It’s a Jungle here also…

  • Chamberlin, Keith, MD, MBA, FASA
| Feb 25, 2013

In last week’s CSA Online First, Dr. Atoian extolled the virtues of what was a compulsory role for an anesthesiologist – the perioperative physician leader in a seriously medical-adverse setting: Moyobamba, Peru. Virtually all the planning, pre-op preparation and post-op pain control fell into the hands of the anesthesiologist, resulting in better patient care, a team-based approach to the surgical patient and a feeling of great satisfaction for the anesthesiologist.

There, in Dr. Atoian’s jungle, the role of perioperative physician was, by circumstance, forced upon him. Here, in our California jungle, that role needs to be voluntarily (and enthusiastically!) claimed by anesthesiologists as the only truly qualified physician to manage patients from start to finish – the real team leader of the surgical home.

As the President of the Board of Directors of a local CMS-approved ACO, I understand the difficulty in providing enough anesthesiologists to act as perioperative physicians. Now is when anesthesiologists need to step up and get up and off our OR stools, and get out of the OR and work towards restoring anesthesiology to that of a truly respected medical specialty. We are already thought leaders, researchers, and the most important patient safety advocates. Now we need to embody the leaders of the new medical paradigm: reduced costs and better health, for individuals and the larger population.

We, as anesthesiologists, are uniquely positioned to accomplish all of this.

Contrary to common practice, it does not have to be a generalist, a hospitalist or a surgeon guiding the perioperative process – as an anesthesiologist, you know what is needed to safely bring a patient into the OR, and manage that patient through and beyond a complex surgery, including medications, monitors, airway control, etc. You are uniquely positioned to determine the best approach to pain management in all aspects: immediately post-op, on the ward and when patients are at home. Your value as a perioperative physician is enormous; it is your job to not only explain this to your facility, but to find a way to create and occupy this role in your local organization.

At every meeting I attend for our ACO, I talk about the surgical home and the anesthesiologist as the ideal physician to lead the team. At first, I was met with blank stares, but now other physicians and administrators are starting to understand what we can do, and how we can save money. I put to rest the concept that we would be reducing payments to PCPs for initial H&Ps, and stressed that we would be determining which lab tests, imaging results and consults (if any!) are needed for preoperative patients. Our group is convinced we can save thousands of dollars per admission, and improve the care for each patient we are involved with.

The surgical home, unlike the medical home, is established quickly and ends quickly, with measurable savings over days, not months or years. We can be in control of a lot of savings by eliminating unnecessary tests and consults. I see this often with all the specialties wanting to do their part, but how often have I called the ICU nurse to ask “Who is this patient’s doctor?” and get the list of specialists, rather than one identified as the patient’s doctor.

Now is the time for us to take up the helm, when medicine is begging for a perioperative physician. If we do not fill the role, another specialty will. 

The change can’t happen over night, but it can begin today. Our own facility and group is not big enough to have an anesthesiologist around every corner, however, we are big enough to do all the cardioversions, endoscopies, EP lab cases and OB. We can appear to be everywhere, and take on the most important physician role of all, that of the perioperative physician. Then we will hold roles that make us indispensible to hospitals and organizations, and very hard to replace.

So how do we get paid for this? As we know, fee for service may have a very short limited future. Dollars for volume will be replaced by dollars for value, and that is where anesthesiologists come in. The ACO will, with proper input from us, will recognize the value of this perioperative physician coordinator.

Some of our colleagues will be only too happy to see this role filled. Surgeons typically prefer to focus on the actual surgery and leave peripheral elements to someone else. Cardiologists and hospitalists will be too busy with medical admissions (remember, 30 million more people coming into the system) to want to deal with routine post-op care. Anesthesiologists can enhance the team model and best practices in efficiency in both cost and procedural excellence, thereby showing value.

This is the anesthesiologist/perioperative physician perfect storm – so take up the opportunity to be the leader of the new team concept. Everyone involved will be begging for a doctor in this role, someone to problem solve, decrease costs, improve care and efficiency. We just need to stand strong, stand up, and push hard. 

The fees for anesthesiologists will be there, eventually. Initially, this is going to take some under-reimbursed work to show the huge advantage we can offer. The ASA leadership will be providing more guidance as we get further down the line, but in the meantime it is up to individuals, to take on this role and demonstrate indispensability to everyone involved in patient care – MDs, RNs, ancillary staff, the hospital/facility, administration and most importantly, the patient. Patients and families will be thrilled to have one doctor to call, who is focused on their complete care.

It's a matter of being at the table or on the menu. As Dr. Atoian articulated, anesthesiologists will either be “essential physicians in the equation” or just a commodity that can be replaced with a less expensive, less educated alternative.

Our time is now. Time to fill the open role, solve problems, decrease costs, improve care and efficiency, for the future of our specialty and the safety and health of our patients. “Doctor” should mean something special for anesthesiologists – it is up to us to make it that way, and the door is wide open. Stand up and walk through, and claim what is yours.

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