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Summer 2016


The Perioperative Surgical Future

Rick Bushnell, MD, MBA
Director, Department of Anesthesia, Shriners Hospital for Children, Los Angeles, CA and
Huntington Memorial Hospital, Pasadena, CA

“I look upon ourselves as partners in all of this, and that each of us contributes and does what he can do best. We can create ourselves and our future.” – Jonas Salk, 1985

Presented with this opportunity by Dr. Salk, how will each of our anesthesia groups create its own future? How will you as a physician maintain your professional relevance? Will you continue to commit yourself to fading traditional practice patterns and reimbursement models? Or will you take advantage of the paradigm shifts in medicine that are already upon us? Payers are demanding better results, hospital administrators are in need of help, patients are in the middle without access and the specialty of anesthesia needs a tune-up. The perioperative surgical home promises to address it all.

Led by the Centers for Medicare and Medicaid Services (CMS), payers are mandating coordinated care and improved quality through pay-for-performance reimbursement models. CMS will soon pay up to a four percent bonus for high self-reported performance scores and impose similar-sized penalties on relatively less successful providers. In 2018 the difference between maximum positive and negative scores will be eight percent and by 2022 the difference will be 18 percent…every single year. Private payers will follow suit, but this 18 percent CMS incentive alone is strong enough incentive that anesthesiologists should fully embrace quality metrics and coordinated care. Those metrics and coordinated care are best embodied by anesthesiologist presence and leadership in the perioperative surgical home preoperative clinic.

Surgeons and hospital administrators need anesthesiologists more than ever. Both are facing their own demands for increased quality metrics and reducing length of stay. Both are subject to their own system of CMS penalties, caps and bundled payments.

Both are severely in need of quality anesthesia leadership and partnership. If they haven’t yet realized the value of your perioperative skill set, then it’s time for you to offer your assistance. You may not personally know it, but your management and vision are in demand outside the operating room. Your new management target is the 20 percent of sickest patients presenting for surgery. In an era where the emphasis is to reduce length-of-stay and readmissions, your anesthesia preoperative surgical involvement is your opportunity for medical, logistical and administrative leadership.

Patients don’t have reasonable access to anesthesiologists. Anesthesiologists do not have reasonable access to patients. We are both subject to a marginal default anesthesia care model that confines access to three minutes before surgery and five minutes afterward. This is the standard of care, but whom does it serve? Whose ‘standard’ is this? How does this model constitute access? Our patients are frequently old, medically complex, pediatric, pregnant or otherwise facing critical moments in life. How is it that we, as a specialty, pretend to serve these people well by spending only the most minimal amount of time with them immediately preoperatively? Are we as anesthesiologists really that good than in the three minutes before surgery we can assess these complex patients, give them optimal care, a quality experience and our best effort? Is this really our best effort? Both patients and anesthesiologists would be much better served by establishing perioperative surgical clinics. Anesthesiologists must make themselves available.

As a specialty, anesthesia has lost a lot of access in the last 25 years. Our patients used to be admitted the night before and then stayed days after surgery. We had a chance to round on them before surgery, write orders, optimize or cancel. We rounded on them after surgery and had an opportunity to learn by observing the results of our work. Now our OR practice too often amounts to mindless assembly-line work; meeting patients three minutes ahead of time, five minutes in recovery, turn over the room in 20 minutes. “Wash, rinse and repeat.” This process makes for a timely, efficient anesthesia practice but what of quality, patient experience and the perception of our specialty? What of anesthesia medical management and leadership? We have abdicated our responsibilities by delegating the preoperative and post-discharge work to others. The perioperative surgical home offers anesthesia a platform. This is the means by which we reclaim ownership of the entire process and credibility with patients, surgeons and administrators.

The best minds in the American Society of Anesthesiologists (ASA) are pointing the way to the perioperative surgical home (PSH); anesthesiologist-staffed clinics are seeing complicated patients days to weeks ahead of surgery. For the ASA, this is the moral and medical core of the future of our specialty. Medically, who better than anesthesiologists to understand the physical challenges posed to patient physiology by surgeries? Logistically, who better to coordinate the preoperative work-up, the acute intraoperative care and the post-discharge medical management? At Pacific Valley Medical Group (PVMG) in Pasadena, California, we understand that cause.

In the last year, PVMG has worked in partnership to lay the foundations for our own joint perioperative surgical anesthesia clinic. Last June we attended the ASA PSH conference. In September we presented to the Huntington Memorial Hospital C-suite. In October we shook hands on a deal with Huntington appointing one of our partners as a physician champion. We’ve held two briefing conferences for our surgeon partners and weekly meetings for the coordination of administrative staff. Huntington has additionally hired a Six-Sigma Master Black Belt PSH coordinator and elevated one of our MD, MBA physicians to Vice President of IT and Quality. I have also personally met with Dan Cole, MD, President of the ASA and Karen Siebert, MD of the California Society of Anesthesiologists seeking their guidance.

Three of our anesthesia group members are seeing patients in a well ordered clinic. Cerner software is being rewritten to accommodate and document perioperative appointments in anticipation of billing CMS. Having presented to you in previous Communiqué issues the math for reimbursement, getting paid is going to be tough, though. There are CMS billing codes, but the rates are low and private payers are holding back waiting for performance data. The PSH fee-for-service income potential for a full-time equivalent (FTE) anesthesiologist cannot yet compete with the income potential of operating rooms. Other potential income streams to support an FTE anesthesiologist in clinic include stipends from the hospital or the anesthesia group its self. At the moment, the PSH is a financial loss-leader.

Profit or loss, though, establishing an anesthesia perioperative surgical home clinic is exactly the right investment for the future. Having an FTE anesthesiologist available in a preoperative clinic to meet with patients days to weeks before surgery offers huge benefits. Anesthesia clearance decreases day-of-surgery cancellations and our presence dramatically improves the patient experience. Many sub-populations of patients (old, sick, parents giving up their children, pregnant) absolutely love the access they have to anesthesiologists. Our Huntington hospital administrators are thrilled to have our anesthesia group take more responsibility for surgical outcome, and the greater cooperation of care has improved our standing with our surgeons. There is every possible good thing about an FTE anesthesiologist and our leadership in pre-op clinic. Additionally, we will open up those clinics for post-discharge and pain management appointments.

As an anesthesiologist, the OR is a wonderful place to make a medical contribution. No one can spot trouble like we can and no one can intervene acutely like an MD anesthesiologist. There is no runner-up. Too often, though, we self-limit that skill set to the narrow paradigm of the OR. You can actually practice that same medical skill set well ahead of time in the preoperative clinic to optimize, precondition, triage and manage your patients to the greater benefit of all. As an anesthesiologist, think of how valuable your clearance of medically complicated patients would be to your anesthesia colleagues, to your patients and to your surgeons. For the 20 percent of those most in need of your attention, it is better than gold. For some, it is life itself.

Consider your anesthesia presence in the PSH clinic your best investment in your future. The distribution of bundled payments through ACOs is looming. Soon every specialty group will present their case to the ACO board to request a percentage of finite capped payments. Increasing your responsibility for the perioperative surgical continuum by your presence in a PSH is guaranteed to provide you with justification for a larger percentage of capped payments. Anesthesiologists must own more if they are to justify a larger request.

Like all great quests, the key to your future isn’t ‘out there.’ Your future lies within. The key to your future lies in how you as an anesthesiologist perceive your own value, your medical skills and the medical contributions only you can make. The key to your future is in stepping up to assume more responsibility. You must lead this effort yourself and make your own case by placing yourself in clinic. You must recognize the new paradigm that only you can lead.

This is the time and place for medical leadership. The perioperative surgical home is your future


Rick Bushnell, MD, MBA is the Director of the Department of Anesthesia, Shriners Hospital for Children, Los Angeles, CA and a Clinical Anesthesiologist at Huntington Memorial Hospital in Pasadena, CA. Dr. Bushnell graduated from the University of Illinois College Of Medicine and attended the University of Pittsburgh Medical Center, Pittsburgh and Loma Linda University for internship and residency. He has been with Pacific Valley Medical Group since 2003 and consults with Shriners Hospital for Children, Los Angeles. He and his partner have six adopted children in Tanzania where he serves as Visiting Clinical Anesthesiologist at St. Elizabeth’s Hospital for the Poor in Arusha. He can be reached at propofolstingsme@gmail.com.