Growth and Expansion of Anesthesia Practice
Anesthesiology has evolved from a specialty dedicated to the care of patients undergoing surgical procedures in an operating room environment to one devoted to the care of patients receiving a wide variety of clinical services, including anesthesia care in both inpatient and outpatient settings. This expansion in the scope of practice of anesthesiology is largely a result of major advances with anesthetics and other new drugs along with the improved ability of anesthesiologists to assess and better prepare patients for surgery. This aspect includes the capability of more effectively addressing changes in patient physiology during and immediately after surgical procedures and providing improved critical care and pain management. These advances in clinical care and outcomes enable anesthesiologists to care for patients with more complex comorbid conditions who in the past might not have been able to undergo any surgical or other procedure. As a consequence, some anesthesiologists are offering an expanded scope of practice that extends beyond the immediate surgical procedure and that builds on the successes in the operating room environment. These anesthesiologists are working collaboratively with other surgeons and providers to apply some of the lessons learned in the operating room into other aspects of care both within and beyond the hospital environment.
This expansion in scope of anesthesia practice comes at an important time, particularly for the United States. Procedural options have increased the number of patients with underlying comorbid conditions who are able to receive care; simultaneously, the population is aging, creating greater demand for services. The percentage of the U.S. population older than 65 years of age continues to grow, with a projected 21% increase in this population by 2050. To meet the resultant growth in demand for additional health care, the health care workforce will have to increase by 20% to 50%. These demographic changes are occurring in parallel with escalating costs of care and building the pressure on an already strained health care system. Addressing these challenges will necessitate major changes in how health care is delivered—to whom and by whom—and how it is to be financed.
Simultaneously, and in response to the changing patient population and clinical needs, the overall specialty of anesthesiology has expanded its numbers of subspecializations and created other educational and diverse fellowship programs to support the changes in clinical practice. For example, cardiac, pediatric, transplantation, trauma, and neurosurgical anesthesia (also see Chapter 25, Chapter 30, Chapter 34, Chapter 36, Chapter 42 ) focuses on specific patient populations and the surgical procedures they require; some of the subspecialties have formal fellowship programs that are accredited by the Accreditation Council for Graduate Medical Education (ACGME), whereas others are nonaccredited training programs. The American Board of Anesthesiology (ABA) has implemented certification examinations and provides special qualifications in many of the subspecialties. Besides the expansion of the responsibilities in anesthesia practice, these advances are also redefining and augmenting the scope of the specialty of anesthesiology. Surgeons have been able to apply innovative approaches to surgical management that would otherwise have been impossible. In addition, building on the experiences in the operating room, the practice of anesthesia has extended beyond the traditional setting. More invasive and minimally invasive procedures are being performed outside the operating room environments both within a hospital setting (non–operating room anesthesia, NORA) as well as in ambulatory facilities. Building on the scientific foundation of anesthesia practice in the operating room, anesthesiology has expanded to include acute and chronic pain management ( Chapter 40, Chapter 44 ), critical care medicine ( Chapter 41 ), palliative care ( Chapter 49 ), sleep medicine ( Chapter 50 ), and several other related clinical services. The broadening of the roles and responsibilities is generating tremendous opportunities for anesthesiologists to take advantage of the evolving changes in health care delivery and management and to develop new roles to meet the needs of patients, other providers, hospitals, and health systems.
Changing Health Care Landscape
In parallel with the changes in anesthesia practice per se is the increasing emphasis on patient safety, quality, and costs of care, which is fostering a major restructuring of the health care system in the United States as well as in many other countries. These countries are striving to emphasize health, wellness, and preventive measures to reduce burden and its associated costs and improve the overall quality of life for their populations. These goals are challenging to accomplish, particularly with the long history of compartmentalized health care in most countries, and the relatively small investment in public health and prevention over that for treatment. The availability of costly drugs and interventions sounds promising, although in many cases their effect on both quality of life and life span is limited. The recent advances in personalized or precision medicine are also promising but are stressing already overburdened health care systems.
As a consequence of the competing pressures to improve quality and health of the population while reducing costs, the health care system and those who support it are being challenged to redesign the system in major ways. These changes in the organizational approach to the practice of medicine in general and anesthesiology specifically are challenging, rewarding, and sometimes frustrating. They can even be distracting to the quality of anesthesia practice. First, the relationship between hospitals and physicians is changing dramatically and rapidly . Hospitals are affiliating or consolidating, creating health care systems that are able to better provide longitudinal care to populations of patients, including out-of-hospital care, high-intensity inpatient services, and coordinated posthospital care (e.g., rehabilitation, skilled nursing care, home health services, telehealth). To successfully expand the scope of care beyond the traditional inpatient focus, hospitals and health care systems are aligning more closely with physicians. In some cases, hospitals hire physicians directly or, when state laws prevent hospitals from doing so, create medical foundations that are “joined at the hip” with the health system. Independent and small group practices are consolidating into single or multispecialty group practices. In the United States, the consolidation into large group practices has been accelerating over the past 5 years, and this growth is impacting the practice of anesthesiology. The consolidation of anesthesia practices allows the group to negotiate from a stronger position than can an individual practitioner or small group practice. In addition, the consolidation of practices, many of which are multispecialty groups, allows anesthesiologists to collaborate with other colleagues more effectively and to negotiate as a group with health care systems and payers.
As the cost of care has continued to increase and the expenditures for health care in the United States in particular have escalated, both government and private payers have been challenged to reduce costs and unnecessary care. Most recently there have been attempts to reduce physician compensation and to increase the percentage of payment based on predefined metrics for quality, patient satisfaction, and cost. One of the most prominent motivators to the changing health care environment in the United States was the implementation of the controversial Affordable Care Act (ACA), which was enacted in 2010. It has a number of provisions that encourage different models of care and collaboration specifically to address quality and value over cost. Another major change that is in part a result of the ACA is the expansion of accountable care organizations (ACOs) to manage and have overall responsibility for providing care to a population of patients. To responsibly manage a diverse population of patients, a health system needs to implement different approaches that take into account the continuum of care including inpatient and outpatient care, managing the transitions of care, and putting increased emphasis on prevention and wellness over high-cost, technologically advanced procedural care. Therefore, for an ACO to be successful will require close cooperation, coordination, and communication among physicians, other providers, hospitals, extended care facilities, home health agencies, and other health care organizations to appropriately utilize and rationalize services that fulfill the needs and goals of the patients for whom they assume responsibility.
These major changes in how health care systems have evolved, how services are delivered, and how health care is funded, while challenging, also have significant implications for anesthesia providers. First, and perhaps most difficult for some anesthesia departments to address, is the expansion of clinical services to environments not familiar to most anesthesiologists. The increase in non–operating room locations has been difficult to manage, but also represents an opportunity for anesthesiologists to be more visible members of the health care team beyond the operating room. The expansion of subspecialties, including critical care and pain medicine, has allowed anesthesiologists to address clinical needs not necessarily related to a surgical procedure and to have some experience in dealing with the transitions and continuum of care, though primarily in the inpatient setting. The new models of care allow anesthesia departments to expand their clinical care beyond the operating room suite and procedural areas to other inpatient environments, and in some cases into community settings—with the caveat that in doing so, they do not lose focus on the delivery of high-quality, safe, and value-based perioperative care, which is the mainstay of any anesthesia practice.
Workforce Changes Affecting the Models of Anesthesia Care
Over the past decade, changes in the workforce have also influenced the role played by physicians in general and anesthesiologists in particular. As a result of the limitations on duty hours imposed by the ACGME and other changes in care delivery, there are many more transitions of care, most notably during hospitalizations. As clinical demands increase, many surgical services have recruited hospitalists or other providers to help coordinate perioperative care. In many cases anesthesiologists, including critical care anesthesiologists, pain medicine physicians, and others are working with surgeons and hospitalists to optimize overall clinical care beyond the operating room, facilitate the transition to posthospital care and manage outpatient clinical needs to reduce readmissions. These changes have created a variety of clinical and management models, many of which have improved clinical care and outcomes and reduced costs. Commensurate with the changing roles for physicians, there has been significant expansion in training of advance practice nurses and physician assistants, including an increase in the number of certified registered nurse anesthetist (CRNA) training programs. In most cases, the advance practice nurses work in close collaboration with physicians and are supervised as part of the clinical care team, particularly for anesthesia practices. There has been some pressure regionally and nationally to allow advance practice nurses to pursue their profession independently. However, for most anesthesia groups, the working relationship between physician anesthesiologists and CRNAs is very good, benefiting patients and ensuring a coordinated approach to clinical management. This collaborative model of care takes advantage of the training and expertise of the CRNAs and the physician anesthesiologists to manage the entire perioperative period, coordinating preoperative management, intraoperative care, and postdischarge clinical needs. The variation in delivery of anesthesia care and how it is organized varies widely internationally.
New Payment Models
In most countries, financial compensation for anesthesiologists varies widely, ranging from straight salaries to some type of “fee for service” arrangement. In response to the change in focus to value and quality, the payment methods are undergoing dramatic change in the United States. The traditional fee for service payment methods are being challenged; the transition to paying for “value” over volume of care delivered is accelerating for both government and private payers. Most notably, the recent enactment of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015 has changed the landscape of payment for physician and hospital services. While the details of the implementation are still under discussion, the changes, no matter how they are finally revised, will transition payment from a volume-based fee for service system to one that puts emphasis on value. The details of the MACRA implementation are under review. The primary components of the implementation will require physicians to operate under an incentive-based program (merit-based incentive program, MIPS) or an alternative payment model (APM).
The changes in payment methodology from a predominant fee for service model to alternative- and value-based payment models require new approaches to how health care is delivered and how “value” will be defined and influence payment. In addition, physicians and health systems will be expected to share risk and, theoretically, rewards resulting from improved care delivery. Current methods to document quality and value are not sophisticated enough, nor outcome-based, to fulfill these goals. Since Medicare has committed to transitioning about 50% of payment from fee for service to alternative payment models and to linking 90% of payment to value within the next 18 months, each practice will be required to identify specific measures of quality that support payment.
One of the most important changes in payment that will have major impact on the role of each provider is the transition to bundled payments for episodes of care (e.g., 90-day episode of care for a patient undergoing a surgical procedure). The goal of bundled approaches to payment is to create financial incentives to encourage coordination of care across the continuum of care and putting the health system rather than Medicare at risk for unnecessary services. Under this model, payment for physician services will be determined based on the “value” each provider or group has contributed to the care of the patient. As a result, anesthesiologists will have to justify why the care they delivered warrants a larger (or smaller) piece of a fixed-bundled payment. To the extent that the anesthesia group is participating broadly in the care of patients throughout the continuum of care (e.g., pre- and postoperative care including critical care and acute pain) and can document quality and cost reduction metrics as a result of the involvement, the group may be able to negotiate from a position of strength for their portion of the payment.
The changes to the health care system, expanding clinical care needs, and the emphasis on value are and will continue to have significant impact on the practice of anesthesiology. They create opportunities to expand the focus of anesthesia care beyond the immediate perioperative period, but also for anesthesiologists to assume a broader role in managing patients throughout the continuum of care, in both inpatient and outpatient settings. Over the past few years, several new models of care have been defined for anesthesiologists, including an expanding role in patient management throughout the perioperative period, administrative roles in perioperative care, and more recently the perioperative surgical home and population health.
Transitions From Anesthesiology to Perioperative Medicine
The practice of anesthesiology has evolved as a result of the improved clinical capabilities and in response to both the new opportunities and the challenges facing health systems to improve care and control costs. As previously described, the most notable changes in practice have been the expansion of the subspecialties that provide care in the operating room, other procedural areas, and the intensive care unit (ICU), and for both acute and chronic pain. The expansion of anesthesiology to include “perioperative medicine” has been very successful, creating a variety of clinical practice opportunities and management roles for anesthesiologists. In extending the scope of practice to perioperative medicine, particularly with the simultaneous changes in health care delivery, new models of care were required to most effectively meet clinical and administrative needs. For example, the implementation of preoperative clinics (see Chapter 13 ) was required because fewer patients were admitted prior to the day of surgery. The evolution of preoperative evaluation programs has been successful in many ways. At the same time, fragmentation of care has increased, because the provider completing the preoperative evaluation is generally not the same anesthesia provider who will be delivering care to the patient for a procedure. In some cases, the preoperative evaluation is performed by another physician or an advanced practice nurse rather than an anesthesiologist. The evaluation provides documentation of the patient’s history and may include a thorough evaluation of the airway and associated concerns specific to the intraoperative anesthesia care, but may include preoperative optimization of underlying clinical conditions, such as optimizing pulmonary function in a patient with asthma or chronic obstructive pulmonary disease (COPD), controlling blood sugar for a patient with diabetes mellitus, or controlling arterial blood pressure for a patient with hypertension that has been difficult to control. As a result, this approach could necessitate a cancellation on the day of scheduled surgery when the assigned anesthesiologist sees the patient for the first time immediately before surgery and identifies concerns that were not adequately addressed. More important is that this approach does not allow the anesthesia provider to develop a relationship with the patient prior to their meeting either in a preoperative holding area or the operating room.
Similar challenges exist with respect to postoperative care. For most patients, the postoperative care provided by the anesthesiologist includes assessment in the postanesthesia care unit (PACU) (see Chapter 39 ) and, if the patient remains hospitalized thereafter, a visit to ensure that the patient has not suffered any immediate complications associated with anesthesia care. For ambulatory patients, a phone call is often made to the patient or family member to ensure that the transition to home has been without incident. For inpatients, many of whom have either had complex surgical procedures or have underlying medical problems, the care is more often provided by the surgeon with or without the assistance of other physicians and advance practice nurses. In some cases, medical or surgical hospitalists, who have no role in intraoperative management, assume responsibility for postoperative care. In other settings, hospitalists working with surgical services manage underlying or associated medical conditions, while surgical issues are addressed by the surgeon. In other settings, surgical hospitalists have been recruited to help manage the patient during the early postoperative period. While these models may have some advantages, they do not facilitate coordination of care, nor provide seamless transitions through the various stages of perioperative care. In addition, most of these models do not acknowledge the role anesthesiologists can play in extending some of the intraoperative management strategies to the postoperative period. As a result of the intimate knowledge and understanding of a patient’s response to anesthetic drugs, changes in intravascular volume, and other intraoperative events, the anesthesiologist often has a great deal of knowledge about the patient’s physiology, which can optimize postoperative management. In addition, participation in postoperative care allows a better understanding of the longer-term implications of intraoperative management, such as the effect of intraoperative care on wound healing, the incidence of central line–associated bloodstream infections, the risk of pressure ulcers, pulmonary function, and the integrity of the airway. By redefining anesthesia practice to include perioperative medicine, many anesthesia groups have successfully addressed these issues by creating a cohesive cohort of providers to manage patients through the continuum of their perioperative course. While there are limited data to differentiate outcomes of this model versus the conventional silo approach to care, the importance of anesthesiologists broadening their focus to include perioperative care for the surgical patient has become increasingly important.
Although extending the scope of anesthesia care to include the continuum of the perioperative course for each surgical patient is important, a number of other models of anesthesia care have been implemented or proposed. These models extend the scope of anesthesia practice to incorporate standard, evidence-based practices into perioperative care, development of quality metrics to support clinical management, and new roles for anesthesia providers in both health system management and population health, particularly as it relates to the development of ACOs.
Enhanced Recovery After Surgery
Enhanced recovery after surgery (ERAS) is one approach that is being utilized to improve clinical care for patients undergoing specific surgical procedures. ERAS utilizes evidence-based practices when they exist to improve outcomes, reduce length of hospital stay, and optimize postoperative care often at reduced overall cost. The success of the ERAS programs is based on the principle that a multidisciplinary approach to care that includes anesthesiologists, surgeons, and other appropriate providers will improve both quality and outcome. The specific participants in each ERAS initiative depend on the surgical procedure, anticipated clinical needs, and resources. For example, for patients undergoing laparoscopic surgery, the anesthesia provider coordinates care with physical therapists, dietitians, and others to ensure early ambulation, nutritional support, and return of bowel function. Other approaches to care that have been demonstrated to improve outcome after selected surgical procedures include goal-directed fluid management and multimodal narcotic-sparing approaches to pain management and appropriate selection of antibiotics for perioperative prophylaxis.
Perioperative Surgical Home
The perioperative surgical home (PSH) is another model of perioperative management that extends some of the concepts of coordinated perioperative care previously described. In many respects, the changing patient population and increasing complexity of perioperative care are creating a demand for better coordination of care and fostering the development of the PSH concept. The development of the PSH is based on the same principles as is the implementation of the patient-centered medical home (PCMH), which is designed to optimize care to patients with complex medical conditions. To some extent the PSH is also an extension of some of the basic principles on which ERAS is based. However, although ERAS models have been implemented to optimize the continuum of care related to specific surgical procedures, the concepts behind the PSH extend beyond any single procedure or time period in the perioperative course.
The PSH incorporates clinical management of the patient through the perioperative period to optimize outcomes specifically related to the surgery and addresses other clinical issues to facilitate safe transition from the inpatient hospital setting to home, rehabilitation, or skilled nursing facilities. Under this model of care, the anesthesiologist assumes a broader role in clinical management while working collaboratively with the surgeon and other providers to optimize care related to the surgical procedure and underlying or associated clinical problems.
The goals for the PSH include the following:
Coordinating the care of a patient scheduled for a surgical procedure and facilitating communication among all providers to ensure that clinical issues are identified and addressed
Providing a thorough preoperative assessment and optimizing management of any underlying medical conditions (also see Chapter 13 )
Defining and implementing appropriate (and evidence-based, when available) approaches to management through the perioperative period
Managing clinical care across the continuum
Assessing and documenting outcomes and performance on predefined metrics
The PSH concept has been utilized in a variety of different clinical settings with considerable success in terms of efficiency, quality of care, and patient and provider satisfaction. As more experience is gained in the implementation of the PSH and its effect on the management of selected patients, dissemination of best practices should help refine the models to best serve the needs of patients, providers, and health care systems.
Both ERAS and the PSH have had significant impact on the practice opportunities and roles for anesthesiologists and on outcomes of clinical care. At the same time, for the most part, these models focus on acute episodes of care for selected patient populations or procedures. With the changes being imposed by the ACA and other initiatives designed to improve quality and reduce costs, many health systems are developing ACO models designed to manage populations of patients. This transition to population health is having major ramifications for patients, providers, and health systems. The foundation on which “population health” is based assumes that care for a population will be optimized if a health system takes clinical and financial responsibility for managing the wellness of a population as well as coordinating care in every setting. In this model, the health system, including the aligned providers, manages all aspects of care including preventive care, wellness, and management of both chronic and acute disease. The concept of population health is creating opportunities for all providers to clarify their value to the health system and its patients, while also to define new roles that not only optimize both acute and chronic care, but also demonstrate value—improved outcomes at reduced cost. To be successful, health systems need to ensure that clinical care is coordinated and collaborative, patient-centric, and that clinical management strategies are based on objective outcome measures of quality and cost.
Although the concept of population health is not evident to many anesthesia practices, population health management provides many opportunities for which anesthesia providers can and do have meaningful roles. The most obvious roles and responsibilities relate to the perioperative course of patients requiring surgical procedures, an extension of the role in perioperative medicine, and the concepts behind both ERAS and the PSH. Beyond these specific roles, however, there are other aspects of anesthesia practice that can be applied to the management of a population of patients. Anesthesiologists can assume a larger role in patient care preoperatively, including managing or coordinating the management of underlying chronic conditions. As an extension of the intraoperative management, anesthesiologists can be more actively involved in coordinating postoperative care, as has been done for some patients in the PSH model of care. Critical care anesthesiologists (also see Chapter 41 ), pain medicine anesthesiologists (also see Chapter 40, Chapter 44 ), and palliative care physicians (also see Chapter 49 ) have important roles in hospital-based care as well as in transitions of care to extended care facilities, skilled nursing homes, and the hospice setting. In some cases, anesthesiologists could serve a meaningful role in working with case managers to identify the appropriate care needs and to facilitate coordination and communication between providers and other facilities.
In addition to the clinically focused roles that anesthesiologists can serve under a population health management strategy, they are often involved in administration and health policy development. Being perioperative medical director with a focus on the efficient management of the operating room suite (also see Chapter 46 ) is an example. Extending the scope of responsibility for perioperative care to include transitions of care and coordination with providers outside the hospital or health care system will be essential in order to most appropriately coordinate resource use between acute care hospitals and other facilities. Population health management will also require new approaches to pain management for individual patients and to the development of procedures that more effectively utilize multimodal approaches to the care of patients with chronic pain to minimize the use and abuse of opioids (also see Chapter 9, Chapter 44 ). Critical care anesthesiologists can provide an important perspective in the overall management strategies for patients requiring long-term mechanical ventilatory support and facilitating and coordinating transitions of care to other settings that may be more appropriate for individual patients (also see Chapter 41 ). Similarly, they can help address how to most effectively manage patients with both acute care needs and extensive rehabilitation, defining the most appropriate management strategies and sites of care. Similarly the anesthesiologist with experience in palliative care can address individual patient goals of care and clinical needs as well as assist the health system in defining how to most appropriately care for this patient population (also see Chapter 49 ).
Identifying new roles for anesthesiologists in population health has obvious benefits to providers, as well as to patients and to the health system. Because the health system and the providers share the financial risk for the care of the patient population, expanding the scope of practice and documenting the value of these services will be critical to the financial integrity of a department and its members. Although these expanded roles are important for an anesthesia department as a whole, each member of the department will have a different role in the clinical management of the patients and, for some members, in the administrative functions needed to support the health system. At the same time, the financial underpinnings of population health require that all providers understand the concepts behind population health management and participate in strategies to optimize care and resource use across the continuum based on objective quality metrics and documented outcomes.