The Clock is Ticking: Lessons from the Rovenstine Lecture

  • Sibert, Karen, MD, FASA
| Oct 14, 2014

Karen Domino, MD, MPH, sees today’s healthcare crisis from both sides—the physician’s point of view, and the government’s.

Dr. Domino, who delivered the Emery A. Rovenstine lecture Monday at ANESTHESIOLOGYTM 2014 in New Orleans, spent a year in Washington DC in 2012 and 2013 as a health policy fellow of the Robert Wood Johnson Foundation, working with the powerful House Ways and Means Committee.  Then she went back to her position as Professor and Vice Chair in the Department of Anesthesiology and Pain Medicine at the University of Washington. 

“Now is not the time for business as usual,” Dr. Domino told the packed audience of anesthesiologists.  “Now is not the time to yearn for things to be as they were in the past.”

Her talk, “Health Care at the Crossroads:  The Imperative for Change,” outlined why anesthesiologists who are reluctant to change the status quo are at risk for losing their contracts and jobs to competitors.  “No group is too big to be replaced,” she said.

At the heart of the problem is the fact that today we have a volume-driven system, where physicians and hospitals are paid for providing services.  If complications occur, the fee-for-service system pays even more.

But what payers—the government, businesses, and consumers—want is a value-driven system, Dr. Domino said.  They are looking in particular toward three innovations:

  1. Skin in the game:  When consumers are involved directly in paying for healthcare, they look more critically at quality and value than when someone else is paying.
  2. Reference pricing:  A healthcare “blue book” comes up with what’s considered a fair price for an imaging test or a surgical procedure.  If consumers want to go to a more expensive facility, they—or the facility—may be responsible for the difference in cost.
  3. Value-based purchasing:  A corporation contracts with a healthcare system, as the Boeing Company has done with the Cleveland Clinic.  If an employee needs a spine procedure or a coronary bypass, Boeing pays for the patient to travel to Cleveland where the procedure is done for a set price.

Physicians need to become stewards of the United States’ finite healthcare resources, Dr. Domino said, since about 1/3 of American healthcare costs are believed to be due to waste.

“There’s a lot we can do to ensure future success,” she said.  Physicians near retirement shouldn’t “kick the can” down the road.  They should become champions of initiatives that their hospitals consider important.  Mid-career anesthesiologists can help create standardized systems of care to reduce variability, errors and costs.

But the bulk of the responsibility for change will be on the shoulders of younger anesthesiologists, Dr. Domino asserted.  She said that successful anesthesia service and manpower corporations advocate use of a blended care team model with fewer anesthesiologists in order to eliminate or reduce hospital subsidies.  They routinely provide quality and performance data to hospital administrations.

Younger anesthesiologists need to specialize with fellowship training, Dr. Domino said.  “They need the skills to deal with the specialty world, which is where we’ll be doing most of our cases.”

The training programs of the future need to teach young anesthesiologists how to lead teams, manage operating rooms, and manage change, Dr. Domino explained.  “Residents need new knowledge and skills,” she said, as they will need to understand informatics, implementation science, and health policy. 

Today’s anesthesiologists need to learn from the experience of those who have lost their jobs to competitors, Dr. Domino concluded.  “The clock is ticking.  The time to act is now.”

CSA officers Christine Doyle, MD and James Moore, MD will be debating “Electronic Health Records Improve Patient Safety - Or Do They?” today. Look for a report on the debate here tomorrow or Thursday.

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