Top Challenges for Anesthesiologists: 5 Thoughts From ASA Incoming President Dr. Jerry Cohen

Jerry A. Cohen, MD, incoming president for the American Society of Anesthesiologists, discusses five issues facing anesthesiologists in 2011 and 2012.

1. The uncertain future of Medicare. Dr. Cohen says the cost of Medicare tops the list of challenges for anesthesiologists over the next few years. "The cost of Medicare is currently unsustainable," he says. "The reasons are debatable as to why, but some of the causes of the increase are overly focused on physicians." Dr. Cohen says while physicians are responsible for making decisions that impact cost, physician fees are not driving Medicare costs as much as the procedures and the number of patients covered by the plan compared to those paying into Medicare.

2. Continuing drug shortages. A recent survey by the American Hospital Association found that 99.5 percent of hospitals are experiencing at least one drug shortage, mirroring survey data presented by the American Society of Anesthesiologists in April. Dr. Cohen says while some scarce drugs can be replaced by generic equivalents, not every drug has an equally effective generic counterpart. "Our muscle relaxants act differently, with different duration of action and side effects. When we come up short on pentothal — which next to nobody has — and use propofol instead, different things happen to our patients," he says. Dr. Cohen also says that anesthesiologists may have to use a combination of drugs when a hospital experiences a shortage of one essential drug — one drug to act as the replacement to the original and several more to correct side-effects from using substitutes. This is an even more serious problem when treating high-risk patients.

He says while the ASA is working on a policy with the Food and Drug Administration, the work may not be enough to correct the shortage. "We have legislation going through the Senate, but it's not necessarily compelling the drug manufacturers to correct the shortage," he says.

3. Debate over scope of practice issues. Dr. Cohen says anesthesiologists are plagued by several scope of practice issues, including the ability of certified registered nurse anesthetists to practice pain medicine and provide anesthesia without physician supervision. He says pain medicine is becoming more of an issue in states where CRNAs seek approval to practice pain medicine alone. Dr. Cohen believes that anesthesia nurse training is not sufficient to make the practice of pain medicine safe.

He says medical training is essential for the practice of pain medicine because of the complexity of the specialty. "In order to know which block to do and follow up on the procedure with comprehensive therapy, you have to understand the medical issues related to co-existing problems," he says. "It's not just treating a particular symptom. It involves the entire milieu of the patient's life, as well as other conditions." For example, he says diabetic patients generally display entirely different pain syndromes than patients who have experienced a traumatic injury.

4. Transition to a global payment model.
Dr. Cohen predicts that payment models will inevitably shift from a base-plus-time approach to a capped or "episode of care" model. The timeline for this is uncertain, but because of this impending shift, anesthesiologists must assist facilities in the coordination and management of patients' perioperative care before, during and after surgery. He says anesthesiologists are in a uniquely appropriate position to improve the entire episode of care. "We have to know a lot about all the medical specialties and manage all the co-morbid conditions of people that go to the OR," he says. "We work with different physicians all the time, and we have a very good idea of the surgical care pathway and how you get people through it efficiently and safely."

He says while some anesthesiologists may initially feel uncomfortable with the added responsibility, they should ultimately be proactive about talking to hospitals about their expanded role in the new system. "There will be a lot of changes to everybody's practice if we move to an episode of care model, and I don't see how we're going to escape that," he says. "Anesthesiologists need to be prepared to say, “We have an extremely valuable patient management component to what we do.'" ASA has been leading the effort in advancing a draft concept — the perioperative surgical home — as a mechanism to improve care coordination, enhance quality and reduce costs in the acute care setting.

5. Shortage of specialists. Dr. Cohen says specialty organizations also need to make headway in explaining why the United States needs more specialists. "In the last dozen years, there has been a big push for primary care, and it has not done all it's supposed to do," he says. "The shortage of specialists is even greater." A study from RAND Corporation anticipated a dramatic shortage of anesthesiologists, stressing the need for their medical education, training and expertise. He says fortunately, the ASA is experiencing growth, unlike many other medical societies that have suffered from dwindling membership in recent years. He says the current challenge is bringing the society's views to its regulators, legislators and members.

Learn more about the American Society of Anesthesiologists.

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