allow the provision of more complex surgical care in am ambulatory setting.

Q: What are some of the latest techniques being used in the field of anesthesiology?

weingartenAlexander Weingarten, MD, Co-Director, Comprehensive Pain Management Associates (Syosset, N.Y.) The Expert Institute: Ultrasound-guided regional anesthesia and total intravenous anesthesia are some of the newest techniques being used in the field.

Q: How have these new techniques impacted patient care?

Dr. Noback: Many of the newer techniques being promulgated are variations on a theme. They are, in my opinion, a rehash of older techniques. A lot of anesthesiologists, including myself, have used older and less expensive drugs for TIVA  — recall the work of Steinhouse, Lowenstein and Hug in the 1960s and 1970s — with successful outcomes. There is not necessarily a correlation between new and expensive drugs and equipment and having successful outcomes. Anesthesiologists should be searching for the least expensive way to provide optimal care, rather than jumping on the bandwagon for the newest drugs and devices. The facility costs for such items can be substantial, diverting capital from other areas of patient care.

Q: Why is it important to use pain management techniques in postoperative care?

Dr. Noback: Integration of postoperative pain management into pre and intraoperative care reduces complications and improves patient satisfaction. It is incumbent on the anesthesiologist to provide comprehensive and long-lasting postoperative pain management so patient discharge is quicker and readmissions and complications are less. Pre-emptive analgesia and extended duration regional anesthesia techniques should be "arrows in the quiver" of every anesthesiologist.  

Q: What are some of the challenges facing anesthesiologists in the coming year? How can they be overcome?

Dr. Noback: The biggest challenges we are facing are limited contractual reimbursement and the move towards bundled payments.

Reduced reimbursement for the same services strains the entire healthcare system. The larger the pool of providers under one umbrella, the better the negotiating power with the payers. Utilizing external anesthesia management companies for contract negotiation allows for a net effect of collective bargaining without the possibility of being accused of collusion. Multiple physicians or groups cannot band together to negotiate, but large management companies have a detailed knowledge of the prevailing professional service rates in a community and can help protect the physician from predatory payer contracts.

Bundled payments are a scheme that payers have come up with to offer one type of payment for a combination of services that are variable in complexity, duration and value. Different surgeons take different amounts of time for different procedures and have varying outcomes. Anesthesia is a time-based service, and the surgeon's skill directly affects the intensity of the anesthesiologist's involvement in patient care.

Part of the solution is to enhance the perception of the anesthesiologist by other providers who are involved in the care of a patient. The common perception is that anesthesiology is exclusively a technical service, but that's not true. Anesthesiologists need to understand the procedure and be proactive, anticipating the next surgical steps and intervening to maintain physiological homeostasis before changes take place. Being at least one step ahead of the surgeon — preferably more than one — is good for the patient and cannot help but to enhance the perception of the anesthesiologist's skill and ability.

Q: What are some clinical performance steps anesthesiologists can take to stay at the forefront of the field?

Dr. Noback: This is a pet peeve of mine — most clinical performance measures don't pertain to anesthesia services. It is difficult to have measurable performance metrics in anesthesia.

There are, however, some things that can be done to improve clinical performance. Anesthesiologists can try to identify the actual cost for the care that is provided and have actual data on how much is spent on drugs and supplies for each case. Most of us practice without knowing the costs of the drugs we use, for example. There is significant room for improvement in the cost of care delivered.

Also anesthesiologists are physicians not technicians — they need to interface with other physicians and help to look proactively for the best outcome for each patient before, during and after the surgical event. We should not fall into the trap of providing one type of anesthesia service for every patient undergoing the same procedure. Individualization in terms of procedure and patient is important. We need to act as physicians and look for ways to enhance the patients and surgeons experiences. By doing so, we can create both real and perceived value.

Q: What advice do you have for anesthesiologists for 2014?

Dr. Weingarten: Fight for reimbursement that is deserving of the work that they do. Also, anesthesiologists should never become old-fashioned, and they should keep up with new techniques.  
Dr. Noback: The light at end of the tunnel is not always daylight. As anesthesiologists we are victimized by our own success. There has been monstrous improvement in patient safety between the 1960s and 1970s and now. The public often presumes that anesthesia is essentially risk-free. The result is that our professional services are devalued. Anesthesiologists need to improve their perceived value.  

Also, there is strength in numbers. Venture capital companies have seen that there is value in anesthesia, which is one of the reasons for all the M&A activity in anesthesiology. Anesthesia practices coming together, under common sources of management or contract negotiation, leads to the ability to negotiate better reimbursement rates. Physicians have historically been individualistic, and the payers have taken advantage of that.

Anesthesiologists need to be, as a group, more aware of the business aspects of the provision of anesthesia care and need a significantly better understanding of the rules of the game being played.

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