February 6, 2017
Anesthesiologists are exploring new opportunities to demonstrate value to their hospitals, both inside and outside of the operating room. Leadership of the intensive care unit provides an option that some practices might want to consider. Critical care medicine is, in many ways, a logical extension of anesthesia practice and can also provide valuable experience for groups interested in making a transition to the perioperative surgical home.
As healthcare’s transition to value-based care via MACRA and the Quality Payment Program continues unabated, so do efforts by anesthesia practices to solidify their relationships with their hospitals and find new ways to demonstrate value.
In recent decades, anesthesiology has steadily expanded from the operating room to postanesthesia care units, intensive care units and pain medicine, including the development of clinics to meet the needs of the vast population of Americans living with chronic pain disorders. The specialty has grown to encompass perioperative medical practice in acute pain medicine, and sleep and palliative care medicine as well.
And yet anesthesiologists still face tough competitive challenges. Anesthesia groups should seek new ways to partner with their hospitals to develop programs and services, consultant Jerry Ippolito, MBA, MHSA, advised in a recent issue of our quarterly newsletter, Communiqué.
Although anesthesia groups have been mining opportunities to broaden their role outside the surgical and obstetrics suites for many years, the need to do so has arguably intensified in the current era of heightened regulation and competitive pressure on hospitals to perform. As financial and regulatory demands increase, hospitals expect more from their services, and anesthesia departments are no exception. As a result, according to Ippolito, “Anesthesiology groups must strategically refocus and realign their relationships with partner hospitals. Anesthesiology groups must go into the hospital board room bringing value and presenting opportunities to assist hospitals.”
The Intensivist
One of these opportunities might be found in the intensive care unit (ICU). Considering the ongoing shortage of critical care physicians and the rapid aging of the population, serving as an intensivist—a physician with special training and experience in treating critically ill patients who completes a fellowship in critical care medicine after finishing a residency in internal medicine, pulmonary medicine, anesthesia or surgery—could give your group a way to help your institution fill an important unmet need. Intensivists have been shown to help improve patient outcomes, including survival rates, reduce complications and shorten ICU lengths of stay.
“Administration often looks to the anesthesiologists, since ICU physicians are a rare commodity and administrators know anesthesiologists have the requisite clinical training,” notes Dan Reale, president of Plexus Management Group, which has anesthesia practice clients that have led ICUs. Citing Leapfrog research, a 2006 article in Managed Care reported that “hospitals in which intensivists manage or co-manage all ICU patients have 40 percent less ICU mortality—and 30 percent less hospital mortality overall—than hospitals in which intensivists manage some or none of the patients.”
One ABC client, the anesthesia group at a large suburban medical center, has four intensive care-trained anesthesiologists who cover the ICU five days a week. The service originated in the hospital’s desire to provide a continuum of care for patients undergoing major surgery. The assumption was that anesthesiologists who were familiar with the care provided in the OR would be better qualified to manage and reduce complications in the ICU. The anesthesia team attributes the hospital’s consistently low complication rates and high levels of patient satisfaction to this continuum.
A 2016 Leapfrog factsheet on ICU staffing reports that mortality rates in patients admitted to the ICU average 10-20 percent and that more than 200,000 patients die in ICUs in the United States annually. “A growing body of scientific evidence suggests that quality of care in hospital ICUs is strongly influenced by (i) whether intensivists are providing care; and (ii) how the staff is organized in the ICU. Intensivists are familiar with the complications that can occur in the ICU and, thus, are better equipped to minimize errors,” the factsheet states.
According to the Society of Critical Care Medicine (SCCM) cost savings of up to $1 billion per year of quality life gained can be attained with critical care management of severe sepsis, acute respiratory failure and general critical care interventions. “Twenty-four–hour intensivist staffing reduces ICU costs and lengths of stay. Up to $13 million in annual hospital cost savings can be realized when care is delivered by an intensivist-directed multiprofessional team,” SCCM states. The organization gives an example of a community hospital that achieved 105 percent return on investment by implementing mandatory intensivist consultation and admission standards, thereby reducing ICU lengths of stay, ventilator-associated events and central venous access device infection rates.
A Natural Connection
Intensivists are good medicine and anesthesiologists have the training to be good intensivists. Critical care medicine is a logical extension of anesthesia practice, and, in fact, anesthesiologists helped create the discipline. Anesthesiologists direct the critical care units at a number of institutions, including the University of California-Los Angeles Medical Center and Johns Hopkins Medicine.
“We already teach and practice many of the necessary skills: the practice of anesthesiology necessitates intimate familiarity with acute pathophysiology, pharmacology, and airway management. Most importantly, anesthesiologists have improved safety and outcomes in both the operating room and the ICU,” said C. William Hanson, MD, FCCM, in Anesthesiology.
Still, despite these contributions, anesthesiologists in the United States play a smaller role in critical care medicine than anesthesiologists in the rest of the world, he said.
According to Dr. Hanson:
One of the consequences of the way in which we currently practice is that the patient does not typically understand what we do, and we are essentially anonymous when viewed from their perspective. Unfortunately, we are often equally anonymous to many of our nonsurgical colleagues. As a result, we are vulnerable to the technician label. This impression may be perpetuated by the success with which we have systematically evaluated and eliminated the sources of unnecessary morbidity and mortality during anesthesia. Anesthesiology was cited in a recent Institute of Medicine Report for reducing anesthetic mortality from 1:10,000 to 1:250,000.
These unique challenges for the specialty, combined with the projected shortage of intensivists, point to the ICU’s potential as a practice growth opportunity.
Critical Care Shortage
Though the article was written several years ago, the scenario is similar today. Currently, anesthesiologists make up only a small minority of critical care specialists.
The results of a study by the Health Resources and Services Administration reported in a 2006 article in American Medical News projected that the United States would need as many as 4,300 intensivists by 2020—a 1,500-doctor shortfall. “Although demand for intensivists has increased after studies showed that care from the specialists can improve patient outcomes and shorten hospital stays, not enough young physicians are willing to take on the long, demanding hours of a critical care doctor,” according to Michael Alberts, MD, then president of the American College of Chest Physicians.
Is your practice willing to help fill that gap if it exists in your hospital? Dr. Hanson highlights the rationale in favor of doing so. “Diversification is a time-honored business strategy for risk management in times of rapid change . . . Diversification into the ICU is one defensive strategy. Anesthesiology can credibly claim both precedence and a proven track record in defending a systematic (re)expansion of the practice of anesthesia-based CCM. The anticipated increase in demand for intensivists is one that the discipline of anesthesiology is capable of filling.”
The Future Model
The emerging model rapidly gaining traction and widely regarded within the profession as the future of anesthesiology is the perioperative surgical home (PSH). Still a work in progress, the PSH shows promise as the path through which anesthesiologists could become leaders in the multidisciplinary delivery of seamless, cost-efficient care.
Responsibility for critical care medicine could offer a segue into the PSH. “In an era of customer service, hospitals love the concept of accountability for quality of care. Clearly a comprehensive service that includes co-management of the ICU with surgery has great potential to accomplish this,” said Jody Locke, vice president of anesthesia and pain practice management for ABC, in Communique.
According to an editorial in the British Journal of Anaesthesia, “regardless of what the model is called around the globe, we have to embrace our expanded role as perioperative physicians as our main value proposition.” Indeed, of 136 academic anesthesiology departments that are members of the Society of Academic Anesthesiology Associations (SAAA), 24 percent now include such terms as perioperative, pain or critical care in their names to reflect their departments’ growing focus on perioperative medicine.
Participation in critical care medicine could help anesthesiologists demonstrate their value as perioperative practitioners and help the PSH gain wider acceptance, said David R. Wetzel, MD, and Daniel R. Brown, MD, PhD, of Mayo Clinic in ASA Monitor.
The PSH is an opportunity for our specialty to secure its place in the future of medicine. In order for physician anesthesiologists to lead this effort, we will need to show that we provide the best value (outcomes as related to costs) compared to others.
A starting point for assessing the value that an anesthesiologist adds to patient care could be critical care outcome measures. Intensive care medicine is expensive, and demonstrating favorable value of anesthesiologist-led practices would provide a powerful platform for our specialty.
Leadership of the ICU offers a potentially useful opportunity to show value to your organizations as they heighten their focus on quality and efficiency. We hope the ideas presented here will help guide you in thoughtful consideration of the possibilities.
ABC clients: Are you interested exploring involvement in the ICU? Feel free to request an analysis from your account manager.
Note: Intensive care documentation is significantly different from intraoperative anesthesia. Please contact your account manager if you’re considering exploring this option as a practice opportunity.
We want to hear from you. Do you have a topic you would like to suggest for an ABC eAlert? Please send your suggestions to info@anesthesiallc.com.
With best wishes,
Tony Mira
President and CEO
1Kain ZN, Fitch JC, Kirsch JR, Mets B, Pearl RG . Future of anesthesiology is perioperative medicine: a call for action. Anesthesiology. 2015;122(6):1192–1195.
