5 Current Trends Affecting Anesthesiologists

American Society of Anesthesiologists President Alexander A. Hannenberg, MD, discusses five trends affecting anesthesiologists and how the ASA is responding to threats to its members.

1. Provider non-discrimination language removes patient safeguards. Section 2706 of the health reform law makes it illegal for insurance companies to discriminate against providers acting within the scope of their state licenses. For anesthesiologists, this means health insurance companies cannot refuse to cover certified registered nurse anesthetists providing interventional pain therapy. Dr. Hannenberg says while the phrase "non-discrimination" sounds positive, "our feeling is that we shouldn't introduce what sounds like civil rights language into the medical scope of practice law." He says the American Society of Anesthesiologists hopes to see the provision repealed.

2. Patient safety must be placed before financial benefits to the facility. When healthcare facilities are looking to cut costs, Dr. Hannenberg says the medical community must guard against the risk of putting patients in danger to keep finances stable. He commented on the increasing use of employment models, saying, "It's anxiety-provoking because while there's good evidence it can be done in a way that's successful for anesthesiologists and their institutions, there can also be some pitfalls." He warns that a center employing anesthesiologists, in which the owners are also the referring physicians, can tread in the territory of kickbacks and fee-splitting.

"Whether you're employed or not, we need to keep a clear view of the anesthesiologist's obligation to the patient. That's the guiding principle that will help you understand what's acceptable and what's not," he says. He says cost-cutting measures may endanger patients if, for example, a facility opts to cut costs by performing fewer postoperative pain procedures. "Is that a model of practice in which we are serving the needs of our patient above all?" he says. "I think neither the anesthesiologist nor the patient would find that acceptable."

3. Questionable data gives nurse anesthetist studies undue weight. A study published in the August issue of Health Affairs reported CRNAs providing anesthesia services without the supervision of a physician do not put patients at increased risk for death or complications. The study is potentially dangerous, as facilities and insurance plans may opt to promote the use of nurse anesthetists in hope of saving money. According to Dr. Hannenberg, the data utilized for the study is not substantial enough to provide conclusive evidence about the effectiveness of CRNA-administered anesthesia. "When you use billing data like that to draw conclusions about outcomes, you come up with completely upside-down conclusions," he says. "I don't think the answer is to produce junk science of our own."

He says instead of hitting back with another meaningless study, anesthesiologists are working to develop tools that collect quality clinical outcomes data over time. The Anesthesia Quality Institute's mission is to "collect and maintain an ongoing registry of anesthesia cases and outcomes to help anesthesiologists assess and improve patient care."

4. "Meaningful use" rules should include incentives for perioperative EMR systems.
According to Dr. Hannenberg, the final "meaningful use" criteria may not incent perioperative information systems in the same way as office-based EMR. In order to promote better patient care, better outcomes management and reduced errors, the ASA is planning to work with CMS on electronic health services to make sure anesthesia information management systems are also recognized. "We want to make sure all the attention, incentives and other pushes toward adoption of EMR serve to promote EMR in anesthesiology," Dr. Hannenberg says. "We fear that perioperative information systems will be marginalized in the government's approach to EMR."

5. A shortage of residency positions may mean a shortage of anesthesiologists.
Though many people are focusing on the impending shortage of primary care physicians, Dr. Hannenberg says policymakers should also pay attention to a drastic shortage of specialists. "The demand for anesthesiologists is going to grow because they will be the preferred providers for sicker patients undergoing complex procedures, and their capability is getting better and better," he says. "The prospects are very bright, but we've got to pay attention to make sure we're meeting that demand."

Over the last two to three years, he says anesthesiology residency programs have placed a greater emphasis on critical care training and are now producing physicians who are simultaneously experts in anesthesiology and critical care. But while existing anesthesiologists may be better equipped to handle acute and chronic illness, health reform must still shift its focus to specialty shortages to meet the needs of the aging population. "It comes down to healthcare workforce planning," Dr. Hannnberg says. "You see an emphasis on shortages of primary care and non-physician groups, but … the shortage of specialists is far more profound than the shortage of PCPs in the long run."

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