4 Ways Anesthesia Provision Will Change in the Next Five Years

Jerry A. Cohen, MD, president-elect of the American Society of Anesthesiologists, discusses four ways the role of anesthesiologists will change over the next five years.

1. Anesthesiologists should be used as peri-operative physicians. According to Dr. Cohen, anesthesiologists are in a good position to become the "peri-operative physicians" necessary for quality patient care in the coming years. "This trend has been evolving for a large number of years," he says. "People think of anesthesiologists as the folks who just go to the OR and put patients to sleep, but the details of medical management are extensive, and the threats to patients during operation are intense as well." He says over the last 5-10 years, the American Board of Anesthesiologists has increased the length of residency for anesthesiologists-in-training and expanded the curriculum to include requirements for pain management and intensive care.

More and more, he says, patients are staying in the hospital post-operatively because a high level of care is required after surgery. Given the costs associated with surgery, efficiency and the prevention of complications will be paramount to saving money in the future. "The prevention of complications such as nausea as well as decreasing the length of stay all require a model that embraces the peri-operative pathway," he says. "Hospitalists are not a match for the surgical pathway because they don't have any contact with the sharp end of surgical care, so to speak."

He says the ability to improve efficiency and safety will become very important as global payments become related to episodes of care rather than procedures. Anesthesiologists can make a significant impact on improved efficiency going forward as managers of the "peri-operative pathway" that handle the entire process of surgical care.

2. Patients will undergo fewer referrals in the pre-operative evaluation process.
Dr. Cohen says the healthcare industry will see a greater emphasis on pre-operative evaluation as facilities endeavor to improve quality and save money by conducting thorough screening and reducing cancelled case numbers. "Some of the preparation that may have been done classically by the patient's surgeon will be taken over by the anesthesiologist," he says. According to Dr. Cohen, this could mean fewer referrals during the pre-operative evaluation because the anesthesiologist will be able to complete the evaluation without the expertise of other specialists.

"If [anesthesiologists] do the pre-operative evaluation, we probably don't need to get anywhere near the number of consults other people would need in preparing the patient," Dr. Cohen says. "The patient's surgeon might need a cardiology consult and a pulmonary medicine consult, but if you send the patient to an anesthesia clinic staffed by an anesthesiologist, it's likely that all those things could be addressed by that one anesthesiologist." He says anesthesiologists have traditionally spent little time in the pre-operative evaluation area, but global payments may make the transition easier as fewer consults will mean money saved.

3. Anesthesia provision may increasingly move to the outpatient arena. As ASCs become more popular for elective and non-emergency surgeries, Dr. Cohen predicts anesthesia providers will increasingly move to ASCs. Traditionally, he says, anesthesiologists — like radiologists and pathologists — have been relatively attached to the hospital setting. "We may be moving away from hospitals more than into them," he says. "An awful lot of anesthesia and surgery is done at ASCs now, largely because patients like coming in, getting a procedure and leaving, and the complications that occur at hospitals are not as likely to happen at surgery centers."

He says anesthesia providers are also moving into office practices, where they work one-on-one with dentists, oral surgeons and others. According to Dr. Cohen, the historical "tight bond" between anesthesiologists and hospitals may diminish over the next few years as the safe, cost-effective nature of outpatient surgery becomes more attractive.

4. Rural communities will struggle to attract anesthesia providers without serious legislative changes.
Rural areas across the country will struggle to attract primary care physicians and specialists in coming years as the number of insured patients increases.. "It's hard to attract both physicians and nurses to rural practices," Dr. Cohen says. "Both of them want to live in urban areas, and that's clearly the reason that rural practices have a problem recruiting." He adds that a loophole in the federal payment rule allows small hospitals to charge directly for full anesthesia costs if the care is delivered by a nurse, making nurse-administered anesthesia more cost-effective for those hospitals and disincenting physicians from moving to those areas. "[The loophole] results in unequal care, and it results in different levels of safety from rural to urban hospitals," Dr. Cohen says. He adds that data has shown this incentive for nurses, as well as state "opt-outs" of physician supervision of anesthesia, have not actually attracted nurses to rural areas — rather, numbers of rural providers have remained relatively static over recent years.

If the payment loophole and state opt-outs don't work to attract anesthesia providers to critically underserved areas, Dr. Cohen says the industry must find an alternative. He says two current ideas — increasing payment for all providers or financing medical education with the stipulation that the provider spends a few years practicing in a rural area — will likely not result in an increase of rural providers. Instead, hospitals must work to effectively transport patients to nearby urban centers, a task more difficult for states where large cities are few and far between. "Hospitals do a lot better when they do a high volume and do things they're very familiar with," he says. "One of the safety problems in a rural area is that if you don't do things very frequently, you tend not to be as good at them. We need to concentrate on not just providing care in rural areas, but getting patients from rural areas to [urban centers] when they're stabilized."

Learn more about the American Society of Anesthesiologists.

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