Trends Impacting Anesthesiology in 2012: Q&A With Dr. Adam Dorin of SHARP Grossmont Plaza Surgery Center

Adam Frederic Dorin, MD, MBA, medical director and anesthesiologist of SHARP Grossmont Plaza Surgery Center and anesthesiologist at the Grossmont Hospital, Surgery Center and Women's Center in La Mesa, Calif., discusses trends impacting anesthesiology over the next year.

Q: What legislative trends do you see impacting anesthesiology over the next year?

Dr. Adam Dorin:
Regardless of one's partisan position, it is important for the public and physicians to be honest about the impact of the [Patient Protection and Affordable Care Act] legislation on hospital-based medical professions such as anesthesiology. I might note, sadly, that even bodies that were ostensibly 'against' the PPACA, like the American Society of Anesthesiologists, did not speak up loudly enough against the new law before its passage. Whether their hesitancy was based in fear of the American Medical Association's power to influence the reimbursement billing codes for anesthesiology, or based on the same AMA fallacy that 'playing along' with the current presidential administration would reap benefits for their constituents in the long run, is unknown.

Here are the factors that could potentially destroy the practice of anesthesiology as a medical profession in America: The PPACA is intertwined with efforts to promote, create and implement ACOs in communities nationwide. ACOs, standing for accountable care organizations, are essentially mini-HMOs. These entities will require bundling of hospital-based services, and huge discounts to anesthesia reimbursements are expected, possibly pushing the profession into the category of mere 'employee status' (as with most CRNAs).

In doing so, there will be little incentive for the best and the brightest to continue to pursue the necessary medical school training, residency and board testing requirements of this challenging and demanding medical specialty. If anesthesiologists begin to decline in numbers [and] proficiency, all of medicine will suffer the great loss of these very crucial peri-operative, acute care, pain management and women's center physicians. I truly hope this never happens.

Furthermore, although likely heading for demise at the level of the Supreme Court — or to be dismantled by the next president, Congress and Senate 'trifecta' — the current PPACA law (and the push to implement its mandates in the face of overwhelming/majority opposition), with its IPAB and reductions in Medicare reimbursement, will put vital anesthetic services out of reach of many Americans.

Q: What new procedures and technologies are impacting anesthesia?


1. Surgical robots.
There appears to be a growing push to further develop and implement 'robotic' surgical services for inpatient and outpatient settings. Some have argued that the cost/benefit ratio is not justified or supported in the context of our shrinking national healthcare budget. Most surgeons, however, argue that statistics for GYN and urologic surgical procedures utilizing the 'robot' result in decreased morbidities and shorter hospital stays for inpatient procedures such as hysterectomies and prostatectomies.

2. Pain management. For anesthesia and pain management, many would like to see a continued increase in utilization of ultrasound-guided nerve blocks and indwelling catheters for post-op pain management pain pumps. Some argue that the costs for these tools and supplies are not justified, and that they only cut a few days out of the expected post-operative pain cycle. They also argue that there are increased risks, especially for lower extremity blocks, in sending patients home with numbness that can impair necessary activities of daily living and ambulation, resulting in falls and other injuries.  Nevertheless, there appears to be a significant impetus to increase the implementation of pain management innovations for the foreseeable future.

Q: The last few years have seen significant drug shortages. How do you see the shortages impacting the specialty in the next year or so?

AD: Drug shortages have been an increasing nuisance vexing the healthcare delivery system in the United States. I have discussed this matter with executives of the major U.S.-based pharmaceutical companies, and this is what they have to report regarding the underlying mechanisms of drug shortages in America:

1. Lawsuits.
An increase in lawsuits that seek the deepest pocket (i.e., the drug company) in med mal cases (e.g., the infected propofol vials in multiple GI patients by the repeated use of the same syringe on multiple patients) can only worsen the incentive for companies to keep producing drugs for the anesthetic market.

2. Patents.
After a drug falls off patent, there is a cascading decrease in pricing by various manufacturers in the market, often including the original brand name manufacturer, until the pricing point approaches or even dips below the manufacturing and distribution costs. Once this occurs, manufacturers begin dropping out of the market, and shortages begin to appear.

Should the length of patents be extended to drug manufacturers to help recoup research and development expenses? Should the federal government subsidize important or key anesthetic drugs? These are crucial questions that remain to be fully addressed.

3. Declining reimbursement.
As ACOs, health systems and insurance companies continue to restrict the formulary and health information technology platforms for brand-name drugs to be prescribed for and used by patients, drug companies receive less and less reimbursement. Eventually, the incentive and ability to supply necessary new drug products to the market decreases. A vital and demanding medical industry, as that which exists in the United States, cannot continue to offer new cures and treatments if only existing generic medicines are allowed to be used by patients. Many people who glibly support a universal, national health system in the United States may not be aware that the United States drives the majority of the bio-pharmaceutical innovations and discoveries for the world over. If we strangle the free market for new drug R&D here at home, soon there will be little of any medicines that will be widely available for use — brand name or generic.

Q: Any other challenges you can think of?

AD: I would add that discussions of restricting or formulating "essential benefits" serve to potentially further strangulate the U.S. healthcare delivery system. When arbitrary decisions limit services and products available in healthcare and medical insurance plans, there are unpredictable consequences in terms of personnel and product, such as drugs, equipment and supplies and supply-side availability down the line.

Q: What do you see as the top concerns of anesthesiologists as they approach the next few years? What are the problems keeping them up at night?

AD: With the continued decrease in credibility and membership of the AMA (now at perhaps 15 percent of practicing doctors in America), anesthesiologists feel especially vulnerable on the medical-political stage. Many local medical societies serve as AMA-feeder organizations and receive AMA trickledown funds. These entities are usually not proper advocates for the profession of anesthesiology. Likewise, most state medical societies are aligned with the AMA or, alternatively, take very neutral positions on grand issues such as the PPACA. Consequently, anesthesiologists are at a loss for true, independent representation at the national and state capital level.

Again, as previously noted, the American Society of Anesthesiologists is a superb organization but did not break with the AMA position forcefully before passage of the Act and, in doing so, may be complicit in the damage that this legislation could ultimately inflict on anesthesiology as an independent, thriving practice of medicine.  Regrettably, the money that the AMA receives annually ($72 million in the year 2010 alone) from its medical billing code copyright monopoly, combined with tens of millions in net revenue from the sale of health and disability insurance, make it a primarily self-serving entity, not requiring the consent or blessing of the majority of doctors in the nation. The AMA's wealth, so divorced from any connection to membership, combined with a powerful lobbying presence in Washington, D.C., make it an unpredictable and dangerous force for practicing physicians.  

Other organizations, such as America's Medical Society, are trying to become a more honest body to represent doctors on legislative and judicial matters affecting the medical profession, but the AMA's power base is firmly entrenched. If the medical billing code royalty monopoly of the AMA was rescinded, and given to freeware on the Internet for all physicians and patients to use without cost, this would go a long way toward leveling the playing field in medical politics.

Q: Do you see anesthesiologists becoming hospital employees, as has happened (and is happening) with other specialties?

AD: Unfortunately, yes. In some states, such as California — [for which] credit goes to the California Medical Association — there is a "bar" on the corporate practice of medicine. In many states, however, it is legal for corporations run by non-physicians to employ physicians. Sadly, this trend will likely only increase, to the detriment of both the medical profession and patient care.

Related Articles on Anesthesia:
5010 Special Information Requirement Will Not Apply to "Not Otherwise Specified" Anesthesia Codes
Pre Surgery Exam Rates Vary Widely Among Hospitals
Sheridan Healthcare Affiliates With Princeton Anesthesia Services

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