5 Thoughts From Industry Experts on the Future of Anesthesia

Anesthesia, like many other specialties, is likely to undergo significant changes as the effects of health reform become clearer. Industry experts discuss five ways anesthesia provision will change over the next several years.

1. Hospitals, ASCs and anesthesia groups will have to increase the focus on anesthesia quality. According to Hugh Morgan, quality assurance officer for Somnia Anesthesia Services, the continued emphasis on a federal level on the importance of anesthesia quality has often been undervalued and overlooked. Now, however, hospitals, ASCs and anesthesia groups will have to work together to prove anesthesia quality, as "it's now creeping into all the criteria that facilities [must] submit on an annual basis in order to receive annual CMS payment updates," Mr. Morgan says.

He says at a minimum, hospitals and ASCs must conduct an annual review of the CMS Conditions of Participation, Interpretive Guidelines for Anesthesia. "CMS has [added interpretive guidelines that apply to specific clinical practices like anesthesia," he says, adding that information on those guidelines is available via CMS and online. "It's important to really have that collaborative transparent partnership with your anesthesia service, to sit down and review those requirements, to maintain a heightened state of compliance and risk avoidance and hit all the regulatory and accreditory requirements," he says.

From: The Future of Anesthesia: Q&A With Hugh Morgan of Somnia Anesthesia

2. Anesthesiologists will find it more difficult to work in critical access rural hospitals. In states where the governor has chosen to "opt out" of physician supervision of anesthesia, giving CRNAs the ability to practice independently, Mark Warner, MD, president of the American Society of Anesthesiologists, says anesthesiologists are finding it increasingly difficult to work in rural, critical access hospitals. "There is a small loophole in federal payment rules that allows some very small hospitals to charge directly for full anesthesia costs if the care is delivered by nurses," he says. "There is no similar loophole payment for physicians, [meaning] a perverse financial incentive exists for these hospitals to discourage the upgraded and expanded care that anesthesiologists could bring to their rural areas." Because of the loophole, an administrator of a small, rural access hospital would be inclined to staff CRNAs because the hospital will make more money with nurses than with anesthesiologists. In effect, he says the loophole incentivizes small hospitals to discourage anesthesiologists from practicing at small facilities — thus limiting the number of anesthesia providers who are attracted to understaffed areas.

He says the loophole will eventually result in a two-tier system of healthcare. In small rural areas, anesthesia could be provided exclusively by CRNAs, while urban areas receive the benefits of anesthesiologists, especially "for those who are quite ill and need intensive care services."

From: 5 Thoughts on the Physician Supervision of Anesthesia Rule From ASA President Dr. Mark Warner

3. Anesthesiologists will be used as peri-operative physicians. According to Jerry Cohen, MD, president-elect of the American Society of Anesthesiologists, anesthesiologists are in a good position to become the "perioperative 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 perioperative 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."

Jonathan Friedman, COO of Somnia Anesthesia Services, agrees that anesthesiologists will be helpful in identifying the problems in the surgical process. He says anesthesia groups accumulate a lot of data that facilities will find useful going forward, as they look at the areas of waste in pre-, intra- and post-operative care. "We have the ability to say, 'Here's where you're more vulnerable, and here's where you may need to provide for additional care,'" he says.

From: 4 Ways Anesthesia Provision Will Change in the Next Four Years and
Defining the Relationship Between Anesthesia and ACOs: Q&A With Jonathan Friedman

4. 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.

From: 4 Ways Anesthesia Provision Will Change in the Next Four Years

5. Advances in acute pain management will continue cut costs. Paul Willoughby, MD, president of the New York State Society of Anesthesiologists, says the advent of ultrasound has been a tremendous boon to regional anesthesia. "Years ago, the majority of anesthesiologists were uncomfortable performing peripheral nerve blocks in regional anesthesia," he says. "After the advent of ultrasound, I watched the number of fellowships in acute pain management increase by 300 percent."

He says training in residences is also increasing, producing more physicians who are comfortable with performing peripheral nerve blocks. "When you manage acute pain better, you're able to get patients functional and out of the hospital sooner," he says. Quality perioperative care is becoming more and more essential to the practice of anesthesiology, shortening the length of stay for many patients and improving patient satisfaction and quality of life.

From: 4 Trends Affecting New York Anesthesiologists

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