Clinical Anesthesia

Chapter 2

Scope of Practice

John H. Eichhorn

Key Points

1. Anesthesia trainees, and many postgraduates also, tend to lack sufficient knowledge (with sometimes unfortunate results) about modes of practice or employment, financial matters of all types, and contracting in particular. They must educate themselves and also seek expert advice and counsel to survive (and hopefully flourish) in today's exceedingly complex medical practice milieu.

2. There are several very helpful detailed information resources concerning practice and OR management available from the American Society of Anesthesiologists and other sources. Factors influencing anesthesiology practice conditions are changing rapidly, and today's anesthesia professionals must be armed with detailed information about concepts (such as “pay for performance”) that did not exist just a few years ago.

3. Securing hospital privileges is far more than a bureaucratic annoyance and must be taken seriously by anesthesiologists.

4. Anesthesiology is the leading medical specialty in establishing and promulgating standards of practice that have significantly influenced practice in a positive manner.

5. The immediate response to a major adverse anesthesia event is critical to the eventual result. An extremely valuable protocol is available at www.apsf.org, “Resource Center: Clinical Safety Tools.”

6. Anesthesiologists need to be involved, concerned, active participants and leaders in their institution and medical community in order to enhance their practice function and image.

7. Managed care's influence has waxed and waned but it must always be considered by modern anesthesia professionals. While cost, value, outcome, and quality issues are certainly central to all anesthesiology practices, difficulties in constructing and applying definitive measurements and rigorous statistical analysis of these parameters have prevented, so far at least, some of the potential negative influences of the core features of fully managed health care on anesthesiology practice.

8. Anesthesiologists must participate in operating room (OR) management in their facilities and should play a central leadership role. OR scheduling, staffing, utilization, and patient flow issues are complex, and anesthesiologists should work hard both to thoroughly understand and positively influence them.

9. Anesthesiology personnel issues involve an elaborate balancing act and groups/departments should give these issues, as well as their constituent personnel, more attention and energy than has been done traditionally in the past or the anesthesia provider shortage will likely continue to worsen.

10. Attention to the many often-underemphasized details of infrastructure, organization, and administration can transform a merely endurable anesthesia practice into one that is efficient, effective, productive, collegial, and even fun.

Medical practice, including its infrastructure and functional details, is evolving rapidly in the United States. Anesthesia practice is no exception. In the past, anesthesia professionals traditionally were little involved in the management of many components of their practice beyond the strictly medical elements of applied physiology and pharmacology, pathophysiology, and therapeutics. This was perhaps somewhat understandable because anesthesia professionals traditionally spent most of their usually very long work hours in a hospital operating room (OR). Business matters were often left to the one or

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two group members who were interested or willing to deal with an outside-contractor billing agency. In that era, very little formal teaching in practice management of any kind occurred in anesthesia training programs. Today the Anesthesiology Residency Review Committee of the Accreditation Council on Graduate Medical Education requires that the didactic curricula of anesthesiology residencies include material on practice management. Most training programs offer at least a cursory introduction to issues of practice management, but these can be insufficient to prepare satisfactorily the professional being graduated for the real infrastructure, administrative, business, and management challenges of the modern practice of anesthesiology.

This chapter presents a wide variety of topics that, until recently, were not included in anesthesiology textbooks. Several basic components are outlined of the background, administrative, organizational (including both practice arrangements and daily functioning of the OR), and financial aspects of anesthesiology practice in the complex modern environment. Although many issues are undergoing almost constant change, it is important to understand the basic vocabulary and principles in this dynamic universe. Lack of understanding of these issues may put anesthesia professionals at a disadvantage when attempting to maximize the efficiency and impact of their daily activities, to create and execute practice arrangements, and to secure fair compensation in an increasingly complex health care system with greater and greater competition for scarcer and scarcer resources.

Administrative Components of Anesthesiology Practice

Operational and Information Resources

Overview summaries such as this chapter are intended as an introduction to practice management. Further, fortunately, the American Society of Anesthesiologists (ASA), the professional association for physician anesthesiologists in the United States, for many years has made available to its members extensive resource material regarding practice in general and specific arrangements for its execution. Citation and availability of this material can be found on the ASA Web site, www. asahq.org. Elements are updated periodically by the ASA through its physician officers, committees, task forces, administrative and support staff, and its various offices. Although many of the documents generated and even the advice given in response to members' questions contain broad-brush generalities that must be interpreted in each individual practice situation, these nonetheless stand as a solid foundation on which many anesthesiology practices can be formulated. Prospective familiarity with the principles outlined in the ASA material likely could help avoid some of the problems leading to calls for help. Selected key documents have been compiled and bound into one volume.¹ Also, each spring, the ASA offers a Practice Management Conference, following which the lecture materials are published in an annual volume (see www.asahq.org, “Publications and Services,” “Publications on Practice Management”).

Background

The ASA Guidelines for the Ethical Practice of Anesthesiology¹ includes sections on the principles of medical ethics; the definition of medical direction of nonphysician personnel (including the specific statement that an anesthesiologist engaged in medical direction should not personally be administering another anesthetic); the anesthesiologist's relationship to patients and other physicians; the anesthesiologist's duties, responsibilities, and relationship to the hospital; and the anesthesiologist's relationship to nurse anesthetists and other nonphysician personnel. Further, the ASA publishes The Organization of an Anesthesia Department¹ and states through it that the ASA “has adopted a Statement of Policy, which contains principles that the Society urges its members to consider in structuring their own individual medical practices.” This document has sections on physician responsibilities for medical care and on medical-administrative organization and responsibilities. Beyond summaries such as this chapter, reference to the considerable body of material created and presented by the ASA (which includes a thick volume specifically on the details of business arrangements²) is an excellent starting point to help young anesthesia professionals during training prepare for the increasing rigors of starting and managing a career in practice. Likewise, there is a great deal of information on the ASA Web site concerning the most recent governmental regulations, rulings, and billing codes. The ASA Newsletter contains the monthly columns “Washington Report” and “Practice Management,” which disseminate related current developments.

In addition to the ASA and the American Association of Nurse Anesthetists, most anesthesiology subspecialty societies and interest groups have Web locations, as do most journals. Particularly, the Web site of the Anesthesia Patient Safety Foundation, www.apsf.org, has been cited as especially useful in promoting safe clinical practice. Electronic bulletin boards allow anesthesiology practitioners from around the world to immediately exchange ideas on diverse topics, both medical and administrative. Traditionally, the ASA has not maintained one. However, one of the original sites that remains very popular is www.gasnet.org, and a Web search (“anesthesiology + bulletin board”) using a search engine such as www.google. com reveals a great number of sites that contain a variety of discussions about all manner of anesthesiology-related topics, including practice organization, administration, and management. Additionally, references to the entirety of the medical literature are readily accessible to any practitioner (such as by starting withwww.nlm.nih.gov to access Medline). A modern anesthesiology practice cannot reasonably exist without readily available high-speed Internet connections.

The Credentialing Process and Clinical Privileges

The system of credentialing a health care professional and granting clinical privileges in a health care facility is motivated by a fundamental assumption that appropriate education, training, and experience, along with the absence of excessive numbers of bad patient outcomes, increase the chances that the individual will deliver acceptable-quality care. The process of credentialing health care professionals has been the focus of considerable public attention (particularly in the mass media), in part the result of very rare incidents of untrained persons (impostors) infiltrating the health care system and sometimes harming patients. The more common situation, however, involves health professionals who exaggerate past experience and credentials or fail to disclose adverse past experiences. There has been some justified publicity concerning physicians who lost their licenses sequentially in several states and simply moved on each time to start practice elsewhere (which should be much, much more difficult now).

Intense public and political pressure has been brought to bear on various law-making bodies, regulatory and licensing agencies, and health care institution administrations to discover and purge both (1) fraudulent, criminal, and deviant health care providers, and (2) incompetent or simply poor-quality

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practitioners whose histories show sufficient poor patient outcomes to attract attention, usually through malpractice suits. Identifying and avoiding or correcting an incompetent practitioner is the goal. Verification of appropriate education, training, and experience on the part of a candidate for a position rendering anesthesia care assumes special importance in light of the legal doctrine of vicarious liability, which can be described as: if an individual, group, or institution hires an anesthesia provider or even simply approves of that person (e.g., by granting clinical privileges through a hospital medical staff), those involved in the decision may later be held liable in the courts, along with the individual, for the individual's actions. This would be especially true if it were later discovered that the offending practitioner's past adverse outcomes had not been adequately investigated during the credentialing process.

Out of these various long-standing concerns has arisen the sometimes cumbersome process of obtaining state licenses to practice and of obtaining hospital privileges. The stringent credentialing process for health care practice is intended both to protect patients and to safeguard the integrity of the profession. Recently, central credentialing systems have been developed, including those affiliated with the American Medical Association, American Osteopathic Association, and, particularly, the Federation Credentials Verification Service of the Federation of State Medical Boards. These systems verify a physician's basic credentials (e.g., identity, citizenship or immigration status, medical education, postgraduate training, licensure examination history, prior licenses, and board actions) once, and then thereafter can certify the validity of these credentials to a state licensing board or medical facility. A few states do not yet accept this verification and most states seek specific supplemental information.

There are checklists of the requirements for the granting of medical staff privileges by hospitals (see the American Hospital Association Resource Center, www.aharc.library.net). In addition, the National Practitioner Data Bank and reporting system administered by the U.S. government now contains many years' worth of information. This data bank is a central repository of licensing and credentials information about physicians. Many adverse situations involving a physician—particularly instances of substance abuse, malpractice litigation, or the revocation, suspension, or limitation of that physician's license to practice medicine or ability to hold hospital privileges—must be reported (via the state board of medical registration/licensure) to the National Practitioner Data Bank. It is a statutory requirement that all applications for hospital staff privileges be cross-checked against this national data bank. The potential medicolegal liability on the part of a facility's medical staff, and the anesthesiology group in particular, for failing to do so is significant. The Data Bank, however, is not a complete substitute for direct documentation and background checking. Often, practitioners reach private negotiated solutions following quality-driven medical staff problems, thereby avoiding the mandatory public reporting. In such cases, a suspect physician may be given the option to resign medical staff privileges and avoid Data Bank reporting rather than undergo full involuntary privilege revocation (although most applications contain a question specifically about this).

Documentation

The documentation for the credentialing process for each anesthesia practitioner must be complete. Privileges to administer anesthesia must be officially granted and delineated in writing.¹ This can be straightforward or it can be more complex to accommodate institutional needs to identify practitioners specially qualified to practice in designated anesthesia subspecialty areas such as cardiac, infant/pediatric, obstetric, intensive care, or pain management. Specific documentation of the process of granting or renewing clinical privileges is required and, unlike some other records, the documentation likely is protected as confidential peer review information. Any questions about complex sensitive issues such as this should be referred to an experienced attorney familiar with applicable federal and state law. Verification of an applicant's credentials and experience is mandatory. Because of another type of legal case, some examples of which have been highly publicized, medical practitioners may be hesitant to give an honest evaluation (or any evaluation at all) of individuals known to them who are seeking a professional position elsewhere. Obviously, someone writing a reference for a current or former coworker should be honest. Sticking to clearly documentable facts is advisable. Stating a fact that is in the public record (such as a malpractice case lost at trial) should not justify an objection from the subject of the reference. Whether such potentially “negative” facts can be omitted by a reference writer is complex. Including positive opinions and enthusiastic recommendations, of course, is no problem. Some fear that including facts that may be perceived as negative (e.g., the lost malpractice case or personal problems such as a history of treatment for substance abuse) and/or negative opinions will provoke a retaliatory lawsuit (such as for libel, defamation of character, or loss of livelihood) from the subject of the reference. Further, however, there have been cases of the facility doing the hiring suing reference writers for failing to mention (perceived as concealing) negative information about an applicant who later was charged with substandard practice. Because of the complexities and even apparent contradictions, many reference writers in these questionable situations confine their written material to brief, simple facts such as dates employed and position held. As always, questions about complex sensitive issues such as this should be referred to an experienced attorney familiar with applicable federal and state law.

Because there should be no hesitation for a reference writer to include positive facts and opinions, receipt of a reference that includes nothing more than dates worked and position held can be a suggestion that there may be more to the story (although some entities have adopted such a policy in all cases simply to eliminate any value judgments as to what is positive or negative information). Receipt of such a “dates/position only” reference about a person applying for a position should usually provoke a telephone call to the writer. A telephone call is likely advisable in all cases, independent of whatever the written reference contains. Frequently, pertinent questions over the telephone can elicit more candid information. In rare instances, there may be dishonesty through omission by the reference giver even at this level. This may involve an applicant who an individual, a department or group, or an institution would like to see leave.

In all cases, new personnel in an anesthesia practice environment must be given a thorough orientation and checkout. Policy, procedures, and equipment may be unfamiliar to even the most thoroughly trained, experienced, and safe practitioner. This may occasionally seem tedious, but it is sound and critically important safety policy. Being in the midst of a crisis situation caused by unfamiliarity with a new setting is not the optimal orientation session.

After the initial granting of clinical privileges to practice anesthesia, anesthesia professionals must periodically renew their privileges within the institution or facility (e.g., annually or every other year). There are moral, ethical, and societal obligations on the part of the privilege-granting entity to take this process seriously. State licensing bodies often become aware of problems with health professionals very late in the evolution of any difficulties. An anesthesia professional's peers in the hospital or facility are much more likely to notice untoward developments as they first appear. However, privilege

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renewals are often essentially automatic and receive little of the necessary attention. Judicious checking of renewal applications and awareness of relevant peer review information is absolutely necessary. The anesthesia professionals or administrators responsible for evaluating staff members and reviewing their practices and privileges may be justifiably concerned about retaliatory legal action by a staff member who is censured or denied privilege renewal. Accordingly, such evaluating groups must be thoroughly objective (totally eliminating any hint of political or financial motives) and must have documentation that the staff person in question is in fact practicing below the standard of care. Court decisions have found liability by a hospital, its medical staff group, or both, when the incompetence of a staff member was known or should have been known and was not acted upon.³ Again, questions about complex sensitive issues such as this should be referred to an experienced attorney familiar with applicable federal and state law.

A major issue in the granting of clinical privileges, especially in procedure-oriented specialties such as anesthesiology, is whether it is reasonable to continue the common practice of “blanket” privileges. This process in effect authorizes the practitioner to attempt any treatment or procedure normally considered within the purview of the applicant's medical specialty. These considerations may have profound political and economic implications within medicine, such as which type of surgeon should be doing carotid endarterectomies or lumbar discectomies. More important, however, is whether the practitioner being evaluated is qualified to do everything traditionally associated with the specialty. Specifically, should the granting of privileges to practice anesthesia automatically approve the practitioner to handle pediatric cardiac cases, critically ill newborns (such as a day-old premature infant with a large diaphragmatic hernia), ablative pain therapy (such as an alcohol celiac plexus block under fluoroscopy), high-risk obstetric cases, and so forth? This question raises the issue of procedure-specific or limited privileges. The quality assurance (QA) and risk management considerations in this question are weighty if inexperienced or insufficiently qualified practitioners are allowed or even expected, because of peer or scheduling pressures, to undertake major challenges for which they are not prepared. The likelihood of complications and adverse outcome will be higher, and the difficulty of defending the practitioner against a malpractice claim in the event of catastrophe will be significantly increased.

There is no clear answer to the question of procedure-specific credentialing and granting of privileges. Ignoring issues regarding qualifications to undertake complex and challenging procedures has clear negative potential. On the other hand, stringent procedure-specific credentialing is impractical in smaller groups, and in larger groups encourages many small “fiefdoms,” with a consequent further atrophy of the clinical skills outside the practitioner's specific area(s). Each anesthesia department or group needs to address these issues. At the very least, the common practice of every applicant for privileges (new or renewal) checking off every line on the printed list of anesthesia procedures should be reviewed. Additionally, board certification for physicians is now essentially a standard of quality assurance of the minimum skills required for the consultant practice of anesthesiology. Subspecialty boards, such as those in pain management, critical care, and transesophageal echocardiography, further objectify the credentialing process. This is now significant because initial board certification after the year 2000 by the American Board of Anesthesiology (ABA) is time-limited and subject to periodic testing and recertification. Clearly, this will encourage an ongoing process of continuing medical education. Many states, some institutions, even some regulatory bodies have requirements for a minimum number of hours of continuing medical education. Documentation of meeting such a standard again acts as one type of quality assurance mechanism for the individual practitioner, while providing another objective credentialing measurement for those granting licenses or privileges.

Professional Staff Participation and Relationships

All medical care facilities and practice settings depend on their professional staffs, of course, for daily activities of the delivery of health care but, very importantly, they also depend on those staffs to provide administrative structure and support. Medical staff activities are increasingly important in achieving favorable accreditation status (e.g., from the Joint Commission for the Accreditation of Healthcare Organizations [JCAHO]), now often known as the “Joint Commission,” and in meeting a wide variety of governmental regulations and reviews. Principal medical staff activities involve sometimes time-consuming efforts, such as duties as a staff officer or committee member. Anesthesiologists should be participants in—in fact, should play a significant role in—credentialing, peer review, tissue review, transfusion review, OR management, and medical direction of same-day surgery units, postanesthesia care units (PACUs), intensive care units (ICUs), and pain management units. Also, it is very important that anesthesiology personnel be involved in fund-raising activities, benefits, community outreach projects sponsored by the facility, and social events of the facility staff.

Anesthesia professionals as a group have a reputation for lack of involvement in medical staff and facility issues because of lack of time (because of long hours in the OR) or simply lack of interest. In fact, anesthesiology personnel are all too often perceived in a facility as the ones who slip in and out of the building essentially anonymously (often dressed very casually or even in the pajamalike comfort of scrub suits) and virtually unnoticed. This is an unfortunate state of affairs, and it has frequently come back in various painful ways to haunt those who have not been involved, or even noticed. Anesthesia professionals sometimes respond that the demands for anesthesiology service are so great that they simply never have the time or the opportunity to become involved in their facility and with their peers. If this is really true, it is clear that more anesthesia professionals must be added at that facility, even if doing so slightly reduces the income of those already there.

If anesthesia professionals are not involved and not perceived as interested, dedicated “team players,” they will be shut out of critical negotiations and decisions. Although one obvious instance in which others will make decisions for anesthesia professionals is the distribution of capitated or bundled practice fee income collected by a central “umbrella” organization, there are many such situations, and the anesthesia professionals will be forced to comply with the resulting mandates.

Similarly, involvement with a facility, a professional staff, or a multispecialty group goes beyond formal organized governance and committee activity. Collegial relationships with professional of other specialties and with administrators are central to maintenance of a recognized position and avoidance of the situation of exclusion previously described. Being readily available for formal and informal consults, particularly regarding preoperative patient workup and the maximally efficient way to get surgeons' patients to the OR in a timely, expedient manner, is extremely important. No one individual can be everywhere all the time, but an anesthesiology group or department should strive to be always responsive to any request for help from physicians or administrators. It often appears that anesthesia professionals fail to appreciate just how great a positive impact a relatively simple involvement

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(starting an intravenous line for a pediatrician, helping an internist manage an ICU ventilator, or helping a facility administrator unclog a jammed recovery room) may have.

Establishing Standards of Practice and Understanding the Standard of Care

The increasing frequency and intensity of “production pressure,”⁴ with the tacit (or even explicit) directive to anesthesia professionals to “go fast” no matter what and to “do more with less,” creates situations in which anesthesia professionals may conclude that they must cut corners and compromise maximally safe patient care just to stay in business. This type of pressure has become even greater with the implementation of more and more protocols or parameters for practice, some from professional societies such as the ASA and some mandated by or developed in conjunction with purchasers of health care (government, insurance companies, or managed care organizations). Many of these protocols are devised to fast-track patients through the medical care system, especially when an elective procedure is involved, in as absolutely little time as possible, thus minimizing costs. Do these fast-track protocols constitute standards of care that health care providers are mandated to implement? What are the implications of doing so? Of not doing so?

To better understand answers to such questions, it is important to have a basic background in the concept of the standard of care.

The standard of care is the conduct and skill of a prudent practitioner that can be expected by a reasonable patient. This is a very important medicolegal concept because a bad medical result due to failure to meet the standard of care is malpractice. Courts have traditionally relied on medical experts knowledgeable about the point in question to give opinions as to what is the standard of care and if it has been met in an individual case. This type of standard is somewhat different from the standards promulgated by various standard-setting bodies regarding, for example, the color of gas hoses connected to an anesthesia machine or the inability to open two vaporizers on that machine simultaneously. However, ignoring the equipment standards and tolerating an unsafe situation is a violation of the standard of care. Promulgated standards, such as the various safety codes and anesthesia machine specifications, rapidly become the standard of care because patients (through their attorneys, in the case of an untoward event) expect the published standards to be observed by the prudent practitioner.

Ultimately, the standard of care is what a jury says it is. However, it is possible to anticipate, at least in part, what knowledge and actions will be expected. There are two main sources of information as to exactly what is the expected standard of care. Traditionally, the beliefs offered by expert witnesses in medical liability lawsuits regarding what is actually being done in real life (de facto standards of care) were the main input juries had in deciding what was reasonable to expect from the defendant. The resulting problem is well known: except in the most egregious cases, it is usually possible for the lawyers to find experts who will support each of the two opposing sides, making the process more subjective than objective. (Because of this, there are even ASA Guidelines for Expert Witness Qualifications and Testimony and an equivalent document from the American Association of Nurse Anesthetists). Of course, there can be legitimate differences of opinion among thoughtful, insightful experts, but even in these cases the jury still must decide who is more believable, looks better, or sounds better. The second, much more objective, source for defining certain component parts of the standard of care is the published standards of care, guidelines, practice parameters, and protocols now becoming more common. These serve as hard evidence of what can be reasonably expected of practitioners and can make it easier for a jury evaluating whether a malpractice defendant failed to meet the applicable standard of care. Several types of documents exist and have differing implications.

Leading the Way

Anesthesiology may be the medical specialty most involved with published standards of care. It has been suggested that the nature of anesthesia practice (having certain central critical functions relatively clearly defined and common to all situations and also having an emphasis on technology) makes it the most amenable of all the fields of medicine to the use of published standards. The original intraoperative monitoring standards⁵ are a classic example. The ASA first adopted its own set of basic intraoperative monitoring standards in 1986 and has modified them several times. The text of all ASA standards, guidelines, and statements is readily available (see www. asahq.org, “Clinical Information,” and “Standards, Guidelines, and Statements”).

This monitoring standards document (www.asahq.org/ publicationsAndServices/standards/02.pdf) includes clear specifications for the presence of personnel during an anesthetic episode and for continual evaluation of oxygenation, ventilation, circulation, and temperature. These ASA monitoring standards very quickly became part of the accepted standard of care in anesthesia practice. This means they are important to practice management because they have profound medicolegal implications: a catastrophic accident occurring while the standards are being actively ignored is very difficult to defend in the consequent malpractice suit, whereas an accident that occurs during well-documented full compliance with the standards will automatically have a strong defense because the standard of care was being met. Several states in the United States have made compliance with these ASA standards mandatory under state regulations or even statutes. Various malpractice insurance companies offer discounts on malpractice insurance policy premiums for compliance with these standards, something quite natural to insurers because they are familiar with the idea of managing known risks to help minimize financial loss to the company. The ASA monitoring standards have been widely emulated in other medical specialties and even in fields outside medicine.

With many of the same elements of thinking, the ASA adopted “Basic Standards for Preanesthesia Care” (www. asahq.org/publicationsAndServices/standards/03.pdf). This was supplemented significantly by another type of document, the ASA Practice Advisory for Preanesthesia Evaluation (see www.asahq.org, “Publications and Services,” and “Practice Parameters”), a 40-page meta-analysis of clinical aspects of preoperative evaluation. Also, the ASA adopted “Standards for Postanesthesia Care,” in which there was consideration of and collaboration with the very detailed standards of practice for PACU care published by the American Society of Post Anesthesia Nurses (another good example of the sources of standards of care). This also was later supplemented by an extensive Practice Guideline.⁶

A slightly different situation exists with regard to the standards for conduct of anesthesia in obstetrics. These standards were originally passed by the ASA in 1988, in the same manner as the other ASA standards, but the ASA membership eventually questioned whether they reflected a realistic and desirable standard of care. Accordingly, the obstetric anesthesia standards were downgraded in 1990 to guidelines, specifically to remove the mandatory nature of the document. Because there was no agreement as to what should be prescribed as the standard of care, the medicolegal imperative of published standards

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in this instance has been temporarily set aside. From a management perspective, this makes the guidelines (www.asahq. org/publicationsAndServices/standards/45.pdf) no less valuable because the intent of optimizing care through the avoidance of complications is no less operative. However, in the event of the need to defend against a malpractice claim in this area, it is clear from this sequence of events that the exact standard of care is debatable and not yet finally established (an extremely important medicolegal consideration). A different ASA document has been generated, Practice Guidelines for Obstetrical Anesthesia, with more detail and specificity as well as an emphasis on the meta-analytic approach.⁷

Practice Guidelines

An important type of related ASA document is the Practice Guideline (formerly “Practice Parameter”). This has some of the same elements as a standard of practice but is more intended to guide judgment, largely through algorithms with some element of guidelines, in addition to directing the details of specific procedures as would a formal standard. Beyond the details of the minimum standards for carrying out the procedure, these practice parameters set forth algorithms and guidelines for helping to determine under what circumstances and with what timing to perform it. Understandably, purchasers of health care (government, insurance companies, and managed care organizations [MCOs]) with a strong desire to limit the costs of medical care have great interest in practice parameters as potential vehicles for helping to eliminate “unnecessary” procedures and limit even the necessary ones.

The ASA has been very active in creating and publishing practice guidelines. The first published parameter (since revised) concerned the use of pulmonary artery (PA) catheters.⁸ It considered the clinical effectiveness of PA catheters, public policy issues (costs and concerns of patients and providers), and recommendations (indications and practice settings). Also, the ASA Difficult Airway Algorithm was published (also since revised).⁹ This thoughtful document synthesized a strategy summarized in a decision tree diagram for dealing acutely with airway problems. It has great clinical value and it is reasonable to anticipate that it will be used to help many patients. However, all these documents are readily noticed by plaintiffs' lawyers, the difficult airway parameter from the ASA being an excellent example.

An important and so-far undecided question is whether guidelines and practice parameters from recognized entities such as the ASA define the standard of care. There is no simple answer. This will be decided over time by practitioners' actions, debates in the literature, mandates from malpractice insurers, and, of course, court decisions. Some guidelines, such as the U.S. Food and Drug Administration (FDA) preanesthetic apparatus checkout, are accepted as the standard of care. There will be debate among experts, but the practitioner must make the decision as to how to apply practice parameters and guidelines such as those from the ASA. Practitioners have incorrectly assumed that they must do everything specified. This is clearly not true, yet there is a valid concern that these will someday be held up as defining the standard of care. Accordingly, prudent attention within the bounds of reason to the principles outlined in guidelines and parameters will put the practitioner in at least a reasonably defensible position, whereas radical deviation from them should be based on obvious exigencies of the situation at that moment or clear, defensible alternative beliefs (with documentation).

The most recent type of document has been the “practice advisory,” which can seem functionally similar, but appears to have the implication of more consensus compromise than previous documents. Examples of practice advisories include: “Intraoperative Awareness and Brain Function Monitoring,” “Perioperative Management of Patients with Cardiac Rhythm Management Devices: Pacemakers and Implantable Cardioverter-Defibrillators,” and “Perioperative Visual Loss Associated with Spine Surgery.” The potential quality assurance and medicolegal implications of these documents are so important to anesthesia professionals and their practices, the ASA has what is essentially a guideline for the guidelines in its 2007 update of the “Policy Statement on Practice Parameters” (see www.asahq.org, “Publications and Services,” and “Standards, Guidelines, and Statements”) in which the distinction is made between evidence-based documents and consensus-based documents with explanations of the background and formulation processes for each.

On the other hand, practice protocols, such as those for the fast-track management of coronary artery bypass graft patients, that are handed down by MCOs or health insurance companies are a different matter. Even though the desired implication is that practitioners must observe (or at least strongly consider) them, they do not have the same implications in defining the standard of care as the other documents. Practitioners must avoid getting trapped. It may well not be a valid legal defense to justify action or the lack of action because of a company protocol. As difficult as it may be to reconcile with the payer, the practitioner still is subject to the classic definitions of standard of care.

The other type of standards associated with medical care are those of the Joint Commission, which is the best-known medical care quality regulatory agency. As noted, these standards were for many years concerned largely with structure (e.g., gas tanks chained down) and process (e.g., documentation complete), but in recent years they have been expanded to include reviews of the outcome of care. Joint Commission standards also focus on credentialing and privileges, verification that anesthesia services are of uniform quality throughout an institution, the qualifications of the director of the service, continuing education, and basic guidelines for anesthesia care (need for preoperative and postoperative evaluations, documentation, and so forth). Full Joint Commission accreditation of a health care facility is usually for 3 years. Even the best hospitals and facilities receive some citations of problems or deficiencies that are expected to be corrected, and an interim report of efforts to do so is required. If there are enough problems, accreditation can be conditional for 1 year, with a complete reinspection at that time. Preparing for Joint Commission inspections starts with verification that essential group/department structure is in place; excellent examples exist.¹ The process ultimately involves a great deal of work, but because the standards usually do promote high-quality care, the majority of this work is highly constructive and of benefit to the institution and its medical staff.

Review Implications

Another type of regulatory agency is the peer review organization. Professional standards review organizations (PSROs) were established in 1972 as utilization review/QA overseers of the care of federally subsidized patients (Medicare and Medicaid). Despite their efforts to deal with quality of care, these groups were seen by all involved as primarily interested in cost containment. Various negative factors led to the PSROs being replaced in 1984 with the peer review organization (PRO).¹⁰ There is a PRO in each state, many being associated with a state medical association. The objectives of a PRO include 14 goals related to hospital admissions (e.g., to shift care to an outpatient basis as much as possible) and 5 related to quality of care (e.g., to reduce avoidable deaths and avoidable complications). The PROs comprise full-time support staff and physician reviewers paid as consultants or directors. Ideally, PRO monitoring will discover suboptimal care, which will lead to specific recommendations for improvement in quality. There is

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a perception that quality of care efforts are hampered by the lack of realistic objectives and also that these PRO groups, like others before them, will largely or entirely function to limit the cost of health care services.

The practice management implications have become clear. Aside from the as-yet unrealized potential for quality improvement efforts and the occasional denial of payment for a procedure, the most likely interaction between the local PRO and anesthesia professionals will involve a request for perioperative admission of a patient whose care is mandated to be outpatient surgery (this could also occur in dealing with an MCO). If the anesthesiologist feels, for example, that either (1) preoperative admission for treatment to optimize cardiac, pulmonary, diabetic, or other medical status or (2) postoperative admission for monitoring of labile situations such as uncontrolled hypertension will reduce clear anesthetic risks for the patient, an application to the PRO for approval of admission must be made and vigorously supported. All too often, however, such issues surface a day or so before the scheduled procedure in a preanesthesia screening clinic or even in a preoperative holding area outside the OR on the day of surgery. This will continue to occur until anesthesia providers educate their constituent surgeon community as to what types of associated medical conditions may disqualify a proposed patient from the outpatient (ambulatory) surgical schedule. If adequate notice is given by the surgeon, the patient can be seen far enough in advance by an anesthesiologist to allow appropriate planning.

In the circumstance in which the first knowledge of a questionable patient comes 1 or 2 days before surgery, the anesthesiologist can try to have the procedure postponed, if possible, or can undertake the time-consuming task of multiple telephone calls to get the surgeon's agreement, get PRO approval, and make the necessary arrangements. Because neither alternative is particularly attractive, especially from administrative and reimbursement perspectives, there may be a strong temptation to “let it slide” and try to deal with the patient as an outpatient even though this may be questionable. In almost all cases, it is likely that there would be no adverse result (the “get away with it” phenomenon). However, the patient might well be exposed to an avoidable risk. Both because of the workings of probability and because of the inevitable tendency to let sicker and sicker patients slip by as lax practitioners repeatedly get away with it and are lulled into a false sense of security, sooner or later there will be an unfortunate outcome or some preventable major morbidity or even mortality.

The situation is worsened when the first contact with a questionable ambulatory patient is preoperatively (possibly even already in the OR) on the day of surgery. There may be intense pressure from the patient, the surgeon, or the OR administrator and staff to proceed with a case for which the anesthesia practitioner believes the patient is poorly prepared. The arguments made regarding patient inconvenience and anxiety are valid. However, they should not outweigh the best medical interests of the patient. Although this is a point in favor of screening all outpatients before the day of surgery, the anesthesia professional facing this situation on the day of operation should state clearly to all concerned the reasons for postponing the surgery, stressing the issue of avoidable risk and standards of care, and then help with alternative arrangements (including, if necessary, dealing with the PRO or managed care organization).

Potential liability in this regard is the other side of the standard of care issue. Particularly concerning is the question of postoperative admission of ambulatory patients who have been unstable. It is an extremely poor defense against a malpractice claim to state that the patient was discharged home, only later to suffer a complication, because the PRO/managed care organization deemed that operative procedure outpatient and not inpatient surgery. As bureaucratically annoying as it may be, it is a prudent management strategy to admit the patient if there is any legitimate question, thus minimizing the chance for complications, and later haggle with the PRO or directly with the involved third-party payer.

Policy and Procedure

One important organizational point that is often overlooked is the need for a complete policy and procedure manual. Such a compilation of documents is necessary for all practices, from the largest departments covering multiple hospitals to a single-room outpatient facility with one anesthesia provider. Such a manual can be extraordinarily valuable, as, for example, when it provides crucial information during an emergency. Some suggestions for the content of this compendium exist¹¹ but, at minimum, organizational and procedural elements must be included.

The organizational elements that should be present include a chart of organization and responsibilities that is not just a call schedule but a clear explanation of who is responsible for what functions of the department and when, with attendant details such as expectations for the practitioner's presence within the institution at designated hours, telephone availability, pager availability, the maximum permissible distance from the institution when on call, and so forth. Experience suggests it is especially important for there to be an absolutely clear specification of the availability of qualified anesthesiology personnel for emergency cesarean section, particularly in practice arrangements in which there are several people on call covering multiple locations. Sadly, these issues often are only considered after a disaster has occurred that involved miscommunication and the mistaken belief by one or more people that someone else would take care of an acute problem.

The organizational component of the policy and procedure manual should also include a clear explanation of the orientation and checkout procedure for new personnel, continuing medical education requirements and opportunities, the mechanisms for evaluating personnel and for communicating this evaluation to them, disaster plans (or reference to a separate disaster manual or protocol), QA activities of the department, and the format for statistical record keeping (number of procedures, types of anesthetics given, types of patients anesthetized, number and types of invasive monitoring procedures, number and type of responses to emergency calls, complications, or whatever the group/department decides).

The procedural component of the policy and procedure manual should give both handy practice tips and specific outlines of proposed courses of action for particular circumstances; it also should store little-used but valuable information. Reference should be made to the statements, guidelines, practice parameters, and standards appearing on the ASA Web site. Also included should be references to or specific protocols for the areas mentioned in the JCAHO standards: preanesthetic evaluation, immediate preinduction re-evaluation, safety of the patient during the anesthetic period, release of the patient from any PACU, recording of all pertinent events during anesthesia, recording of postanesthesia visits, guidelines defining the role of anesthesia services in hospital infection control, and guidelines for safe use of general anesthetic agents. Other appropriate topics include the following:

1. Recommendations for preanesthesia apparatus checkout, such as from the FDA¹² (see Chapter 26)

2. Guidelines for admission to, minimal monitoring and duration of stay of an infant, child, or adult in, and then discharge from the PACU

3. Procedures for transporting patients to/from the OR, PACU, or ICU

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4. Policy on ambulatory surgical patients—for example, screening, use of regional anesthesia, discharge home criteria

5. Policy on evaluation and processing of same-day admissions

6. Policy on ICU admission and discharge

7. Policy on physicians responsible for writing orders in recovery room and ICU

8. Policy on informed consent for anesthesia and its documentation

9. Policy on the use of patients in clinical research (if applicable)

10. Guidelines for the support of cadaveric organ donors and its termination (plus organ donation after cardiac death)

11. Guidelines on environmental safety, including pollution with trace gases and electrical equipment inspection, maintenance, and hazard prevention

12. Procedure for change of personnel during an anesthetic and documentation (particularly if a printed hand-off protocol is used)

13. Procedure for the introduction of new equipment, drugs, or clinical practices

14. Procedure for epidural and spinal narcotic administration and subsequent patient monitoring (e.g., type, minimum time, nursing units)

15. Procedure for initial treatment of cardiac or respiratory arrest (updated Advanced Cardiac Life Support guidelines)

16. Policy for handling patient's refusal of blood or blood products, including the mechanism to obtain a court order to transfuse

17. Procedure for the management of malignant hyperthermia

18. Procedure for the induction and maintenance of barbiturate coma

19. Procedure for the evaluation of suspected pseudocholinesterase deficiency

20. Protocol for responding to an adverse anesthetic event (such as a copy of the update of the “Adverse Event Protocol”¹³)

21. Policy on resuscitation of do-not-resuscitate patients in the OR

Individual departments will add to these suggestions as dictated by their specific needs. A thorough, carefully conceived policy and procedure manual is a valuable tool. The manual should be reviewed and updated as needed but at least annually, with a particularly thorough review preceding each Joint Commission inspection. Each member of a group or department should review the manual at least annually and sign off in a log indicating familiarity with current policies and procedures.

Meetings and Case Discussion

There must be regularly scheduled departmental or group meetings. Although didactic lectures and continuing education meetings are valuable and necessary, there also must be regular opportunities for open clinical discussion about interesting cases and problem cases. Also, the Joint Commission requires that there be at least monthly meetings at which risk management and QA activities are documented and reported. Whether these meetings are called case conferences, morbidity and mortality conferences, or deaths and complications conferences, the entire department or group should gather for an interchange of ideas. More recently these gatherings have been called QA meetings. An open review of departmental statistics should be done, including all complications, even those that may appear trivial. Unusual patterns of small events may point toward a larger or systematic problem, especially if they are more frequently associated with one individual practitioner.

A problem case presented at the departmental meeting might be an overt accident, a near accident (critical incident), or an untoward outcome of unknown origin. Honest but constructive discussion, even of an anesthesia professional's technical deficiencies or lack of knowledge, should take place in the spirit of constructive peer review. The classic question, “What would you do differently next time?” is a good way to start the discussion. There may be situations in which inviting the surgeon or the internist involved in a specific case would be advantageous. The opportunity for each type of provider to hear the perspective of another discipline is not only inherently educational, but also can promote communication and cooperation in future potential problem cases.

Records of these meetings must be kept for accreditation purposes, but the enshrining of overly detailed minutes (potentially subject to discovery by a plaintiff's attorney at a later date) may inhibit true educational and corrective interchanges about untoward events. In the circumstance of discussion of a case that seems likely to provoke litigation, it is appropriate to be certain that the meeting is classified as official “peer review” and possibly even invite the hospital attorney or legal counsel from the relevant malpractice insurance carrier (to guarantee the privacy of the discussion and minutes).

Support Staff

There is a fundamental need for support staff in every anesthesia practice. Even independent practitioners rely in some measure on facilities, equipment, and services provided by the organization maintaining the anesthetizing location. In large, well-organized departments, reliance on support staff is often very great. What is often overlooked, however, is a process analogous to that of credentialing and privileges for anesthesia professionals, although at a slightly different level. The people expected to provide clinical anesthesia practice support must be qualified and must at all times understand what they are expected to do and how to do it. It is singularly unfortunate to realize only after an anesthesia catastrophe has occurred that basic details of simple work assignments, such as the changing of carbon dioxide absorbent, were routinely ignored. This indicates the need for supervision and monitoring of the support staff by the involved practitioners. Further, such support personnel are favorite targets of cost-cutting administrators who do not understand the function of anesthesia technicians or their equivalent. In the modern era, many administrators seem driven almost exclusively by the “bottom line” and cannot appreciate the connection between valuable workers such as these and the “revenue stream.” Even though it is obvious to all who work in an OR that the anesthesia support personnel make it possible for there to be patients flowing through the OR, it is their responsibility to convince the facility's fiscal administrator that elimination of such positions is genuinely false economy because of the attendant loss in efficiency, particularly in turning over the room between surgeries. Further, it is also false economy to reduce the number of personnel below that genuinely needed to retrieve, clean, sort, disassemble, sterilize, reassemble, store, and distribute the tools of daily anesthesia practice. Vigorous defense (or initiation of new positions if the staff is inadequate) by the anesthesia professionals should be undertaken, always with the realization that it may be necessary in some circumstances for them to supplement the budget from the facility with some of their practice income to guarantee an adequate complement of competent workers.

Business and organizational issues in the management of an anesthesia practice are also critically dependent on the existence of a sufficient number of appropriately trained support staff. One frequently overlooked issue that contributes to the

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negative impression generated by some anesthesiology practices centers on being certain there is someone available to answer the telephone at all times during the hours surgeons, other physicians, and OR scheduling desks are likely to call. This seemingly trivial component of practice management is very important to the success of an anesthesiology practice as a business whose principal customers are the surgeons. Certainly there is a commercial server–client relationship both with the patient and the purchaser of health care; however, the uniquely symbiotic nature of the relationship between surgeons and anesthesiologists is such that availability even for simple “just wanted to let you know” telephone calls is genuinely important. The person who answers the telephone is the representative of the practice to the world and must take that responsibility seriously. From a management standpoint, significant impact on the success of the practice as a business often hinges on such details. Further, anesthesiologists should always have permanent personal electronic pagers and reliable mobile telephones (or the radio equivalent) to facilitate communications from other members of the department or group and from support personnel. This may sound intrusive, but the unusual position of anesthesia professionals in the spectrum of health care workers mandates this feature of managing an anesthesiology practice. Anesthesiology professionals should have no hesitation about spending their own practice income to do so. The symbolism alone is obvious.

Anesthesia Equipment and Equipment Maintenance

Problems with anesthesia equipment have been discussed for some time.^14,15,16 However, compared with human error, overt equipment failure rarely causes intraoperative critical incidents¹⁷ or deaths resulting from anesthesia care. Aside from the obvious human errors involving misuse of or unfamiliarity with the equipment, when the rare equipment failure does occur, it often appears that correct maintenance and servicing of the apparatus has not been done. These issues become the focus of anesthesia practice management efforts, which could have significant liability implications because there can often be confusion or even disputes about precisely who is responsible for arranging maintenance of the anesthesia equipment—the facility or the practitioners who use it and collect practice income from that activity. In many cases, the facility assumes the responsibility. In situations in which that is not true, however, it is necessary for the practitioners to recognize that responsibility and seek help securing a service arrangement, because this is likely an unfamiliar obligation for clinicians.

Programs for anesthesia equipment maintenance and service have been outlined.^1,18 A distinction is made between failure resulting from progressive deterioration of equipment, which should be preventable because it is observable and should provoke appropriate remedial action, and catastrophic failure, which, realistically, often cannot be predicted. Preventive maintenance for mechanical parts is critical and involves periodic performance checks every 4 to 6 months. Also, an annual safety inspection of each anesthetizing location and the equipment itself is necessary. For equipment service, an excellent mechanism is a relatively elaborate cross-reference system (possibly kept handwritten in a notebook but ideal for maintenance on an electronic spreadsheet program) to identify both the device needing service and also the mechanism to secure the needed maintenance or repair.

Equipment-handling principles are straightforward. Before purchase, it must be verified that a proposed piece of equipment meets all applicable standards, which will usually be true when dealing with recognized major manufacturers. The renewed efforts of some facility administrators to save money by attempting to find “refurbished” anesthesia machines and monitoring systems should provoke thorough review by the involved practitioners. On arrival, electrical equipment must be checked for absence of hazard (especially leakage of current) and compliance with applicable electrical standards. Complex equipment such as anesthesia machines and ventilators should be assembled and checked out by a representative from the manufacturer or manufacturer's agent. There are potential adverse medicolegal implications when relatively untrained personnel certify a particular piece of new equipment as functioning within specification, even if they do it perfectly. On arrival, a sheet or section in the departmental master equipment log must be created with the make, model, serial number, and in-house identification for each piece of capital equipment. This not only allows immediate identification of any equipment involved in a future recall or product alert, but also serves as the permanent repository of the record of every problem, problem resolution, maintenance, and servicing occurring until that particular equipment is scrapped. This log must be kept up-to-date at all times. There have been rare but frightening examples of potentially lethal problems with anesthesia machines leading to product alert notices requiring immediate identification of certain equipment and its service status. It is also very important to involve the manufacturer's representative in pre- and in-service training for those who will use the new equipment. Anesthesia systems with their ventilation and monitoring components have become significantly more integrated and more complex, particularly as they are increasingly electronic and less mechanical. Accordingly, it is critical that anesthesia professionals are properly trained to use their equipment safely. The perception that inadequate training is common and that this represents a threat to patient safety has led the Anesthesia Patient Safety Foundation to initiate a campaign urging anesthesia departments and groups to ensure organized verified complete training of all professionals who will use this new technology.¹⁹

Service

Beyond the administrative liability implications, precisely what type of support personnel should maintain and service major anesthesia equipment has been widely debated. Some groups or departments rely on factory service representatives from the equipment manufacturers for all attention to equipment, others engage independent service contractors, and still other (often larger) departments have access to personnel (either engineers and/or technicians) permanently within their facility. The single underlying principle is clear: the person(s) doing preventive maintenance and service on anesthesia equipment must be qualified. Anesthesia practitioners may wonder how they can assess these qualifications. The best way is to unhesitatingly ask pertinent questions about the education, training, and experience of those involved, including asking for references and speaking to supervisors and managers responsible for those doing the work. Whether an engineering technician who spent a week at a course at a factory can perform the most complex repairs depends on a variety of factors, which can be investigated by the practitioners ultimately using the equipment in the care of patients. Failure to be involved in this oversight function exposes the practice to increased liability in the event of an untoward outcome associated with improperly maintained or serviced equipment.

Replacement of obsolete anesthesia machines and monitoring equipment is a key element of a risk-modification program. Ten years is often cited as an estimated useful life for an anesthesia machine, but although an ASA statement repeats that idea, it also notes that the ASA promulgated “Guidelines for Determining Anesthesia Machine Obsolescence” in 2004 that

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does not subscribe to any specific time interval. Anesthesia machines considerably more than 20 years old likely do not meet certain of the safety standards now in force for new machines (such as vaporizer lockout, fresh gas ratio protection, and automatic enabling of the oxygen analyzer) and, unless extensively retrofitted, do not incorporate the new technology that advanced very rapidly during the 1980s, much of it directly related to the effort to prevent untoward incidents. Further, it appears that this technology will continue to advance, particularly because of the adoption of anesthesia workstation standards by the European Economic Union that are affecting anesthesia machine design worldwide. Note that some anesthesia equipment manufacturers, anxious to minimize their own potential liability, have refused to support (with parts and service) some of the oldest of their pieces (particularly gas machines) still in use. This disowning of equipment by its own manufacturer is a very strong message to practitioners that such equipment must be replaced as soon as possible.

Should a piece of equipment fail, it must be removed from service and a replacement substituted. Groups, departments, and facilities are obligated to have sufficient backup equipment to cover any reasonable incidence of failure. The equipment removed from service must be clearly marked with a prominent label (so it is not returned into service by a well-meaning technician or practitioner) containing the date, time, person discovering, and the details of the problem. The responsible personnel must be notified so they can remove the equipment, make an entry in the log, and initiate the repair. As indicated in the protocol for response to an adverse event,¹³ a piece of equipment involved or suspected in an anesthesia accident must be immediately sequestered and not touched by anybody—particularly not by any equipment service personnel. If a severe accident occurred, it may be necessary for the equipment in question to be inspected at a later time by a group consisting of qualified representatives of the manufacturer, the service personnel, the plaintiff's attorney, the insurance companies involved, and the practitioner's defense attorney. The equipment should thus be impounded following an adverse event and treated similarly to any object in a forensic “chain of evidence,” with careful documentation of parties in contact with and responsible for securing the equipment in question following such an event. Also, major equipment problems may, in some circumstances, reflect a pattern of failure due to a design or manufacturing fault. These problems should be reported to the FDA's Medical Device Problem Reporting system²⁰ via MedWatch on Form 3500 (found at www.fda.gov/ medwatch/index.html, or telephone 800-FDA-1088). This system accepts voluntary reports from users and requires reports from manufacturers when there is knowledge of a medical device being involved in a serious incident. Whether or not filing such a report will have a positive impact in subsequent litigation is impossible to know, but it is a worthwhile practice management point that needs to be considered in the unlikely but important instance of a relevant event involving equipment failure.

Malpractice Insurance

All practitioners need liability insurance coverage specific for the specialty and role in which they are practicing. It is absolutely critical that applicants for medical liability insurance be completely honest in informing the insurer what duties and procedures they perform. Failure to do so, either from carelessness or from a foolishly misguided desire to reduce the resulting premium, may well result in retrospective denial of insurance coverage in the event of an untoward outcome from an activity the insurer did not know the insured engaged in.

Proof of adequate insurance coverage is usually required to secure or renew privileges to practice at a health care facility. The facility may specify certain minimum policy limits in an attempt to limit its own liability exposure. It is difficult to suggest specific dollar amounts for policy limits because the details of practice vary so much among situations and locations. The malpractice crisis of the 1980s eased significantly in the early 1990s for anesthesia professionals, largely because of the decrease in number and severity of malpractice claims resulting from anesthesia catastrophes as anesthesia care in the United States became safer.^21,22,23 The exact analysis of this phenomenon can be debated,^24,25 but it is a simple fact that malpractice insurance risk ratings have been decreased and premiums for anesthesia professionals have not been increased at the same rate as for other specialties over the past 15 years and, in many cases, have actually decreased. In 2008, coverage limits of $1 million/$3 million are still common and would seem the minimum advisable. This policy specification usually means that the insurer will cover up to $1 million liability per claim and up to $3 million total per year, but this terminology is not necessarily universal. Therefore, anesthesia professionals must be absolutely certain what they are buying when they apply for malpractice insurance. Even though anesthesiologists have not recently suffered a great number of very large malpractice payments or jury verdicts,²⁶ in specific parts of the United States known for a pattern of exorbitant settlements and jury verdicts, liability coverage limits of $2 million/$5 million or even greater may be prudent. An additional feature in this regard is the potential to employ “umbrella” liability coverage above the limits of the base policy, as will be noted.

Background

The fundamental mechanism of medical malpractice insurance changed significantly in the last 3 decades because of the need for insurance companies to have better ways to predict their losses (amounts paid in settlements and judgments). Traditionally, medical liability insurance was sold on an “occurrence” basis, meaning that if the insurance policy was in force at the time of the occurrence of an incident resulting in a claim, whenever within the statute of limitations that claim might be filed, the practitioner would be covered. Occurrence insurance was somewhat more expensive than the alternative “claims made” policies, but was seen as worth it by some (many) practitioners. These policies created some open-ended exposure for the insurer that sometimes led to unexpected large losses, even some large enough to threaten the existence of the insurance company. As a result, medical malpractice insurers have converted almost exclusively to claims-made insurance, which covers claims that are filed while the insurance is in force. Premium rates for the first year a physician is in practice are relatively low because there is less likelihood of a claim coming in (a majority of malpractice suits are filed 1 to 3 years after the event in question). The premiums usually increase yearly for the first 5 years and then the policy is considered “mature.” The issue comes when the physician later, for whatever reason, must change insurance companies (e.g., because of relocation to another state). If the physician simply discontinues the policy and a claim is filed the next year, there will be no insurance coverage. Therefore, the physician must secure “tail coverage,” sometimes for a minimum number of years (e.g., 5) or, more often, indefinitely to guarantee liability insurance protection for claims filed after the physician is no longer primarily covered by that insurance policy. It may be possible in some circumstances to purchase tail coverage from a different insurer than was involved with the primary policy, but by far the most common thing done is to simply extend the existing insurance coverage for the period of the tail. This very often yields a bill for the entire tail

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coverage premium, which can be quite sizable, potentially staggering a physician who simply wants to move to another state where his or her existing insurance company is not licensed to or refuses to do business. Individual situations will vary widely, but it is reasonable for anesthesiologists organized into a fiscal entity to consider this issue at the time of the inception of the group and record their policy decisions in writing, rather than facing the potentially difficult question of how to treat one individual later. Other strategies have occasionally been employed when insuring the tail period, including converting the previous policy to part-time status for a period of years, and purchasing “nose” coverage from the new insurer—that is, paying an initial higher yearly premium with the new insurer, who then will cover claims that may occur during the tail period. Whatever strategy is adopted, it is critical that the individual practitioner is absolutely certain though personal verification that he or she is thoroughly covered at the time of any transition. The potential stakes are much too great to leave such important issues solely to an office clerk. Further, a practitioner arriving in a new location is often filling a need or void and is urged to begin clinical work as soon as possible by others who have been shouldering an increased load. It is essential that the new arrival verify with confirmation in writing (often called a “binder”) that malpractice liability insurance coverage is in force before there is any patient contact.

Another component to the liability insurance situation is consideration of the advisability of purchasing yet another type of insurance called umbrella coverage, which is activated at the time of the need to pay a claim that exceeds the limits of coverage on the standard malpractice liability insurance policy. Because such an enormous claim is extremely unlikely, many practitioners are tempted to forgo the comparatively modest cost of such insurance coverage in the name of economy. As before, it is easy to see that this is potentially a very false economy—if there is a huge claim. Practitioners should consult with their financial managers and advisors, but it is likely that it would be considered wise management to purchase “umbrella” liability insurance coverage.

Medical malpractice insurers are becoming increasingly active in trying to prevent incidents that will lead to insurance claims. They often sponsor risk-management seminars to teach practices and techniques to lessen the chances of liability claims and, in some cases, suggest (or even mandate) specific practices, such as strict documented compliance with the ASA “Standards for Basic Anesthetic Monitoring.” In return for attendance at such events and/or the signing of contracts stating that the practitioner will follow certain guidelines or standards, the insurer often gives a discount on the liability insurance premium. Clearly, it is sound practice management strategy for practitioners to participate maximally in such programs. Likewise, some insurers make coverage conditional on the consistent implementation of certain strategies such as minimal monitoring, even stipulating that the practitioner will not be covered if it is found that the guidelines were being consciously ignored at the time of an untoward event. Again, it is obviously wise from a practice management standpoint to cooperate fully with such stipulations.

Response to an Adverse Event

In spite of the decreased incidence of anesthesia catastrophes, even with the very best of practice, it is statistically likely that each anesthesiologist at least once in his or her professional life will be involved in a major anesthesia accident (see Chapter 4). Precisely because such an event is rare, very few are prepared for it. It is probable that the involved personnel will have no relevant past experience regarding what to do. Although an obvious resource is another anesthetist who has had some exposure or experience, one of these may not be available either. Various authors have discussed what to do in that event.^27,28,29 Cooper, et al.³⁰ have thoughtfully presented the appropriate immediate response to an accident in a straightforward, logical, compact format (that has been updated¹³) that should periodically be reviewed by all anesthesiology practitioners and should be included in all anesthesia policy and procedure manuals. This “adverse events protocol” is also always immediately available at www.apsf.org (“Resource Center,” and “Clinical Safety Tools”). Unfortunately, however, the principal personnel involved in a significant untoward event may react with such surprise or shock as to temporarily lose sight of logic. At the moment of recognition that a major anesthetic complication has occurred or is occurring, help must be called. A sufficient number of people to deal with the situation must be assembled on site as quickly as possible. For example, in the unlikely but still possible event that an esophageal intubation goes unrecognized long enough to cause a cardiac arrest, the immediate need is for enough skilled personnel to conduct the resuscitative efforts, including making the correct diagnosis and replacing the tube into the trachea. Whether the anesthesiologist apparently responsible for the complication should direct the immediate remedial efforts will depend on the person and the situation. In such a circumstance, it would seem wise for a senior or supervising anesthesiologist quickly to evaluate the scenario and make a decision. This person becomes the “incident supervisor” and has responsibility for helping prevent continuation or recurrence of the incident, for investigating the incident, and for ensuring documentation while the original and helping anesthesiologists focus on caring for the patient. As noted, involved equipment must be sequestered and not touched until such time as it is certain that it was not involved in the incident.

If the accident is not fatal, continuing care of the patient is critical. Measures may be instituted to help limit damage from brain hypoxia. Consultants may be helpful and should be called without hesitation. If not already involved, the chief of anesthesiology must be notified as well as the facility administrator, risk manager, and the anesthesiologist's insurance company. These latter are critical to allow consideration of immediate efforts to limit later financial loss. (Likewise, there are often provisions in medical malpractice insurance policies that might limit or even deny insurance coverage if the company is not notified of any reportable event immediately.) If there is an involved surgeon of record, he or she probably will first notify the family, but the anesthesiologist and others (risk manager, insurance loss control officer, or even legal counsel) might appropriately be included at the outset. Full disclosure of facts as they are best known—with no confessions, opinions, speculation, or placing of blame—is currently still believed to be the best presentation. Any attempt to conceal or shade the truth will later only confound an already difficult situation. Obviously, comfort and support should be offered, including, if appropriate, the services of facility personnel such as clergy, social workers, and counselors. There is a new movement in medical risk management and insurance advocating immediate full disclosure to the victim or survivors, including “confessions” of medical judgment and performance errors with attendant sincere apologies. If indicated, early offers of reasonable compensation may be included. There have been instances when this overall strategy has prevented the filing of a malpractice lawsuit and has been applauded by all involved as an example of a shift from the “culture of blame” with punishment to a “just culture” with restitution. A widespread movement to implement immediate disclosure and apology has received support.^31,32

Certain states have enacted or proposed so-called “I'm sorry!” legislation intended to prevent any explanation or apology from being used as plaintiff's evidence in a subsequent malpractice suit. The importance of the patient's perspective

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on a serious adverse anesthesia event was highlighted in a riveting account of the stories of both survivors of anesthesia catastrophes and the families of patients who died.³³ In each case, one main message was the enormous negative impact of the perceived failure of the involved anesthesia professionals and their institutions to share detailed information about what exactly happened. A recent review summarizes what patients want and expect following an adverse event.³⁴ Laudable as this policy of immediate full disclosure and apology may sound, it would be mandatory for an individual practitioner to check with the involved liability insurance carrier, the practice group, and the facility administration before attempting it.

The primary anesthesia provider and any others involved must document relevant information. Never, ever change any existing entries in the medical record. Write an amendment note if needed, with careful explanation of why amendment is necessary, particularly stressing explanations of professional judgments involved. State only facts as they are known. Make no judgments about causes or responsibility and do not “point fingers.” The same guidelines hold true for the filing of the incident report in the facility, which should be done as soon as is practical. Further, all discussions with the patient or family should be carefully documented in the medical record. Recognizing that detailed memories of the events may fade in the 1 to 3 years before the practitioner may face deposition questions about exactly what happened, it is possible that it will be recommended, immediately after the incident, that the involved clinical personnel sit down as soon as practical and write out their own personal notes, which will include opinions and impressions as well as maximally detailed accounts of the events as they unfolded. These personal notes are not part of the medical record or the facility files. These notes should be written in the physical presence of an involved attorney representing the practitioner, even if this is not yet the specific defense attorney secured by the malpractice insurance company, and then that attorney should take possession of and keep those notes as case material. This strategy is intended to make the personal notes “attorney–client work product,” and thus not subject to forced “discovery” (revelation) by other parties to the case.

Follow-up after the immediate handling of the incident will involve the primary anesthesiologist but should again be directed by a senior supervisor, who may or may not be the same person as the incident supervisor. The “follow-up supervisor” verifies the adequacy and coordination of ongoing care of the patient and facilitates communication among all involved, especially with the risk manager. Lastly, it is necessary to verify that adequate postevent documentation is taking place.

Of course, it is expected that such an adverse event will be discussed in the applicable morbidity and mortality meeting. It is necessary, however, to coordinate this activity with the involved risk manager and attorney so as to be completely certain that the contents and conclusions of the discussion are clearly considered peer review activity, and thus are shielded from discovery by the plaintiffs' attorney.

Unpleasant as this is to contemplate, it is better to have a clear plan and execute it in the event of an accident causing injury to a patient. Vigorous immediate intervention may improve the outcome for all concerned.

Practice Essentials

The “Job Market” for Anesthesia Professionals

While it is true that in the mid-1990s, for the first time, uncertainty faced residents finishing anesthesiology training because of a perception that there were not enough jobs for physician anesthesiologists available, that concept faded quickly. A tension between supply and demand developed, with a significant ongoing component of the idea that there is an overall shortage of anesthesia professionals. It appears that late in the first decade of the 2000s this fundamental paradigm will persist. With the fading of the concept that managed care would significantly reduce the demand for medical services and also the aging of the Baby Boom population, it is clear that there is a significant shortage of all medical professionals in the United States, and this especially includes anesthesia professionals.

Types of Practice

At least through the first decade of the 21st century, residents finishing anesthesiology training will still need to choose among three fundamental possibilities: academic practice in a teaching hospital environment; a practice exclusively of patient care in the private practice marketplace; and a practice exclusively of patient care as an employee of a health care system, organization, or facility.

Teaching hospitals with anesthesiology residency programs constitute only a very small fraction of the total number of facilities requiring anesthesia services. These academic departments tend to be among the largest groups of anesthesiologists, but the aggregate fraction of the entire anesthesiologist population is small. It is interesting, however, that by the nature of the system, most residents finishing their training have almost exclusively been exposed only to academic anesthesiology. Accordingly, finishing residents in the past often were comparatively unprepared to evaluate and enter the anesthesiology job market.

Specialty certification by the ABA should be the goal of all anesthesia residency graduates. Some finishing residents who know they are eventually headed for private practice have started their attending careers as full-time junior faculty in an academic department. This allows them to obtain some clinical practice and supervisory experience and offers them the opportunity to prepare for the ABA examinations in the nurturing, protected academic environment with which they are familiar. Most residents, however, do not become junior faculty; they accept practice positions immediately. But such newly trained residents should take into account the need to become ABA-certified and build into their new practice arrangements the stipulation that there will be time and consideration given toward this goal.

Academic Practice

For those who choose to stay in academic practice, a number of specific characteristics of academic anesthesia departments can be used as screening questions.

How big is the department? Junior faculty sometimes can get lost in very big departments and be treated as little better than glorified senior residents. On the other hand, the availability of subspecialty service opportunities and significant research and educational resources can make large departments extremely attractive. In smaller academic departments, there may be fewer resources, but the likelihood of being quickly accepted as a valued and contributing member of the teaching faculty (and research team, if appropriate) may be higher. In very small departments, the number of expectations, projects, and involvements could potentially be overwhelming. Additionally, a small department may lack a dedicated research infrastructure, so it may be necessary for the faculty in this situation to collaborate with other, larger departments to accomplish meaningful academic work.

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What exactly is expected of junior faculty? If teaching one resident class every other week is standard, the candidate must enthusiastically accept that assignment and the attendant preparation work and time up front. Likewise, if it is expected that junior faculty will, by definition, be actively involved in publishable research, specific plans for projects to which the candidate is amenable must be made. In such situations, clear stipulations about startup research funding and nonclinical time to carry out the projects should be obtained as much as possible (although clinical workload demands and revenue generation expectations may make this very difficult in some settings). Particularly important is determining what the expectation is concerning outside funding. For example, it can be a rude shock to realize that projects will suddenly halt after 2 years if extramural funding has not been secured.

What are the prospects for advancement? Many new junior faculty directly out of residency start with medical school appointments as instructors unless there is something else in their background that immediately qualifies them as assistant professors. It is wise to understand from the beginning what it takes in that department and medical school to facilitate academic advancement. There may be more than one academic “track”; the tenure track, for example, usually depends on published research whereas the clinical or teacher track relies more heavily on one's value in patient care and as a clinical educator. The criteria for promotion may be clearly spelled out by the institution—number of papers needed, involvement and recognition at various levels, grants submitted and funded, and so on—or the system may be less rigid and depend more heavily on the department chairman's and other faculty evaluations and recommendations. In either case, careful inquiry before accepting the position can avert later surprise and disappointment.

How much does it pay? Traditionally, academic anesthesiologists have not earned quite as much as those in private practice—in return for the advantage of more predictable schedules, continued intellectual stimulation, and the intangible rewards of academic success. There is now great activity and attention concerning reimbursement of anesthesiologists, and it is difficult to predict future income for any anesthesiology practice situation. However, all of the forces influencing payment for anesthesia care may significantly diminish the traditional income differential between academic and private practice. In some cases, a faculty member is exclusively an employee of the institution, which bills and collects or negotiates group contracts for the patient care rendered by the faculty member, and then pays a negotiated amount (either an absolute dollar figure or a floating amount based on volume and/or collections—or a combination of the two) that constitutes the faculty person's entire income. Under other much less common arrangements, faculty members themselves may be able to bill and collect or negotiate contracts for their clinical work. Some institutions have a (comparatively small) academic salary from the medical school for being on the faculty, but many do not; some channel variable amounts of money (from so-called Part A clinical revenue) into the academic practice in recognition of teaching and administration or simply as a subsidy for needed service. A salary from the medical school, if extant, is then supplemented significantly by the practice income. Usually, the faculty will be members of some type of group or practice plan (either for the anesthesia department alone or the entire faculty as a whole) that bills and collects or negotiates contracts and then distributes the practice income to the faculty under an arrangement that must be examined by the candidate. In most academic institutions, practice expenses such as all overhead and malpractice insurance as well as reasonable benefits, including discretionary funds for meetings, subscriptions, books, dues, and so forth, are automatically part of the compensation package, which often may not be true in private practice and must be counted in making any comparison. An important corollary issue is that of the source of the salaries of the department's primary anesthesia providers—residents and, in some cases, nurse anesthetists. Although the hospital usually pays for at least some of these, arrangements vary, and it is important to ascertain whether the faculty practice income is also expected to cover the cost of the primary providers. Overall, it is reasonable to sound out faculty, both anesthesiology and others, regarding the past and likely future commitment of the institution to the establishment and maintenance of reasonable compensation for the expected involvement.

Private Practice in the Marketplace

Obviously, rotations to a private practice hospital in the final year of anesthesia residency could help greatly in this regard, but not all residency programs offer such opportunities. In that case, the finishing resident who is certain about going into private practice must seek information on career development and mentors from the private sector.

Armed with as much information as possible, one fundamental initial choice is between independent individual practice and a position with a group (either a sole proprietorship, partnership, or corporation) that functions as a single financial entity. Independent practice may become increasingly less viable in many locations because of the need to be able to bid for contracts with managed care entities. However, where independent practice is possible, it usually first involves attempting to secure clinical privileges at a number of hospitals or facilities in the area in which one chooses to live. This may not always be easy, and this issue has been the subject of many (frequently unsuccessful) antitrust suits over recent years (see “Antitrust Considerations”). Then the anesthesiologist makes it known to the respective surgeon communities that he or she is available to render anesthesia services and waits until there is a request for his or her services. The anesthesiologist obtains the requisite financial information from the patient and then either individually bills and collects for services rendered or employs a service to do billing and collection for a percentage fee (which will vary depending on the circumstances, especially the volume of business; for billing [without scheduling services] it would be unlikely to be >7% or, at the most, 8% of actual collections).

How much of the needed equipment and supplies will be provided by the hospital or facility and how much by the independent anesthesiologist varies widely. If an anesthesiologist spends considerable time in one operating suite, he or she may purchase an anesthesia machine exclusively for his or her own use and move it from room to room as needed. It is likely to be impractical to move a fully equipped anesthesia machine from hospital to hospital on a day-to-day basis. Among the features of this style of practice are the collegiality and relationships of a genuine private practice based on referrals and also the ability to decide independently how much time one wants to be available to work. The downside is the potential unpredictability of the demand for service and the time needed to establish referral patterns and obtain bookings sufficient to generate a livable income.

When seeking a position with a private group, the applicant should search for potential practice opportunities through word of mouth, recruiting letters sent to the training program supervisor, journal advertisements, and placement services (either commercial or professional, such as that provided at the ASA annual meeting). Some of the screening questions are the same as for an academic position, but there must be even more emphasis on the exact details of clinical expectations and financial arrangements. Some residents finish residency (or fellowship training to an even greater extent) very highly skilled in complex, difficult anesthesia procedures. They

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can be surprised to find that in some private practice group situations, the junior-most anesthesiologist must wait some time, perhaps even years, before being eligible to do, for example, open heart anesthesia, and in the meantime will mostly be assigned more routine or less challenging anesthetics.

Financial arrangements in private group practices vary widely. Some groups are loose organizational alliances of independent practitioners who bill and collect separately and rotate clinical assignments and call for mutual convenience. Many groups act also as a fiscal entity, and there are many possible variations on this theme. In many circumstances in the past, new junior members started out as functional employees of the group for a probationary interval before being considered for full membership or partnership. This is not a classic employment situation because it is intended to be temporary as a prelude to full financial participation in the group. However, there have been enough instances of established groups abusing this arrangement that the ASA includes in its fundamental “Statement of Policy” the proviso: “Exploitation of anesthesiologists by other anesthesiologists is improper.”¹ This goes on to say that after a reasonable trial period, income should reflect services rendered. Unfortunately, these statements may have little meaning or impact on groups in the marketplace. Some groups have a history of demanding excessively long trial periods during which the junior anesthesiologist's income is artificially low and then denying partnership and terminating the relationship to go on to employ a new probationer and start the cycle over again. Accordingly, new junior staff attempting to join groups should try to have such an arrangement spelled out carefully in the agreement drafted by an expert representing the anesthesiologist. Another variation of this, in an attempt to disguise the fundamentally unethical nature of the practice, is to employ anesthesiologists on a fixed salary with the false incentive of no night or weekend call. This is disingenuous, as most income is usually generated during routine scheduled day work, for which the anesthesiologist-employee is poorly compensated. Yet another usurious scheme is for a group to employ an anesthesiologist for a period of years at a low salary and then require a further cash outlay to purchase partnership in the corporation. As the cash outlay can be quite substantial, it is frequently borrowed from the corporation, leading to a sophisticated form of indentured servitude. Sadly, when the job market conditions are poor as they were some years ago, the tendency is for there to be less likelihood of securing a prospective commitment of partnership at a specified future time.

Private Practice as an Employee

There has been some trend toward anesthesiologists becoming permanent employees of any one of various fiscal entities. The key difference is that there is no intention or hope of achieving an equity position (share of ownership, usually of a partnership, thus becoming a full partner). Hospitals, outpatient surgery centers, multidisciplinary clinics, other facilities tied to a specific location where surgery is performed, physician groups that have umbrella fiscal entities specifically created to serve as the employer of physicians, and even surgeons may seek to hire anesthesiologists as permanent employees. The common thread in this system is that these fiscal entities see the anesthesiologists as additional ways of generating profits. Again, in many cases it would appear that employees are not paid a salary that is commensurate with their production of receivables. That is, the fiscal entity will pay a salary substantially below collections generated plus appropriate overhead. These arrangements are particularly favored by some large MCOs in certain cities that view anesthesiologists simply as expensive necessities that prevent hospitals from realizing maximum profit (although sometimes there is a promise of a lighter or more manageable schedule in these positions compared with marketplace private practice).

Negotiating for a position as a permanent full-time employee is somewhat simpler and more straightforward than it is in marketplace private practice. It parallels the usual understandings that apply to most regular employer–employee situations: job description, role expectations, working conditions, hours, pay, and benefits. The idea of anesthesiologists functionally becoming shift workers disturbs many in the profession because it contradicts the traditional professional model. Again, the complex nature and multiple levels of such considerations make it a personal issue that must be carefully evaluated by each individual with full awareness and consideration of the issues outlined here and commensurate research of ASA resources and available data about common regional circumstances and details of any specific medical community.

Practice for a Management Company

One prominent newer development is the growth and impact of large state, regional, or even national management companies that advertise the provision of comprehensive anesthesia services on a contract basis with hospitals, surgery centers, and clinics. These companies, some started and/or managed by anesthesia professionals, promise the facility availability of anesthesia care during the specified hours in return for a lucrative contract to do so. This relieves the facility from any concern about recruiting, hiring/contracting, and retaining anesthesia professionals, virtually eliminating concern about disruption of OR schedules due to limited availability of anesthesia care. The only requirement of the facility is approval of the already prepared credentialing information for each anesthesia professional. Unlike many locum tenens companies in which anesthesia professionals are considered independent contractors and paid fixed contract amounts per hour, per day, or per job for a limited interval with no benefits, some of the management companies may employ anesthesia professionals full-time on a salary with benefits (paid vacation, health insurance, retirement contribution, and so forth). The employment agreement would stipulate whether travel for assignments in locations away from the employee's permanent home would be required as a condition of the full-time job or the position will always be in the practitioner's home community.

Practice as a Hospital Employee

While certified registered nurse anesthetists in some locations have traditionally practiced as hospital employees, until recently, it was less common outside full vertically integrated MCOs for physician anesthesiologists to be hospital (or facility) employees. In recent years, one of the responses of hospitals to requests for subsidies from exclusive-contract practice groups of anesthesiologists has been to offer the anesthesiologists full-time employment status rather than subsidize an independent practice group that has its own significant administrative and overhead costs.³⁵ The hospital likely suggests that integrating the billing, collecting, and management functions as well as major overhead costs such as malpractice insurance into the existing larger hospital operation would be very cost-efficient, allowing more financial resources to go to physician salaries, and also with possibly a somewhat greater predictability in uncertain times. The hospital can also guarantee the availability of anesthesia care (a requirement to sustain the OR, one of the main hospital revenue sources) in an era when some anesthesiologist groups may simply walk away from a hospital in search of greater income elsewhere, leaving the hospital to seek a contract probably with one of the large and very expensive anesthesia management companies (previously described). Of course, in return for employee status, the anesthesiologists surrender some degree of independence and also, for the group's partners, their equity stake in sharing in any subsequent increased

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practice revenue. A hospital might counter that concern with the contention that traditional fee-for-service practice that has been so common for so long for private-practice anesthesiologists will never again yield enough revenue to maintain the income levels anesthesiologists have come to expect, so they will not be losing anything.

Billing and Collecting

In practices in which anesthesiologists are directly involved with the financial management, they need to understand as much as possible about the complex world of health care reimbursement. This significant task has been made easier by the ASA, which some time ago added a significant component to its Washington, D.C., office (see www.asahq.org/government.htm) by adding a practice management coordinator to the staff. One of the associated assignments is helping ASA members understand and work with the sometimes confusing and convoluted issues of effective billing for anesthesiologists' services. There are often updates with the latest information and codes in the monthly ASA Newsletter.

There continue to be proposals for significant changes in billing for anesthesiology care. However, the basics have changed only slightly in recent years. It is important to understand that many of the most contentious issues, such as the requirement for physician supervision of nurse anesthetists and the implications of that for reimbursement, apply in many circumstances mostly to Medicare and, in some states, Medicaid. Thus, the fraction of the patient population covered by these government payers is important in any consideration. Different practice situations have different arrangements regarding the financial relationships between anesthesiologists and nurse anesthetists, and this can affect the complex situation of who bills for what. The nurses may be employees of a hospital, of the anesthesiologists who medically direct them, or of no one in that they are independent contractors billing separately (even in cases in which physician supervision—not medical direction—is required but where those physicians do not bill for that component). In 1998, Medicare mandated that an anesthesia care team of a nurse anesthetist medically directed by an anesthesiologist could bill as a team no more than 100% of the fee that would apply if the anesthesiologist did the case alone. The implications of this change are complex and variable among anesthesiology practices, particularly because there is another trend for health care facilities that traditionally had employed nurse anesthetists to seek to shift total financial responsibility for them to the anesthesiologist practice group. Also, complex related issues played out in the early 2000 years. The federal government issued a new regulation allowing individual states to “opt out” of the requirement that nurse anesthetists be supervised by physicians and several states did so. This was opposed by the ASA. Because perioperative patient care, one component of which is administering anesthesia, is traditionally considered the practice of medicine, the implications of this change as far as the role of surgeons supervising nurse anesthetists and the malpractice liability status of nurse anesthetists practicing independently were unclear. Further, the implications of all this for billing insurers other than Medicare and Medicaid are exceedingly complex.

Classic Methodology

Because there is still widespread application of the traditional method of billing for anesthesiology services, understanding it is very important for anesthesiologists starting practice. In this system, each anesthetic generates a value of so many “units,” which represent effort and time. A conversion factor (dollars per unit) that can vary widely multiplied by the number of units generates an amount to be billed. Each anesthetic has a base value number of units (e.g., 8 for a cholecystectomy) and then the time taken for the anesthetic is divided into units, usually 15 minutes per unit. Thus, a cholecystectomy with anesthesia time of 1 hour and 50 minutes would have 8 base units and 7.33 time units for a total of 15.33 units. In some practice settings, it may be allowed to add modifiers, such as extra units for complex patients with multiple problems as reflected by an ASA physical status classification of 3–5 and/or E (“emergency”) or for insertion of an arterial or PA catheter. The sum is the total billing unit value. Determining the base value for an anesthetic in units depends on full and correct understanding of what operation was done. Although this sounds easy, it is the most difficult component of traditional anesthesia billing. The process of determining the procedure done is known as coding because the procedure name listed on the anesthesia record is assigned an identifying code number from the universally used current procedural terminology (CPT)-4 coding book. This code is then translated through the ASA “Relative Value Guide,” which assigns a base unit value to the type of procedure identified by the CPT-4 code. In the past, some anesthesiologists failed to understand the importance of correct coding to the success of the billing process. Placing this task in the hands of someone unfamiliar with the system and with surgical terminology can easily lead to incorrect coding. This can fail to capture charges and the resulting income to which the anesthesiologist is entitled or, worse, can systematically overcharge the payers, which will bring sanctions, penalties and, in certain cases, criminal prosecution.

In recent years a prevailing official attitude has been that there are no simple, innocent coding errors. All upcoding (charging for more expensive services than were actually delivered) is considered to be prima facie evidence of fraud and is subject to severe disciplinary and legal action. All practices should have detailed compliance programs in place to ensure correct coding for services rendered.³⁶ Outside expert help (such as from a health care law firm that specializes in compliance programs) is highly desirable for the process of formulating and implementing a compliance plan regarding correct coding.

Assembly and transfer of the information necessary to generate bills must be efficient and complete. Traditionally, this involved depositing in a secure central location a paper extra copy of the anesthesia record and often a “billing sheet” with it, on which was inscribed the names of all the involved personnel and any additional information about other potentially billable services, such as invasive monitors. Any practice involved with a comprehensive electronic perioperative information management system in the facility should be using that to assemble this “front end” billing information. Short of that, some practices collect electronic information specifically generated by the anesthesia providers for that purpose. They have equipped each staff member with a hand-held organizer into which data are entered and then the device is synched with a departmental computer at the end of the day. If the OR suite has “Wi-Fi” (wireless electronic connection), the same function could be accomplished in real time with the providers entering the requisite information into a miniprogram on a laptop computer affixed to each anesthesia machine (or one carried by each staff member). Once the information has been secured, a mechanism must be employed to generate the actual bill and communicate it to the payer (on paper, on disk, or, usually, directly computer-to-computer: “electronic claims submission”). The possible exact arrangements for doing this vary widely.

Whether an anesthesia practice that will be billing and collecting for anesthesia services should employ its own in-house clerical and bookkeeping personnel to perform this function or should contract with an outside company whose sole function is medical billing and collecting (possibly, ideally, for

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anesthesiology only) can be debated endlessly. Whichever is chosen, knowledgeable oversight by the anesthesia professionals who ultimately will derive income from the revenue collected is required. Ultimately, the entity actually submitting the bill will verify that it has been paid (posting of receipts) and may or may not actually handle the incoming money. Very often, anesthesia practices or individuals who use a billing service (and even some who have in-house billing staffs) will arrange that the actual payments go directly to a bank lockbox, which is a post office box (better individual than shared, even if more expensive) to which the payments come and then go directly into a bank account. This system avoids the situation of having the people who generate the bill actually handle the incoming receipts, a practice that has led to theft and fraud in a few cases. Eventual decisions about how hard to try to collect from payers who deny coverage and then from patients directly will depend on the circumstances, including local customs.

Table 2-1 Types of Data an Anesthesiology Group Should Track and Maintain Concerning Its Own Practice

Types of Data the Anesthesiology Group's Computer System Should Track · Transaction-based system (track each case and charge as separate record) o Track individual charges by CPT-4 code o Track individual payments by payer · Track all data elements on an interrelated basis o By place of service o By charge, broken down § by number of units (time and base) § by ASA modifiers § by number of lines o By CPT-4 code o By payer o By payment code (full payment, discount, write-off, or refund) o By diagnosis (ICD-9 code) o By surgeon o By anesthesiologist o By anesthesia care team provider o By start and stop times o By age o By gender o By employer o By ZIP code Type of Information to Generate From These Data · Aggregate number of cases per year for the group · Total number of cases per year for each provider within the group o Number of cases performed by anesthesiologists o Number of cases performed by the anesthesia care team · Average number of units per case (as one measure of intensity per case) · Average number of units per CPT-4 code · Average time units per case and per CPT-4 code o Group should be able to calculate time units per individual surgeon · Average line charge per case · Charges per case by CPT-4 code · Payments per case by payer · Patient mix o Percent traditional indemnity o Percent managed care (broken down by each MCO for which services are provided) o Percent self-pay o Percent Medicare o Percent Medicaid · Collection rate for each population served · Overall collection rate · Costs per unit (total costs, excluding compensation ÷ total units) (costs include liability insurance, rent, collection costs, and legal and accounting fees) · Compensation costs per unit (total compensation ÷ total units) for MCO populations, utilization patterns by age, gender, and diagnosis CPT, current procedural terminology; ASA, American Society of Anesthesiologists; ICD-9, International Classification of Diseases, ninth revision; MCO, managed care organization. Reprinted from Managed Care Reimbursement Mechanisms: A Guide for Anesthesiologists. Park Ridge, IL, American Society of Anesthesiologists, 1994, with permission.

Detailed summary statistics of the work done by an anesthesiology practice group are critical for logistic management of personnel, scheduling, and financial analysis. Spreadsheet and database computer programs customized for an individual practice's characteristics will be invaluable. A summary of the types of data an anesthesia practice should track is shown in

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Table 2-1. Once all the data are assembled and reviewed, at least monthly analysis by a business manager or equivalent as well as officers/leaders of the practice group can spot trends very early in their development and allow appropriate correction or planning. Often the responsible members of an anesthesiology group question how effective their financial services operation is, particularly regarding net collections. This is a complex issue³⁷ that, again, often requires outside help. Routine internal audits can be useful but could be self-serving. No billing office or company that is honest and completely above board should ever object to a client, in this case the anesthesiology practice group, engaging an independent outside auditor to come in and thoroughly examine both the efficiency of the operation and also “the books” concerning correctness and completeness of collections.

Anesthesia billing and collecting are among the most complex challenges in the medical reimbursement field. Traditional anesthesia reimbursement is unique in all of medicine. The experience of many people over the years has suggested that it often is well advised to deal with an entity that is not only very experienced in anesthesia billing, but also does anesthesia billing exclusively or as a large fraction of its efforts. It is very difficult for an anesthesiologist or a family member to do billing and collecting as a side activity to a normal life. This has led to inefficient and inadequate efforts in many cases, illustrating the value of paying a reasonable fee to a professional who will devote great time and energy to this challenging endeavor.

Antitrust Considerations

There can be antitrust implications of business arrangements involving anesthesiologists—particularly with all the realignments, consolidations, mergers, and contracts associated with the attempted implementation of managed care. The applicable statutes and regulations are often poorly understood. Contrary to popular belief, the antitrust laws do not involve the rights of individuals to engage in business. Rather, the laws are concerned solely with the preservation of competition within a defined marketplace and the rights of the consumer, independent of whether any one vendor or provider of service is involved. When an anesthesiologist has been excluded from a particular hospital's staff or anesthesia group and then sues based on an alleged antitrust violation, the anesthesiologist loses virtually automatically. This is because there is still significant competition in the relevant medical care marketplace (community or region) and competition in that market is not threatened by the exclusion of one physician from one staff.

In essence, if there are several hospitals offering relatively similar services to an immediate community (the market), denial of privileges to one physician by one hospital is not anticompetitive. If, on the other hand, there is only one hospital in a smaller market, then the same act, the same set of circumstances, could be seen very differently. In that case, there would be a limitation of competition because the hospital dominates and, in fact, may control the market for hospital services. Exclusion of one physician, then, could limit access by the consumers to alternative competing services and hence would likely be judged an antitrust violation.

The Sherman Antitrust Act is a federal law more than 100 years old. Section 1 deals with contracts, combinations, conspiracy, and restraint of trade. By definition, two or more separate economic entities must be involved in an agreement that is challenged as illegal for this section to apply. Section 2 prohibits monopolies or conspiracy to create a monopoly, and it is possible that this could apply to a single economic entity that has illegally gained domination of a market. Consideration of possible monopolistic domination of a market involves a situation in which a single entity controls at least 50% of the business in that market. The stakes are high in that the antitrust legislation provides for triple damages if a lawsuit is successful. The U.S. Department of Justice and the Federal Trade Commission are keenly interested in the current rapid evolution in the health care industry, and thus are actively involved in evaluating situations of possible antitrust violations.

There are two ways to judge violations. Under the per se rule, which is applied relatively rarely, conduct that is obviously limiting competition in a market is automatically illegal. The other type of violation is based on the rule of reason, which involves a careful analysis of the market and the state of competition. The majority of complaints against physicians are judged by this rule. The more competitors there are in a market, the less likely that any one act is anticompetitive. In a community with two hospitals, one smaller than the other, with an anesthesiology group practice exclusively at each, if the larger anesthesiology practice group buys out and absorbs the smaller, leaving only one group for the only two hospitals in the community, that may be anticompetitive, particularly if a new anesthesiologist seeks to practice solo at those hospitals.

Legal Implications

In the current era of rapidly evolving practice arrangements, the antitrust laws are important. If physicians (individuals or groups) who normally would be competitors because they are separate economic entities meet and agree on the prices they will charge or the terms they will seek in a managed care or institutional contract, that can be anticompetitive, monopolistic, and hence possibly illegal. Note that sharing a common office and common billing service alone is not enough to constitute a true group. If, on the other hand, the same physicians join in a true economic partnership to form a new group (total integration) that is a single economic entity (and meets certain other criteria) that will set prices and negotiate contracts, that is perfectly legal. The other criteria are critical. There must be capital investment and also risk sharing (if there is a profit or loss, it is distributed among the group members)—that is, total integration into a genuine partnership (that is usually incorporated, some times as a limited liability corporation). This issue is very important in considering the drive for new organizations to put together networks of physicians that then seek contracts with major employers to provide medical care. Sometimes, hospitals or clinics attempt to form a network comprising all the members of the medical staff so that the resulting entity can bid globally for total care contracts. Any network is a joint venture of independent practitioners. If the participating physicians of one specialty in a network are separate economic entities and the network advertises one price for their services, this would seem to suggest an antitrust violation (horizontal price fixing). In the past, if a network involved fewer than 20% of one type of medical specialist in a market, that was called asafe harbor, meaning that it was permissible for nonpartners to get together and negotiate prices. The federal government has tried to encourage formation of such networks to help reduce health care costs, and as a result made some relevant exceptions to the application of these rules. As long as the network is nonexclusive (other nonnetwork physicians of a given specialty are free to practice in the same facilities and compete for the same patients), the network can comprise up to 30% of the physicians of one specialty in a market. Note specifically that this does not allow a local specialty society in a big city to serve as a bargaining agent on fees for its members because it is very likely that >30% of the specialists in an area will be members of the society. The only real exception to this provision is in thinly populated rural areas where there may be just one physician network. In such cases

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(which are, so far, rare because the major managed care and network activity has occurred mainly in heavily populated urban areas), there is no limit on how many of one specialty can become network members and have the network negotiate fees, as long as the network is nonexclusive.

Relevant legislation, regulations, and court actions all happen rapidly and often. Mergers among anesthesiology groups in a market area for the purposes of both efficiency and strength in negotiating fees have been very popular as a response to the rapidly changing marketplace. A list of questions must be answered to determine if such a merger would have anticompetitive implications. Although compendia of relevant information are available to anesthesiologists,^38,39,40 they cannot substitute for expert advice and help. Obviously, anesthesiologists contemplating a merger or facing any one of a great number of other situations in the modern health care arena must secure assistance from professional advisors, usually attorneys, whose job it is to be aware of the most recent developments, how they apply, and how best to forge agreements in formal contracts. Anesthesiologists hoping to find reputable advisors can start their search with word-of-mouth referrals from colleagues who have used such services. Local or state medical societies frequently know of attorneys who specialize in this area. Finally, the ASA Washington, D.C., office has compiled a state-by-state list of advisors who have worked successfully with anesthesiologists in the past.

Exclusive Service Contracts

Often, one of the larger issues faced by anesthesiologists seeking to define practice arrangements concerns the desirability of considering an exclusive contract with a health care facility to provide anesthesia services. An exclusive contract states that anesthesiologists seeking to practice at a given facility must be members of the group holding the exclusive contract and, usually, that members of the group will practice nowhere else. A hospital may want to give an exclusive contract in return for a guarantee of coverage as part of the contract. Also, the hospital may believe that such a contract can help ensure the quality of practitioner because the contract can contain credentialing and performance criteria. It is important to understand that the hospital likely will exercise a degree of control over the anesthesiologists with such a contract in force, such as requiring them to participate as providers in any contracts the hospital makes with third-party payers and also tying hospital privileges to the existence of the contract (the so-called clean-sweep provision that bypasses any due process of the medical staff should the hospital terminate the contract). Certain of these types of provisions constitute economic credentialing, which is defined as the use of economic criteria unrelated to the quality of care or professional competency of physicians in granting or renewing hospital privileges (such as the acceptance of below-market fees associated with a hospital-negotiated care contract or even requiring financial contributions in some form to the hospital).

The ASA in 1993 issued a statement condemning economic credentialing.¹ The anesthesiologists involved may accept such an exclusive services contract to guarantee that they alone will get the business from the surgeons on staff at that hospital, and hence the resulting income. There may be other considerations on both sides, and these have been outlined in extensive relevant ASA publications that also include a sample contract for information purposes only.^36,39 Although many exclusive contracts with anesthesiology groups are in force, the sentiment, particularly from the ASA, is against them. As stated, it is critical that anesthesiologists faced with important practice management decisions such as whether to enter into an exclusive contract must seek outside advice and counsel. There are a great many nuances to these issues,^{39,40,41,42,43} and anesthesiologists are at risk attempting to negotiate such complex matters alone, just as patients would be at risk if a contract attorney attempted to induce general anesthesia.

Denial of hospital privileges as a result of the existence of an exclusive contract with the anesthesiologists in place at the facility has been the source of many lawsuits, including the well-known Louisiana case of Hyde v Jefferson Parish. In that case, the court found for the defendant anesthesiologists and the hospital, saying that there was no antitrust violation because there was no real adverse effect on competition as far as patients were concerned because there were several other hospitals within the market to which they could go, and therefore they could exercise their rights to take advantage of competition in the relevant market. Thus, existence of an exclusive contract only in the rare setting where anticompetitive effects on patients can be proved might lead to a legitimate antitrust claim by a physician denied privileges. This was proven true in the Kessel v Monongalia County General Hospital case in West Virginia in which an exclusive anesthesiology contract was held illegal. Therefore, again, these arrangements are by definition complex and fraught with hazard. Accordingly, outside advice and counsel are always necessary.

Hospital Subsidies

Modern economic realities have forced a great number of anesthesiology practice groups (in both private and academic settings) to recognize that their patient care revenue, after overhead is paid, does not provide sufficient compensation to attract and retain the number and quality of staff necessary to provide the expected clinical service (and fulfill any other group/department missions). Attempting to do the same (or more) work with fewer staff may temporarily provide increased financial compensation. Cutting benefits (discretionary personal professional expenses, retirement contributions, or even insurance coverage) may also be a component of a response to inadequate practice revenue. However, the resulting decrements in personal security, in convenience, and in quality of life as far as acute and chronic fatigue, decreased family and recreation time, and tension among colleagues fearful someone else is getting a “better deal” will quickly overcome any brief advantage of a somewhat higher income. Therefore, many practice groups in such situations are requesting their hospital (or other health care facility where they practice) to pay them a direct cash subsidy that is used to augment practice revenue in order to maintain benefits and amenities while maintaining or even increasing the direct compensation to staff members, hopefully to a market-competitive level that will promote recruitment and retention of group members.

Obviously, requests by a practice group for a direct subsidy must be thoroughly justified to the facility administration receiving the petition. The group's business operation should already have been examined carefully for any possible defects or means to enhance revenue generation. Explanation of the general trend of declining reimbursements for anesthesia services should be carefully documented. Facts and figures on that and also the shortage of anesthesia providers can be obtained from journal articles and ASA publications, particularly the Newsletter. Demand for anesthesia coverage for the surgical schedule is a key component of this proposal. Scheduling and utilization, particularly if early-morning staffing is required for many ORs that are routinely unused later during the traditional work day, is a major issue to be understood and presented. Any other OR inefficiencies created by hospital support staff and previous efforts to deal with them should also be highlighted. Unfavorable payer mix, impact of contracts, and programs initiated by the hospital also often are major factors

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in situations of inadequate practice revenue. Always, the group's good will with the surgeons and the community in general should be emphasized, as well as of the indirect or “behind the scenes” services and benefits the anesthesiology group provides to the hospital. Note that the necessity for such a subsidy request is precisely the time when the anesthesia professionals will benefit from being perceived as “good citizens” of the health care facility. An overly aggressive effort beyond the bounds of logic could provoke the facility to consider alternative arrangements, even up to the point of putting out a request for proposal from other anesthesiology practice groups. Therefore, thoughtful calculations are required and a careful balance must be sought, seeking enough financial support to supplement practice revenues so that members' compensation is competitive but not so much as to be excessive. Supporting statements and documents about offers and potential earnings elsewhere must be completely honest and not exaggerated or credibility and good faith will be lost. Further, part of any agreement will be the full sharing of the group's detailed financial information with the facility administration, both at the time of the request and on an ongoing basis if the payment is more than a one-time “bail out.” Plans for review and renewal should be made once a subsidy is paid.

Any subsidy will likely require a formal contract. There may be concern about malpractice liability implications for the hospital even though the practice group stays an independent entity as before. There may be “inurement” or “private benefit” concerns that could be perceived as a threat to the tax-exempt status of a nonprofit hospital. Lack of understanding of the applicable laws may lead to fears that a subsidy could be an illegal “kickback” or a violation of the Stark II self-referral prohibition. As is almost always the case, expert outside professional consultant advice, usually from an attorney who specializes exclusively in health care finance contracting, is mandatory in such circumstances. The ASA Washington, D.C., office maintains lists of consultants who have helped other anesthesiologists or groups in the past with various subjects, and the ASA has some basic information on subsidies to anesthesiology practice groups.^44,45,46

New Practice Arrangements

Even though the impact of managed care plans has waned somewhat over the first decade of the 21st century, various iterations still exist and have ongoing impact on anesthesiology practice. Further, renewed concern at the end of the decade about disproportionate increases in health care spending as a percentage of U.S. gross domestic product and the fear of the postulated bankruptcy of Medicare and Medicaid again raise the specter of new efforts to impose managed care.

In the initial stages of the evolution of a managed care marketplace, the MCO usually seeks contracts with providers based on discounted fee-for-service arrangements. This preserves the basic traditional idea of production-based physician reimbursement (do more, bill more) but the price of each act of services is lower (the providers are induced to give deep discounts with the promise of significant volumes of patients); also, the MCO gatekeeper primary care physicians and the MCO reviewers are strongly encouraged to limit complex and costly services as much as possible. There are other features intermittently along the way, such as global fees and negotiated fee schedules (agreed-upon single prices for individual procedures, independent of length or complexity). In an application of the concept of risk-sharing (spend too much for patient care and lose income), this usually is initially manifest in the form of “withholds,” the practice of the MCO holding back a fraction of the agreed-upon payment to the providers (e.g., 10 or 15%) and keeping this money until the end of the fiscal year. At that time, if there is any money left in the risk pool or withhold account after all the (partial) provider fees and MCO expenses are paid, it is distributed to the providers in proportion to their degree of participation during the year. This is a clever and powerful incentive to providers to reduce health care expenses. It is not as powerful as the stage of full risk-sharing, however. As the managed care marketplace matures and MCOs grow and succeed, the existing organizations and, especially any new ones, shift to prospective capitated payments for providers.

Prospective Payments

Prospective capitated payments constitutes an entirely new world to health care providers, involving prospective capitated payments for large populations of patients, in which each group of providers in the MCO receives a fixed amount per enrolled covered life (member) per month (PMPM) and agrees, except in the most unusual circumstances, to provide whatever care is needed by that population for that prospective payment. The most unusual circumstances involve “carve-out” arrangements in which specific very costly and unusual conditions or procedures (such as the birth of a child with disastrous multiple congenital anomalies) are covered separately on a discounted fee-for-service basis. With full capitation, the entire financial underpinning of American medical care does a complete about-face from the traditional rewards for giving more care and doing more procedures to new rewards for giving and doing less. Some managed care contracts contain other features intended to protect the providers against unexpected overutilization by patients that would stretch the providers beyond the bounds of the original contract with the MCO. The provisions setting the boundaries are called risk corridors, and the “stop-loss clauses” add some discounted fee-for-service payment for the excess care beyond the risk corridor (capitated contract limit). Providers who were used to getting paid more for doing more can suddenly find themselves getting paid a fixed amount no matter how much or how little they do with regard to a specified population—hence, the perceived incentive to do, and consequently spend, less. If the providers render too much care within the defined boundary of the contract, they essentially will be working for free, the ultimate in risk-sharing.

There are clearly potential internal conflicts in such a system,⁴⁷ and how patients reacted initially to this radical change in attitude on the part of physicians demonstrated that this overall mechanism is unlikely to be readily embraced by the general public. Health care providers (physicians, other health care professionals, and facilities), in turn, allied themselves in a wide variety of organizations to create strength and desirable resources to present to the MCOs in contract negotiations. Management service organizations are joint-venture network arrangements that do not involve true economic integration among the practitioners, but merely offer common services to physicians who may, as a loosely organized informal group, elect to seek MCO contracts. Preferred provider organizations are network arrangements of otherwise economically independent physicians who form a new corporate entity to seek managed care contracts in which there are significant financial incentives to patients to use the network providers and financial penalties for going to out-of-network providers. This has proved a relatively popular model and appears to be gaining wide acceptance. Physician–hospital organizations are similar entities but involve understandings between groups of physicians and a hospital so that a large package or bundle of services can be constructed as essentially one-stop points of care. Independent practice associations are like preferred provider organizations but are specifically oriented toward capitated contracts for covered lives with significant risk-sharing by the

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providers. Groups (or clinics) “without walls” are collections of practitioners who fully integrate economically into a single fiscal entity (true partnership) and then compete for MCO contracts on the basis of risk-sharing incentives among the partners. Fully integrated groups or health maintenance or-ganizations (such as Kaiser Permanente in California or Harvard Pilgrim Health in New England) house the group of partner provider physicians and associated support staff at a single location for the convenience of patients, a big selling point when they seek MCO or employer contracts.

Changing Paradigm

The era of solo independent practitioners may be ending in some locations where MCOs dominate because the organizations simply will not contract with one person. Independent hospital-based groups (likely still the most common private practice model) may face growing similar difficulties.⁴⁸ These smaller groups of anesthesiologists may find themselves at a competitive disadvantage unless they become part of a vertically integrated (multispecialty) or horizontally integrated (with other anesthesiologists) organization. An extensive compendium of relevant information has been prepared by the ASA.³⁸ Because it appears likely that many anesthesiologists in the United States will be affected by evolving changes in practice arrangements, the information in this and related publications⁴⁹ is very important. Negotiations with MCOs require expert advice, probably even more so than the traditional exclusive contracts with hospitals as previously noted. Before any negotiation can even be considered, the MCO must provide significant amounts of information about the covered patient population. The projected health care utilization pattern of a large group of white-collar workers (and their families) from major upscale employers in an urban area will be quite different from that of a relatively rural Medicaid population. Specific demographics and past utilization histories are absolutely mandatory for each proposed population to be covered, and this information should go directly to the advising experts for evaluation, whether the proposed negotiation is for discounted fee-for-service, a fee schedule, global bundled fees, or full capitation.

Significant questions were pointedly raised about the reimbursement implications for anesthesiologists of the putative managed care/practice reorganization revolution. Again, the ASA has assembled relevant information, the understanding of which is essential to successful negotiations.³⁸ Table 2-1 has a list of information an anesthesia practice should have about its activities. Initial consideration of a capitated contract should involve an attempt to take all the data about the existing practice and the proposed MCO-covered population from a “capitation checklist”³⁸ and translate back from the proposed capitated rate to income figures that would correlate with the existing practice structure, to allow a comparison and an understanding of the relationship of the projected work in the contract the to projected income from it. It is, of course, impossible to suggest dollar values for capitated rates for anesthesiology care because details and conditions vary so widely. One ASA publication³⁸ used examples, purely for illustrative purposes, involving $2.50 or $4.00 PMPM, but there were unconfirmed reports at the peak of the managed care bubble of capitated rates as low as $0.75 PMPM for anesthesiology.

Discounted fee-for-service arrangements are easier for anesthesiologists to understand because these are directly referable to existing fee structures. Reports of groups instituting 10 to 50% discounts off the starting point of 80% of usual and customary reimbursement in various practice circumstances were circulated at national meetings of anesthesiologists. Were rigidly controlled fully mature managed care to dominate the practice community, it would be likely that the average income for anesthesiologists would decrease from past levels. However, it likely also would be true that anesthesia professionals would continue to have incomes still above average among all health care professionals in that market.

Another recent feature of this discussion is the tendency of private (nongovernmental) contracting organizations to attempt to tie their payments for professional services to the government's Medicare rate for specific CPT-4 codes. It is common for both commercial indemnity insurance entities (e.g., Blue Shield, Aetna, Humana, United Health) as well as MCOs to offer primary care physicians, for example, 125% of the Medicare payment rate for specific services. Although groups of primary care physicians may view this as somewhat reasonable and, thus, they sign such contracts, anesthesiologists face unique challenges in this regard. Even with the most recent promise from the responsible offices within Medicare of a reimbursement upgrade for anesthesia services, most anesthesia professionals still believe that the Medicare reimbursement rate is unfairly low for the work involved in providing anesthesia care. The new rate would still be less than half the per unit “conversion factor” that the large indemnity carriers have been paying for anesthesia care in recent years. Therefore, 125% of what many anesthesia professionals consider woefully inadequate would still be inadequate. Thus, in spite of sometimes intense pressure, anesthesia professionals in many markets have been reluctant to accept indemnity insurance contract rates tied to Medicare rates. As always, anesthesia professionals faced with complex reimbursement situations and decisions should seek expert advice from the national offices of their professional practice organizations and from knowledgeable paid consultants and attorneys.

“Pay for Performance”

Commercial indemnity insurance entities (e.g., Blue Shield, Aetna, Humana, United Health), MCOs, and particularly, the federal Center for Medicare and Medicaid Services (CMS) are all currently fixated on the concept of “performance-based payments” as a significant new way to limit the growth of (and even reduce) health care costs,⁵⁰ especially by reducing expensive complications of medical care. This “pay for performance” movement began with the federal Tax Relief and Healthcare Act of 2006 and continues with the Physician Quality Reporting Initiative in 2008. The potential implications for anesthesia practice have been summarized.⁵¹

In general, CMS made strenuous efforts to attempt to define and promulgate objective quality measures that could be documented as indicators of the “quality” of health care delivered. The main issue is the promotion of specific care elements that help avoid expensive outcomes or complications that currently generate a disproportionate (preventable) fraction of health care costs. The administration of aspirin and beta-blockers within a fixed brief interval after the arrival of an acute myocardial infarction patient is a good example, as are various parameters in the care of patients with community-acquired pneumonia or congestive heart failure. Defining and validating objective and easily quantifiable so-called quality measures that will prevent expensive complications of anesthesia care proved to be more difficult. The initial targeted parameter was somewhat indirect: the timing of the administration of prophylactic antibiotics prior to surgical incision. The anesthesia professional is judged to be in compliance when the antibiotic is administered within the 1 hour (2 hours for vancomycin and fluoroquinolones) prior to incision. This must be verifiably documented on the anesthesia record. Benchmark criteria such as an initial 80% compliance (but likely increasing to at least 95%) for a specific financial entity billing Medicare and Medicaid must be met or the reimbursement for anesthesia services by that financial entity will be

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reduced by a specific fraction (or a promised “bonus” will be withheld) as a compliance incentive, but also somewhat as an offset to the increased cost of the consequent complications associated with failure to comply. If performance is in compliance, CMS will pay the maximum allowable reimbursement (pay for performance).

The second target is catheter-related bloodstream infection, and the performance behavior expected of anesthesia professionals is observance of strict aseptic protocol during central vascular catheter placement (and avoiding the femoral route if at all possible). As of this writing, the third objective parameter of anesthesia care quality is scheduled to target temperature management of the surgical patient with the compliance behavior being met by achieving one of three possible goals: use of active warming intraoperative or documented temperature ≥36°C either in the last 30 minutes of anesthesia or the first 30 minutes in the PACU. Future potential objective performance criteria intended to encourage avoidance of costly complications of anesthesia care may include glucose control in major surgery, use of pencil-point spinal needles in obstetric anesthesia, use of electronic medical records, preoperative screening for sleep apnea, preoperative fasting instructions, meperidine administration for postoperative shivering, and several others. In all cases when a parameter is adopted, benchmark criteria for degree of compliance will be established and reimbursement will be reduced one way or another for failure to comply, as documented on the relevant records and self-reported by the billing financial entity (subject to audit, of course).

Hospitals will have even more at stake in the sense that the pay for performance movement is creating paradigms in which hospitals will not receive reimbursements for care associated with preventable complications such as catheter-related sepsis, ventilator-acquired pneumonia, and decubitus ulcers. This concept has several implications. One is that smaller hospitals often populated by less acute patients will be more likely and quicker to transfer sicker patients to larger referral facilities in order to avoid losing reimbursement associated with the development of patient complications. Concomitantly, documentation of the timing of the development of complications will become critical. If a hospital or department has documented the pre-existing presence of a complication at the time of a patient's admission, it should not be penalized for the development of that condition. In this context, anesthesia professionals can have an important role documenting the existence of pneumonia or sacral decubitus ulcers in their records when they first see a newly admitted patient, usually for preoperative evaluation. This will be perceived as excellent institutional citizenship by the anesthesia professional because it may prevent significant reimbursement reduction to the hospital.

HIPAA

The 2003 implementation of the Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 required significant changes in how medical records and patient information are handled in the day-to-day delivery of health care. The impact on and requirements for anesthesiologists are summarized in a comprehensive publication from the ASA⁵² that followed two educational summaries.^53,54

Attention is focused on “protected health information” (identifiable as from a specific patient by name). Patients must be notified of their privacy rights. Usually this will be covered by the health care facility in which anesthesiologists work, but if separate private records are maintained, separate notification may be necessary. Privacy policies must be created, adopted, and promulgated to all practitioners, all of whom then must be trained in application of those policies. Often, anesthesiology groups can combine with the facilities in which they practice as an “organized health care arrangement” so that the anesthesia practitioners can be covered in part by the HIPAA compliance activities of the facility. A “privacy officer” must be appointed for the practice group. Finally, and most importantly, medical records containing protected health information must be secured so they are not readily available to those who do not need them to render care.

One of the most obvious applications for many anesthesiologists is concern about the assembled preoperative information and charts for tomorrow's cases that frequently were placed prominently in the OR holding area at the end of one work day in readiness for the next day's cases. HIPAA provisions require that all that patient information be locked away overnight. Another classic example is what many ORs refer to as “the board.” Often, a large white dry-marker board occupies a prominent wall near the front desk of an OR suite, and the rooms, cases, and personnel assignments are inscribed thereon at the beginning of the day and modified or crossed off as the day progresses. Under HIPAA, patients' names may not be used on such a board if there is any chance that anyone not directly involved in their care could see them. Alternatively, some facilities tape a copy of the day's OR schedule (including patients' names, ages, and operations) on the wall, which would also be a violation. The same is true for similar boards or posted schedules in OR holding areas and PACUs. Another issue often overlooked that is very problematic and probably the one that concerns patients the most is the obtaining of history information in a location, such as a “bed slot” behind just a curtain in the OR holding area, where sensitive medical and personal information is spoken out loud within earshot of other patients, other patients' families, and noninvolved caregivers. This concern is difficult to address and there is no one universally applicable suggestion. However, anesthesia professionals who interact with patients in such environments should be as sensitive as physically possible to being overheard and also should bring such concerns to the attention of the facility administrators.

Further, many anesthesiology practices also must apply HIPAA provisions to their billing operations; the details will vary depending on the mechanisms used and a great deal will depend on which type of electronic claims submission software is being used by the billing entity actually submitting the claims.⁵⁵ Telephone calls and faxes into offices must be handled specially if containing identifiable patient information. Presentation of patient information for QA or teaching purposes must be free of all identifiers unless specific individual permission has been obtained on prescribed printed forms. Requests for patient information from a wide variety of outside entities, including insurance companies and collection agencies, must be processed in HIPAA-compliant ways. HIPAA policy and actions, as well as enforcement activities, are being developed over time and as situations develop. This system depends in part on patient complaints for both enforcement and policy evolution. In many practices and practice locations, there have been few or even no formal complaints of violations of patient privacy, indicating the initial implementation of HIPAA compliance may have largely had the desired effect.

Electronic Medical Records

Databases, spreadsheets, and electronic transfer of information are nonspecific features that have been applied to health care. The classic medical record, on the other hand, has required the creation of entirely new software in an attempt to duplicate the function of the handwritten or dictated traditional “chart.” This has afforded opportunities to multiple

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competing commercial entities to attempt to fill this need. Usually, competing proprietary systems are incompatible and do not “talk to each other.” This fact severely limits one of the highly touted benefits of medical practices “going electronic.” Cost is another great barrier, as is the formidable task of entering the required information from the old paper records into the electronic system. There has been governmental and public pressure for health care institutions, facilities, and practices to adopt electronic records because of the potential for increased legibility causing reduction in errors and confusion, greater speed of filing and retrieval, easy transmission of large amounts of information (such as from a surgeon's office to an anesthesia practice's booking office and also to a hospital's preoperative clinic or OR holding area), and QA monitoring of vast databases. Increased ease of transmission and filing of reimbursement claims and cost savings from clerical staff down-sizing are claims intended to encourage physician practice groups to adopt electronic medical records (EMRs). However, experience to date has suggested that the commercially available software systems (both for institutions and practice groups) are not as robust or reliable as advertised by their often aggressive manufacturers. Accordingly, the expected benefits have not materialized quite as predicted, particularly in that costs have been great, often far in excess of estimates, and cost savings have been minimal at best. Practice groups of anesthesia professionals should consider all of these noted points prior to investing in an EMR system. At minimum, careful study and evaluation of the same system already in place in another anesthesiology practice should be undertaken.

If basic EMR implementation has been problematic for practices, true electronic anesthesia information management systems have been even more difficult. These include preoperative, intraoperative, postoperative, billing, and QA components. For the actual OR anesthesia record, several commercial versions are available. Different anesthesia professionals have various opinions about ease of implementation and subsequent use. Unless one massive bolus of fully integrated new technology from a single manufacturer is installed all at one time, integration of a new EMR with the existing anesthesia machines and monitors to ensure full accurate capture of all data parameters can often be difficult and frustrating. The function and value of electronic anesthesia records can be debated endlessly. All of them today will require computers on or in the anesthesia machine. These computers should be Internet-enabled so that demographic and billing information can be automatically uploaded to the facility's and the practice's database. Any such system must also integrate with the billing systems of the facility and the practice or the touted benefits will be largely negated. Again, the best, and in some senses, the only way to evaluate seriously and thoroughly a proposed major investment of money, effort, and time is to visit a fully up-and-working installation of that electronic anesthesia information management system and talk directly in detail with the users. The costs, in all senses of the word, are so great that it remains a significant gamble to be the first to purchase and implement such a system.

Expansion Into Perioperative Medicine, Hospital Care, and Hyperbaric Medicine

Some anesthesiologists now function at least some of the time in preoperative screening clinics because of the great fraction of OR patients who do not spend the night before surgery in the hospital or who do not come to a hospital at all. In such settings, these anesthesiologists frequently assume a role analogous to that of a primary care physician, planning and executing a workup of one or more significant medical or surgical problems before the patient can reasonably be expected to undergo surgery. Likewise, this concept would be excellent for the postoperative period. An anesthesiologist, completely free of OR or other duties, could not only make at least twice-daily rounds of patients after surgery and provide exceedingly comprehensive pain-management service, but also could follow the surgical progress and make reports (likely via an EMR or e-mail) to the surgeon's office or alphanumeric pocket communicator. A fundamental aspect of the practice of anesthesiology is the management of acute problems in the hospital setting. It is logical that anesthesiologists would be among the physicians best suited to provide primary care for patients in the hospital setting.

An additional evolving opportunity is the creation and implementation of “rapid response teams” within acute care hospitals. In essence, studies have revealed that patients on general care nursing floors sometimes begin to deteriorate and, for one reason or another but often because of the responsible physician being unavailable or at a considerable distance at that moment, the patients are not evaluated or treated in a timely manner and often not until they have further deteriorated, sometimes to a critical status. Therefore, a national trend has developed in which hospitals create a team of knowledgeable professionals (who have other regular responsibilities) who usually have no prior knowledge of the deteriorating patient but who will respond within a very few minutes to the call from (usually) a floor nurse who detects a deteriorating patient (e.g., increasing fever, relative hypotension and tachycardia, absent urine output). Frequently, the rapid response team institutes immediate symptomatic treatment, arranges for a higher acuity level of care, and contacts the primary responsible physician. Importantly, in larger hospitals, it has been suggested that the in-house anesthesiologists are uniquely qualified to be key members of the rapid response team because the interventions almost always involve acute “bread-and-butter” resuscitative care. Although many anesthesiologists may believe they already have plenty of work in the OR, such participation when possible would be an outstanding and highly visible contribution to the hospital's mission of enhanced patient care. Also, such interventions could be separately billable encounters as consultations or, alternatively, excellent support for the maintenance or even increase of the hospital's financial subsidy to its anesthesia professional group.

Finally, anesthesiologists in some locations have become involved in the practice of hyperbaric medicine and wound care. This is likely related to the familiarity of anesthesiologists with concepts of gas laws and physics, along with their constant presence in the hospital. The treatment of various medical conditions by the application of oxygen under increased pressure, usually 2 to 3 atmospheres absolute, at one time was one of the more rapidly growing hospital services. Anesthesiologists are among the leaders of this field, with unlimited opportunities for clinical care, teaching, and research. Even a brief discussion of this field is outside the scope of this chapter, and interested readers are referred to the Undersea and Hyperbaric Medical Society (www.umhs.org).

Operating Room Management

The role of anesthesiologists in OR management has changed dramatically in the past few years. With the current climate of a considerable shortage of anesthesia professionals, hospitals subsidizing many anesthesiology group practices, and an increasing workload, participation in OR management is essentially mandatory. The current emphasis on cost containment and efficiency will force anesthesiologists to take an

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active role in eliminating many dysfunctional aspects of OR practice that were previously ignored. First-case morning start times have changed from a suggestion to a mandate. Delays of any sort are now often tracked electronically in real time and carefully scrutinized to eliminate waste and inefficiency. Together, anesthesiologists, surgeons, OR nurses and technicians, and increasingly, professional administrators/managers need to determine who is best qualified to be a leader in the day-to-day management of the OR.⁵⁶ Clearly, different groups have different perspectives. However, anesthesiologists are in the best position to see the “big picture,” both overall and on any given day. Surgeons are commonly elsewhere before and after their individual cases (and sometimes for the beginning and the end of their cases); nurses and administrators may lack the medical knowledge to make appropriate, timely decisions, often “on the fly.” It is the anesthesiologist with the insight, overview, and unique perspective who is best qualified to provide leadership in an OR community. The subsequent recognition and appreciation from the other groups (especially hospital administration) will clearly establish the anesthesiologists as concerned physicians genuinely interested in the welfare of the OR and the institution.

Organization

The symbiotic relationship between anesthesia professionals and surgeons remains unchanged. Both groups recognize this fact and also the common goal of having the OR function in a safe, expeditious manner. The age-old question, “Who is in charge of the operating room?” still confronts many hospitals/institutions. Because some anesthesiology groups are subsidized by the hospital, the OR organization in such cases has changed accordingly. Many hospital administrators want to have input regarding who is in charge of the OR with an eye to increasing efficiency and throughput while reducing cost. Their wishes have an even added significance when more of their dollars are involved through the anesthesiology group subsidy. Sometimes there can be no real answer to, “Who's in charge?” because of the complexity of the interpersonal relationships in the OR. Some institutions have a professional manager (often a former OR registered nurse) whose sole job is to organize and run the OR. This individual may be vested with enough authority to be recognized by all as the person in charge. Other institutions ostensibly have a “medical director of the OR.” However, the implications to the surgeons that an anesthesiologist is in charge, or vice versa, have caused many institutions to abandon the title or retain the position but assign no authority to it. In such instances, institutions usually resolve disputes through some authority with a physician's perspective. If there is no medical director with authority to make decisions stick, central authority usually resides with the OR committee, most often populated by physicians, senior nurses, and administrators. Every OR has this forum for major policy and fiscal decisions. As part of committee function, the standard practices of negotiation, diplomacy, and lobbying for votes are regularly carried out. The impact of such an OR committee varies widely among institutions.

Despite the constantly changing dynamics of the OR management and the frequent major frustrations, anesthesiologists should pursue a greater role in day-to-day management in every possible applicable practice setting. An anesthesiologist who is capable of facilitating the start of cases with minimal delays and solving problems “on the fly” as they arise will be in an excellent position to serve his or her department. Succeeding in this role will have a dramatic positive impact on all the OR constituents. The surgeons will be less concerned about who is in charge because their cases are getting done. The hospital administration will welcome the effort because they want something extra in return for any money they are now giving to the anesthesiology groups as a subsidy. Furthermore, the OR committee (or whatever system for dispute resolution is in place) is still functional and has not been circumvented (and will be thankful for the absence of disputes needing resolution).

Some institutions use the term Clinical Director of the OR. The person awarded this designation should be a senior-level individual with first-hand knowledge of the OR environment and function. Anesthesiologists have a better understanding of the perioperative process. They possess the medical knowledge to make appropriate decisions. Their intimate association with surgeons and their patients allows them to best allocate resources. The American Association of Clinical Directors in 2002 reported that 71% of survey respondents stated that an anesthesiologist was designated as the Clinical Director of the OR.

Contact and Communication

An important issue for the anesthesia professionals in any OR setting is who among the group will be the contact person to interact with the OR and its related administrative functions. In situations in which everyone is an independent contractor, there may be a titular chief who by design is the contact person. The anesthesiologist in this role commonly changes yearly to spread the duties among all the members. Large groups or departments that function as the sole providing entity for that hospital/facility often identify an individual as the contact person to act as the voice for the department. Furthermore, these same groups delineate someone on a daily basis to be the clinical director, or the person “running the board.” Frequently, this position is best filled by one of a small dedicated fraction of the group (e.g., three people) rather than rotating the responsibility among every member of the group. Experienced “board runners” have an instinctually derived better perspective on the nuances of managing the operating schedule in real time. Certain procedures may require specific training (e.g., transesophageal echocardiography skills) that not all members of the group possess. Clearly, changes sometimes have to be made to match the ability of the anesthesia provider and the requirements of the procedure when urgent or emergent cases are posted.

Another benefit of a very small number of daily clinical directors is a relative consistency in the application of OR policies, particularly in relationship to the scheduling of cases, especially add-ons. One of the most frustrating aspects to both surgeons and OR personnel is unpredictability and inconsistency in the decisions made by the anesthesia group/department members. A patient deemed unacceptable for surgery by anesthesiologist X on Monday may be perfectly acceptable, in the same medical condition, for anesthesiologist Y on Tuesday. Disagreements are inevitable in any large group. However, day-to-day OR function may be hampered by a large number of these types of circumstances. Having one member of a very small group in charge will lead to more consistency in this process, especially if the board runner/clinical director has the authority to switch personnel to accommodate the situation. Without stifling individual practices, philosophies, and comfort levels, a certain amount of consistency applied to similar clinical scenarios will improve OR function immeasurably. These few dedicated directors should be able to accomplish both goals better than a large rotating group.

A newer potential component of intra-OR communications is the concept of checklists and team briefings. Analogous to the now-required “time out” in each OR prior to surgical incision when the correct identity of the patient, the intended procedure, and any laterality involved is verified, some ORs are attempting to have a similar interprofessional communication

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involving all relevant OR personnel (the team) prior to the patient entering the actual OR, during which the involved surgeon, anesthesia professional, circulating nurse, scrub person, and support persons as indicated each acknowledge a summary of what is projected to take place in this case, any anticipated need for extra or unusual resources or equipment, any anticipated difficulties or increased risks, and specific plans to deal with any feature of any of these points that would require intervention. In many models, a printed single-page checklist with routine prompts and fill-in boxes is used to facilitate the process. One study reported a two-thirds' reduction in “communication failures” that have otherwise likely caused problems, risks, or inefficiencies.⁵⁷

Materials Management

Usually, the institutional component of the anesthesia service staffs and maintains a location containing the specific supplies unique to the practice of anesthesia (“the workroom”). Objectives necessary for efficient materials management include the standardization of equipment, drugs, and supplies. Avoidance of duplication, volume purchasing, and inventory reduction are also worthwhile. There needs to be coordination with the OR staff as to who is responsible for acquisition of routine hospital supplies such as syringes, needles, tubing, and intravenous fluids. Decisions as to which brands of which supplies to purchase ideally should be made as a group. Often, when several companies compete against each other in an open market, lower prices are negotiable. These negotiations may occur between the anesthesia professionals and the hospital administration, or by the physician components of the OR committee. In many cases, however, hospitals belong to large buying groups that determine what brands and models of equipment and supplies will be available, with no exceptions possible except at greatly increased cost. Sometimes, this is false economy if the provided items are inferior (cheap) or annoying and, for example, if it routinely takes opening three or four intravenous cannulae in the process of starting a preoperative intravenous line as opposed to the higher quality and reliable single one that may cost more per cannula but is less expensive overall because far fewer will be used. Dispassionate presentation of such logic by a respected team-player senior anesthesiologist to the OR committee or director of materials management may help resolve such conundrums.

Scheduling Cases

Anesthesiologists need to participate in the OR scheduling process at their facility or institution. In some facilities the scheduling office and the associated clerical personnel work under the anesthesia group. Commonly, scheduling falls under the OR staff's responsibility. Direct control of the schedule usually resides with the OR supervisor or charge person, frequently a nurse. Whatever the arrangements, the anesthesia group must have a direct line of communication with the scheduling system. The necessary number of anesthesia professionals that must be supplied often changes on a daily basis per the caseload and sometimes because of institutional policy decisions. After-hours call must be arranged, policy changes factored in, and additions/subtractions to the surgical load (day-to-day, week-to-week, and long-term as surgical practices come and go in that OR) dealt with as well. These issues are important even when all the anesthesia professionals are independently contracted and are not affiliated with each other. In such situations, the titular chief of anesthesia should be the one to act as the link to the scheduling system. When the anesthesia group/department functions as a single entity, the chairman/chief, clinical director, or appointed spokesperson will be the individual who represents his or her group at meetings in which scheduling decisions are made in conjunction with the OR supervisors, surgeons, and hospital administrators.

There are as many different ways to create scheduling policies as there are OR suites. Most hospitals/facilities follow patterns established over the years. Despite all the efforts directed toward its creation, the OR schedule (both weekly time allotments and day-to-day scheduling of specific cases) remains one of the most contentious subjects for the OR. Recognizing the fact that it is impossible to satisfy everyone, the anesthesia group should endeavor to facilitate the process as much as possible. Initially, anesthesiologists need to be sympathetic toward all the surgeons' desires/demands (stated or implied) and attempt to coordinate these requests with the institution's ability to provide rooms, equipment, and staff. Secondly, the anesthesia group should make every possible effort to provide enough anesthesia services and personnel to realistically meet the goals of the institution. In light of the current shortage of anesthesia professionals in this country, these efforts need to be made with a great deal of open communication among all contingencies of the OR committee as well as every member of the anesthesia group.

Regarding scheduling, surgeons essentially fall into one of three groups. One group wants to operate any time they can get their cases scheduled. This group wants the OR open 24/7. Another larger group wants “first case of the day” as often as possible so they can get to their offices. A smaller third group wants either the first time slot or an opening following that time slot, a several-hour hiatus, then to return to the OR after office hours to complete additional cases; usually starting after 5 PM. Clearly a compromise among these disparate constituencies must be reached. Anesthesiologists who approach the OR committee regarding this dilemma with a nonconfrontational attitude will greatly facilitate agreement on a compromise.

Types of Schedules

The majority of ORs use either block scheduling (preassigned guaranteed OR time for a surgeon or surgical service to schedule cases prior to an agreed-upon cut-off time; e.g., 24 or 48 hours before) or open scheduling (first come, first serve). Most large institutions have a combination of both. Block scheduling inherently contains several advantageous aspects for creating a schedule. Block scheduling allows for more predictability in the daily OR function as well as an easy review of utilization of allotted time. Historic utilization data should be reviewed with surgeons, OR staff, and the OR committee to determine its validity. Many operating suites have found it useful to assemble rather comprehensive statistics about what occurs in each OR. Some computerized scheduling systems (see following discussion) are part of a larger computerized perioperative information management system that automatically generates statistics. Graphic examples are 13-month “statistical control charts” or “run charts” that show the number of cases, number of OR minutes used for those cases (and when, such as in block, exceeding block, evenings, nights, weekends, and so forth), number of cancellations (and multiple other related parameters if desired) by service, by individual surgeon, and total for the current month and the 12 prior months, always with “control limits” (usually 2 SD from the 13-month moving average) clearly indicated. All these data are valuable in that they generate a clear picture of what is actually going on in the OR. It is also extremely valuable in that block time allocation should be reviewed periodically and adjusted based on changes, degree of utilization, and projected needs. Inflexible block time scheduling can create a major point of contention if the assigned blocks are not regularly reevaluated. The surgeon or surgical service with the early starting block that habitually

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runs beyond his or her block time will create problems for the following cases. If this surgeon were made to schedule into the later block on a rotating basis, delays in his or her start caused by others may provoke improved accuracy of his or her subsequent early case postings. Adjustments in availability of block time can also be made in the setting of the “release time,” the time prior to the operative date that a given block is declared not full and becomes available for open scheduling. Surgeons prefer as late a release time as possible in order to maintain their access to their OR block time. However, unused reserved block time wastes resources and prevents another service from scheduling. A single release time rarely fits all circumstances, but negotiating service-specific release times may lead to improved satisfaction for all. In the ideal system, enough OR time and equipment should exist to provide for each surgical service's genuine needs while retaining the ability to add to the schedule (via open scheduling) as needed. Such an environment does not exist. Invariably, in busy environments, surgical demand exceeds available block and open time, leading services to request additional block time. When this time is not granted, services perversely then schedule procedures in open time before filling their block time. Surgeons who prefer open time would then be shut out of OR time. Open scheduling may reward those surgeons who run an efficient service, but it also may be a source of problems to those surgeons who have a significant portion of their service arrive unscheduled, such as orthopaedic surgeons. Some degree of flexibility will be necessary whichever system is used. The anesthesia group should adopt a neutral position in these discussions while being realistic about what can be accomplished given the number of ORs and the length of the normal operating day.

The handling of the urgent/emergent case posting precipitates a great deal of discussion in most OR environments. No studies allow determination of exactly what rate of OR utilization is the most cost-effective. However, many institutions subscribe to following parameters: adjusted utilization rates averaging below 70% are not associated with full use of available block time, wasting resources, while rates above 90% are frequently associated with the need for overtime hours.⁵⁸ Different OR constituencies have different comfort zones for degrees of utilization (Table 2-2). Most institutions cannot afford to have one or two ORs staffed and waiting unless there is a reliable steady supply of late open-schedule additions, that is, urgent cases/emergencies, during the regular work day. A previously agreed-upon, clear algorithm for the acceptance and ordering of these cases will need to be adopted. In general, critical life-threatening emergencies and elective add-ons are fairly straightforward and at the two ends of the spectrum. The critical emergency goes in the next available room, whereas the elective case gets added to the end of the schedule. The so-called urgent patient requires the most judgment. Individual services should provide guidelines and limitations for their expected urgent cases. These “add-on case policy” guidelines⁵⁹ should be common knowledge to everyone involved in running the OR. Consequently, these cases, such as ectopic pregnancies, open fractures, the patient with obstructed bowel, and eye injuries, can then be triaged and inserted into the elective schedule as needed with minimal discussion from the delayed surgeon. The surgeons whose urgent case is presented as one that must immediately bump another service's patient, yet could wait several hours if it is their own patient that will be delayed, will have to face their own previously agreed-upon standards in a future OR committee meeting. A simple way to express one logical policy for urgent cases (e.g., acute appendicitis, unruptured ectopic pregnancy, intestinal obstruction) is: 1) bump the same surgeon's elective scheduled case; 2) if none, bump a scheduled case on the same service (gynecology, general A, and so forth); 3) if none, bump a scheduled case from an open-schedule surgical service; and 4), if none, bump a scheduled case from a block schedule service.⁵⁹ Some institutions require the attending surgeon of the posted urgent/emergent patient to speak personally with the surgeon of any bumped case.

Table 2-2 Operating Room (or) Utilization: “Comfort Zones” of the Operating Room Personnel Constituencies

BLOCK TIME UTILIZATION (%) FACILITY ADMINISTRATION ANESTHESIOLOGY GROUP OR STAFF SURGEONS >100 ++ -- --- ---- 85–100 ++++ ++ - --- 70–84 +++ ++++ + + /- 53–69 + +++ +++ ++ <55 -- - ++ ++++ “+”, favorable; “-”, unfavorable. Reprinted from Mazzei WJ: OR management: State of the art. Proceedings of the 2003 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2003, p. 65 with permission.

Another area of burgeoning growth that must be accounted for in the daily work schedule is the non-OR “off site” diagnostic test, or therapeutic intervention that requires anesthesia care. In many instances these procedures replace operations that, in the recent past, would have been posted on the OR schedule as urgent/emergency cases. For example, cerebral aneurysm coiling and computed tomography-guided abscess drainage, among other procedures, are done in imaging suites; some patients, adult as well as pediatric, require deep sedation or even general anesthesia for magnetic resonance imaging or computed tomography in radiology or for invasive procedures in catheterization laboratories. Additionally, depending on distances involved and logistics, it may even be necessary to assign two people, a primary provider and an attending, exclusively to that one remote location when, had the case come to the OR, the attending may have been able to cover another or other cases also. Hospital administration or the OR committee may try to view these cases as unrelated to OR function and, thus, purely a problem for the anesthesia group to solve. These cases must be treated with the same methodology regarding access and prioritization as all other OR procedures.

In order to apportion hospital-based anesthesia resources reasonably, these off-site procedures should be subject to the same guidelines and processes as any other OR posting. Most institutions have added at least one extra anesthetizing location to their formal operating schedule to designate these off-site

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procedures (occasionally with an imaginative name such as “road show,” “outfield,” or “safari”). For many of these off-site cases, there is little or no reimbursement for anesthesia care. Most government plans and insurance carriers will probably not pay for the claustrophobic adult to receive monitored anesthesia care or even a general anesthetic for an obviously needed diagnostic magnetic resonance image, even though the patient, the surgeon, and the hospital benefit from the test results. The anesthesia group, the OR committee, and the hospital administration need to reach compromises regarding off-site procedures, regarding scheduling, allocation of anesthesia resources that would otherwise go to the OR, and even subsidization of the personnel costs in order to continue this obviously beneficial service.

Computerization

Computerized scheduling will likely benefit every OR regardless of size. Whether this scheduling function should be one component of a comprehensive EMR system is a complex question, as previously noted. In the OR, however, computerization allows for a faster, more efficient method of case posting than any hand-written system. Changes to the schedule can be made quickly without any loss of information. Rearranging the daily schedule is much simpler on a computer than erasing and rewriting on a ledger. Furthermore, most hospitals have adopted a computer-determined average time for a given surgical procedure for that particular surgeon. Commonly, this time is the average of the last 10 (or 10 of the last 12, with the longest and shortest discarded) of the specific procedure (e.g., total knee replacement) with the potential to add a modifier (e.g., it is a repeat surgery) that shows a material difference in the projected time length (almost always longer) for one particular patient type. Suppose surgeon X has block time of 8 hours on a given day and wants to schedule four procedures in that allotted time. The computerized scheduling program looks at surgeons X's past performances and determines a projected length for each of the procedures that are identified to the computer usually by CPT-4 codes or possibly some other code developed locally for frequent procedures done by surgeon X. (Note that the recorded time length includes the turnover time, thus making the case time definition from the time the patient enters the OR until the time any following patient enters that OR [unless an “exception” is entered specifically for an unusual circumstance].) The use of agreed-upon codes instead of just text descriptions helps ensure accuracy because it eliminates any need for the scheduling clerk to guess what the surgeon intends to do. Bookings in most circumstances should not be taken without the accompanying codes (surgeons' offices objections not withstanding). The computer then decides whether surgeon X will finish the four procedures in the allotted block time. If the computer concludes that the fourth case would finish significantly (the definition of which can be determined and entered into the program) beyond the available block time, it will not accept the fourth case into that room's schedule on that particular day. The surgeon will accept the computer's assigned times and adjust accordingly, planning only three cases, or appeal for an “exception” based on some factor not in the booking that is claimed will materially decrease the time needed for at least one of the four cases, which the surgeon must explain to the “exception czar” (anesthesiology clinical director or OR charge nurse) of the day. An alternative method has the computer simply add (to each case except the last) a projected turnover time that is agreed upon by all involved at an (often contentious) OR committee meeting. Computerizing the scheduling process significantly reduces any personal biases and smoothes out the entire operating day. The long-standing ritual of late-afternoon disputes between the surgeons and the anesthesia group and/or OR staff whether or not to start the last case may be eliminated or at least reduced by this more realistic prospective OR scheduling method.

There are many variables to consider in any OR scheduling system. The patient population served and the nature of the institution dictate the overall structure of the OR schedule. Inner-city level 1 trauma centers must accommodate emergencies on a regular basis, 24 hours a day. These centers are unlikely to create a workable schedule more than a day in advance. An ambulatory surgery center serving plastic surgery patients may see only the rare emergency bring-back bleeding patient. Their schedule may be accurate many days in advance, with a high degree of expectation that the patient will arrive on time properly prepared for surgery. The anesthesia group at this ambulatory center may rarely have to make changes to the schedule, allowing them to proceed with a fairly predictable daily workload. At the inner-city trauma hospital, a great deal of flexibility and constant communication with the surgeons will be required in an attempt to get the cases done in a reasonable time frame with the inherent constraints placed on the OR staff's resources and the time available. These two extreme examples from opposite ends of the scheduling-process spectrum can provide guidelines for the majority of the institutions that fall somewhere in between. Beyond open communication, how best to work toward this mutual understanding depends on the particulars of the people involved and the environment, but some ORs report benefits from team-building exercises, leadership retreats, and even OR-wide social events. ORs with a particularly malignant history of finger-pointing and bad feelings among the personnel groups may constitute one of the few instances an outside consultant really may be valuable in that there are workplace psychologists who specialize in analyzing dysfunctional work environments and implementing changes to improve the situation for all involved.

Preoperative Clinic

An anesthesia preoperative evaluation clinic (APEC) that provides a comprehensive perioperative medical evaluation usually results in a more efficient running of the OR schedule.^60,61Unanticipated cancellations or delays are avoided when the anesthesia group evaluates complex patients prior to surgery. Even if the patient arrives to the OR on time the day of surgery, inadequate preoperative clearance mandating the ordering of additional tests will consume precious OR time during the delay waiting for results. Cancellations or delays adversely affect the efficiency of any OR. Subsequent cases in the delayed room, whether for the same or a different surgeon, may get significantly delayed or forced to be squeezed into an already busy schedule on another day. The financial impact of delays or cancellations on the institution is considerable. Revenue is lost with no offsetting absence of expenses. Worse, expenses may actually increase when overtime has to be paid, or the sterile equipment has to be repackaged after having been opened for the canceled procedure. Even worse, the inconvenienced patient and/or surgeon may go to another facility.

Optimal timing for preoperative evaluation should be related to the institution's scheduling preferences, patient convenience, and the overall health of the patient. Earlier completion of the preoperative evaluation may not reduce the overall cancellation rate when compared with a more proximate evaluation. However, an early evaluation and clearance may well provide a larger pool of patients available to place on the OR schedule (block or open) resulting in a more efficient use of OR time. Additionally, a protocol-driven evaluation process can anticipate possible need for time-consuming investigations (such as a cardiology evaluation for the patient with probable angina). Early recognition of a failed preoperative test allows

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time for another patient to be moved into the now-vacant time slot. Also, early identification of certain problems requiring special care on the day of surgery (e.g., preoperative epidural or PA catheter placement) should lead to fewer unanticipated delays. Unfortunately, many issues precipitating delays are discovered on the day of surgery. Some of these preventable delays are unrelated to the patients' health status. Seemingly simple issues such as verification of a ride home or incomplete financial information also contribute to unexpected delays. A properly functioning APEC may be able to eliminate a majority of these annoying causes of preventable delays.

Regardless of the institutional specifics surrounding the service provided by the APEC, further cost savings can be obtained through its proper usage by the anesthesia group. The APEC frequently reduces dramatically the number of preoperative tests performed by focusing on which diagnostic tests and medical consults are really required for any specific patient. In some circumstances, the APEC may also function as an additional source of revenue for the anesthesia group when a formal preoperative consult on a complicated patient is ordered well in advance by the surgeon, in the same manner as would have otherwise been directed to a primary care physician for “clearance for surgery.” The ability to centralize pertinent information including admission precertification/clearance, financial data, diagnostic and laboratory results, consult reports, and preoperative recommendations improves OR function by decreasing the time spent searching for all these items after changes have been made to the schedule. Patient and family education performed by the APEC frequently leads to an increase in patients' overall satisfaction of the perioperative experience. In addition, patient anxiety may be reduced secondary to the more in-depth contact possible inherent in the APEC process when compared with anesthesia practitioners meeting an ambulatory outpatient for the first time in an OR holding area immediately prior to surgery. The APEC model enables the anesthesia group to be more active and proactive in the perioperative process, improving their relations with the other OR constituents.

Anesthesiology Personnel Issues

In light of the current and future shortage of anesthesia care providers, creating, managing, and maintaining a stable supply of anesthesia practitioners promises to dominate the OR landscape for years to come.⁶² Active recruiting for anesthesiologists appears to be widespread and intense, sometimes involving creative marketing and incentives.⁶³ The lean resident recruiting years of the mid to late 1990s continue to impact the profession. Even though applications to anesthesiology residencies from highly qualified applicants rebounded significantly,⁶² it will take many more years of relatively large numbers of anesthesia residency graduates to even begin to address actual needs.⁶⁴ Further, just as the overall projected dramatic shortage of physicians in general has led to the opening and planning of several new medical schools in the United States, perhaps the shortage of anesthesiologists (still estimated at several thousand) will provoke the establishment of new residency training programs. Furthermore, the supply of nonphysician anesthesia professionals is also dwindling. With the aging population of nurse anesthetists and the limited number of applications to schools in that profession, as well as the very limited number of training facilities for anesthesiology assistants, the overall supply of anesthesia professionals remains inadequate to meet current and, at least, short-term future demands. The need for anesthesia groups to create a flexible, attractive work environment in order to retain providers who might leave or retire will continue to increase.

A related issue is consideration of what is a reasonable work load for an anesthesiologist and how best to measure, if possible, the clinical productivity of an anesthesia group/ department. These questions have been the subject of considerable discussion.^65,66,67,68 Beyond the simple number of full-time equivalents, cases, and OR minutes, consideration of factors such as the nature of the facility, types of surgical practice, patient acuity, and speed of the surgeons must be incorporated to allow fair comparisons. Thoughtful filtering of resulting data should take place before dissemination of the aggregate information to all members of a group because of the understandable extreme sensitivity among stressed and fatigued anesthesiologists to a suggestion that they are not working as hard as their group/department peers.

Except in highly unusual circumstances, flexible scheduling of anesthesia professionals and also fulfilling the demands placed on the group by the institution continues to be a constant balancing act. This demand assumes added significance because institutions now subsidize many anesthesia groups. Even when a majority of providers in a facility are independent contractors where it is required that a specific surgeon request their services, there are time conflicts ranging from no one at all being available to unwanted down time. When the anesthesia group/department accepts the responsibility of providing anesthesia services for an institution, they must schedule enough providers for that OR suite on each given day. Ideally, a sufficient number of professionals would be hired so that there would always be enough personnel to staff the minimum number of rooms scheduled on any given day, as well as after-hours call duty. This situation rarely exists because it would be financially disadvantageous to have an excess number of providers with no clinical activity. Having exactly the right number of anesthesia professionals in a group for the clinical load works well until one (or more) of them is out with an unplanned absence such as an extended illness or a family emergency. Many academic departments have a natural buffer with some clinicians assigned intervals of nonclinical time for research, teaching, or administrative duties. However, repeated loss of these nonclinical days because of inadequate clinical staffing in the OR leads to undermining the academic/research mission of the department. Continued loss of this time will eventually lead to faculty resignations (and possible migration to private practice), thus eliminating the original buffer. Consequently, anesthesia groups/departments need to anticipate available clinical personnel and match them to the OR demands. Ideally, this information should be accurate for several months into the future. Meeting this specification has become more difficult in the recent past. Hospital administrators must offer reasonable assurances to the anesthesia group providing service that a given OR utilization rate is likely, as well as accurate data regarding reimbursement (payer mix and any package contracts negotiated by the hospital). These data must be provided accurately and updated frequently if a health care institution is to acquire and retain an anesthesia group staffed with the personnel to meet the expected demands.

Timing

Each operating environment has its own personnel scheduling system and expectations for the anesthesia group. Daily coordination between the anesthesia group's clinical director and the OR supervisor permits the construction of a reasonable schedule showing the number of ORs that day and when the schedule expects each of them to finish. Invariably, some cases take longer than anticipated or add-ons are posted, requiring the OR to run into the late afternoon or early evening. Many anesthesia professionals accept this occurrence as a matter of course. Few anesthesia professionals will tolerate this sequence of events as an essentially daily routine whether they are paid

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overtime or not. These practitioners become exhausted and resent the burdens continuously placed on them. If the OR schedule is such that add-ons frequently occur and elective cases run well into the evening, many anesthesia professionals will opt to protect their personal and family time and cut back their working hours or resign. Neither would be welcome in such a tight market. Under these circumstances, hiring additional personnel who are scheduled to arrive at a later time, for example, 11: 00 AM, and then providing lunch relief and staying late (e.g., 7: 30 PM or later if needed) to finish the schedule may well be a very worthwhile investment.

Another possible solution to the demands of an extended OR schedule on an anesthesia group's personnel may revolve around employing part-time anesthesia professionals. Part-time opportunities could enhance a group's ability to attract additional staff. In the past, a disproportionately high percentage of women chose anesthesiology as a career. In 1970, women represented 7.6% of the physician population but were 14% of anesthesiologists; much more recently, they make up 45% of the physician population and only 20% of anesthesiologists, proportionately a significant reduction.⁶⁹ Beyond the basic demographic shift among all physicians, one likely partial explanation for the decreased number of women anesthesiologists may be the lack of part-time positions, which will hamper an anesthesia group's ability to attract and keep at least some of the female anesthesia professionals.

Scheduling after-hours coverage also adds to the personnel difficulties facing the anesthesia group. The variations of call schemes are endless. The nature of the institution and the workload determine the degree of late-night coverage. Major referral centers and level 1 trauma centers require in-house primary providers. If these providers include residents and/or nurse anesthetists, then the supervising attending staff will also be in-house 24 hours a day. A common solution employed at many institutions is to staff the evening/night call shifts for an average workload, recognizing that on some occasions there will be idle ORs, and on other nights, the surgical demand will exceed the call team's numbers.

There are also medicolegal issues surrounding the call team's availability. At a small community hospital with a limited number of independent attending practitioners, the practitioners may agree to cover call on a rotating basis. The individuals not on call are usually not obligated to the OR and may well be truly unreachable. What happens then when the on-call anesthesiologist is administering an anesthetic and another true emergency case arrives in the OR suite and the remaining staff anesthesiologists are legitimately unavailable? Does that anesthesiologist leave his or her current patient under the care of an OR nurse and go next door to tend to a more acutely (possibly critically) ill patient? Should the patient be transferred from the emergency department to another (hopefully nearby) hospital? These questions have no easy answers. Clearly, those practitioners on the scene have to assess in real time the relative risks and benefits and make the difficult decisions. If the call duty requires the practitioner(s) frequently to work much or all of the night, leaving the individual(s) stressed and fatigued, they should not be required to work the next day during normal working hours.

A more complicated answer involves what to do when the call assignment rarely requires a long night's work and the on-call anesthesia professionals routinely have rooms assigned to them the next day, but at least one person has just finished a difficult 24-hour shift being awake and working all night. Anesthesia groups need to decide how to handle the possible call shift scenarios, with permutations and combinations, and clearly communicate prospectively their decisions to the OR committee before any difficult decision has to be made one morning. As always, the medicolegal aspects of any decision such as this need to be taken into consideration. Whether or not fatigue was a factor, the practitioner who worked throughout the night before and appeared to contribute to an anesthetic catastrophe the next morning would have a very difficult defense in court. Further, the anesthesiology group may also be held liable in that their practice/policy was in place, allegedly authorizing the supposedly dangerous conduct.

Cost and Quality Issues

One of the more pervasive aspects of American medical care in today's environment is the drive to maintain and improve high-quality health care while reducing the cost of that care. Health care costs account for a remarkable 16% of the gross domestic product, nearly triple the fraction a generation ago. Even more alarming, if costs continue to increase at the current rate, by 2016, it will be 20% of the gross domestic product. Consequently, all physicians, including anesthesiologists, are urged constantly to include cost-consciousness in decisions balancing the natural desire to provide the highest possible quality of care with the overall priorities of both the health care system and the individual patient, all while facing increasingly limited resources.⁷⁰ Anesthesiologists remain a target for limiting health care expenditures. Anesthesia professionals (directly and indirectly) have represented 3 to 5% of the total health care costs in the country.⁷¹ Complicated decisions are required regarding which patients are suitable for ambulatory surgery, what preoperative studies to order, what anesthetic drugs or technique is best for the patient, what monitors or equipment are reasonably required to run an OR, and the list goes on and on. With this as background, anesthesiologists legitimately can include economic considerations in their decision processes. When presented with multiple options to provide for therapeutic intervention or patient assessment, one should not automatically choose the more expensive approach (just to “cover all the bases”) unless there is compelling evidence proving its value. Decisions that clearly materially increase cost should only be pursued when the benefit outweighs the risk. In anesthesia care as well as medicine in general, such decisions can be difficult regarding interventions that provide marginal benefit but contain significant cost increases.⁷² Because cost containment initially requires accurate cost awareness, anesthesiologists need to find out the actual costs and benefits of their anesthesia care techniques. Details will be unique to each practice setting. Because they will be excited that the anesthesiologists actually care, usually it is possible to get the cooperation of the facility administration's financial department members in researching and calculating the actual cost of anesthesia care so that thoughtful evaluations of potential reductions can be initiated.

Anesthesia drug expenses represent a small portion of the total perioperative costs. However, the great number of doses actually administered contributes substantially to aggregate total cost to the institution in actual dollars. Prudent drug selection combined with appropriate anesthetic technique can result in substantial savings. Reducing fresh gas flow from 5 L/min to 2 L/min wherever possible would save approximately $100 million annually in the United States.⁷³ A majority of anesthesia professionals usually attempt a practical approach to cost savings, but they are more frequently faced with difficult choices regarding methods of anesthesia that likely produce similar outcomes but at substantially different cost. When comparing the total costs of more expensive anesthetic drugs and techniques to lesser expensive ones, many variables need to be added to the formula. The cost of anesthetic drugs needs to include the costs of additional equipment such as special vaporizers or extra infusion pumps and the associated maintenance. There are other indirect costs that may be difficult to quantitate and are commonly overlooked. Some of

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these indirect costs include increased set-up time, possibly increasing room turnover time, extended PACU recovery time, and additional expensive drugs required to treat side effects. Sometimes, more expensive techniques reduce indirect costs. A propofol infusion, although more expensive than vapor, commonly results in a decreased PACU stay for a short noninvasive procedure. If fewer PACU staff are needed or patient throughput is increased, the more expensive drug can reduce overall cost. Conversely, using comparatively expensive propofol for a long procedure definitely requiring postoperative admission to an ICU is hardly justified. The impact of shorter-acting drugs and those with fewer side effects is context-specific. During long surgical procedures, such drugs may offer limited benefits over older, less expensive, longer-acting alternatives.⁷⁴ Under these conditions, advocating cost containment using educational efforts may decrease drug expenditures for several categories of drugs.⁷⁵ Drugs in the same therapeutic class have widely varying costs. The acquisition expenses may vary as much as 50-fold in some pharmacologic categories. It is estimated that the 10 highest expenditure drugs account for >80% of the anesthetic drug costs at some institutions.⁷⁶ Although newer, more expensive drugs may be easier to use, no data exist to support or refute the hypothesis that these drugs provide a “better” anesthetic experience when compared with carefully titrated older, less expensive, longer-acting drugs in the same class.

Evaluation of outcomes and their subsequent application to cost analysis can be derived from two principle sources: data published in the literature and data collected from experience. As noted, computerized information management systems are useful tools to track outcomes and analyze the impact on the cost/benefit ledger. Using the collated data in the same manner as for OR utilization and case load, practitioners can readily apply a statistical process to evaluate outcomes in their practice, possibly including correlation with cost. This information may take on added importance in that published incidence studies may not exist for the specific outcome an anesthesia group is searching for. Cause-and-effect diagrams can track the parameters involved in the process and relate them to the various outcomes desired. Multiple pertinent examples could be constructed from the now-extensive body of literature on the factors contributing to postoperative nausea and vomiting and the various possible preventions and treatments, many of which involve very expensive medications. Of course, this can be done locally within an institution. Information would be collected and stored in the database. Ideally, the database would identify and track as many variables as needed/possible to delineate sources for possible improvement and its ultimate cost analysis. Once these sources for improvement and the ensuing cost impact are known, the anesthesia group can determine whether or not to pursue changing their practice. Outcomes related to adverse effects can also be monitored. If analysis reveals a significant difference in an adverse outcome among practitioners, after all the other variables such as surgeon, patient mix, and so forth are eliminated, the outcome database can investigate the anesthetic technique used by that practitioner. If significant variations are identified, that practitioner would be able to learn of these variations in a nonthreatening manner because computer-derived data is used as opposed to a specific case analysis, which might lead that practitioner to feel singled out for public criticism. The database becomes a tool both for QA and professional education.

Conclusion

Practice and OR management in anesthesiology today is more complex and more important than ever before. Attention to details that previously either did not exist or were perceived as unimportant can likely make the difference between success and failure in anesthesiology practice.

Outlined here are basic descriptions and understandings of many different administrative, organizational, financial, and personnel components and factors in the practice of anesthesiology. Ongoing significant changes in the health care system will provide a continuing array of challenges. Application of the principles presented here will allow anesthesiologists to extrapolate creatively from these basics to their own individual circumstances and then forge ahead in anesthesiology practice that is efficient, effective, productive, collegial, and even fun.

References

1. American Society of Anesthesiologists: 2003–04 Manual for Anesthesia Department Organization and Management. Park Ridge, IL, American Society of Anesthesiologists, 2003

2. American Society of Anesthesiologists: Anatomy of the Bargain: Sword, Shield, or Shackle? Park Ridge, IL, American Society of Anesthesiologists, 1999

3. Peters JD, Fineberg KS, Kroll DA, et al: Anesthesiology and the Law. Ann Arbor, MI, Health Administration Press, 1983

4. Gaba DM, Howard SK, Jump B: Production pressure in the work environment. Anesthesiology 1994; 81: 488

5. Eichhorn JH, Cooper JB, Cullen DJ, et al: Anesthesia practice standards at Harvard: A review. J Clin Anesth 1988; 1: 56

6. American Society of Anesthesiologists Task Force on Postanesthetic Care: Practice Guidelines for Postanesthetic Care. Anesthesiology 2002; 96: 742

7. Hawkins JL (Chair), et al: Practice guidelines for obstetrical anesthesia. Anesthesiology 2007; 106: 843

8. American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization: Practice guidelines for pulmonary artery catheterization: An updated report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Anesthesiology 2003; 99: 988

9. American Society of Anesthesiologists Task Force on Management of the Difficult Airway: Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98: 1269

10. Dans PE, Weiner JP, Otter SE: Peer review organizations: Promises and potential pitfalls. N Engl J Med 1985; 313: 1131

11. Peer review in anesthesiology, Park Ridge, IL, American Society of Anesthesiologists, 1993, pp 105

12. Eichhorn JH: Anesthesia equipment: Checkout and quality assurance. Anesthesia Equipment: Principles and Applications, Edited by Ehrenwerth J, Eisenkraft JB. St. Louis, Mosby–Yearbook, 1992, p 473

13. Eichhorn JH: Organized response to major anesthesia accident will help limit damage: Update of “Adverse Event Protocol” provides valuable plan. Anesthesia Patient Safety Foundation Newsletter 2006; 21: 11

14. Spooner RB, Kirby RR: Equipment-related anesthetic incidents. Analysis of Anesthetic Mishaps. Edited by Pierce EC, Cooper JB. Boston: International Anesthesiology Clinics 1984; 22: 133

15. Cooper JB, Newbower RS, Kitz RJ: An analysis of major errors and equipment failures in anesthesia management: Considerations for prevention and detection. Anesthesiology 1984; 60: 34

16. Caplan RA, Vistica M, Posner KL, et al: Adverse anesthetic outcomes arising from gas delivery equipment: A closed claims analysis. Anesthesiology 1997; 87: 741

17. Cooper JB, Newbower RS, Long CD, et al: Preventable anesthesia mishaps: A study of human factors. Anesthesiology 1978; 49: 399

18. Duberman S, Wald A: An integrated quality control program for anesthesia equipment, Risk Management and Quality Assurance: Issues and Interactions. Edited by Chapman-Cliburn G. Chicago, Joint Commission on the Accreditation of Hospitals, 1986, p 105

19. Olympio MA, Reinke B, Abramovich A: Challenges ahead in technology training: A report on the training initiative of the Committee on Technology. APSF Newsletter 2006; 21: 43

20. HHS Publication No. (FDA) 85-4196. Food and Drug Administration, Center for Devices and Radiologic Health, Rockville, MD 20857, p 10

21. Eichhorn JH: Influence of practice standards on anesthesia outcome, Outcome After Anesthesia and Surgery. Edited by Desmonts JM. Bailliere's Clinical Anaesthesiology—International Practice and Research. 1992; 6: 663

22. Eichhorn JH: Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology 1989; 70: 572

23. Keats AS: Anesthesia mortality in perspective. Anesth Analg 1990; 71: 113

24. Lagasse RS: Anesthesia safety: Model or myth? Anesthesiology 2002; 97: 1609

P.56

25. Cooper JB, Gaba DM: No myth: Anesthesia is a model for addressing patient safety. Anesthesiology 2002; 97: 1335

26. Peterson GN: Malpractice insurance: What are the limits? ASA Newsletter 2007; 71: 14

27. Bacon AK: Death on the table: Some thoughts on how to handle an anaesthetic-related death. Anaesthesia 1989; 44: 245

28. Runciman WB, Webb RK, Klepper ID, et al: Crisis management: Validation of an algorithm by analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21: 579

29. Davies JM, Webb RK: Adverse events in anaesthesia: The wrong drug. Can J Anaesth 1994; 41: 83

30. Cooper JB, Cullen DJ, Eichhorn JH, et al: Administrative guidelines for response to an adverse anesthesia event. J Clin Anesth 1993; 5: 79

31. Kraman SS, Hamm G: Risk management: Extreme honesty may be the best policy. Ann Intern Med 1999; 131: 963

32. Lazare A: Apology in medical practice: An emerging clinical skill. JAMA 2006; 296: 1401

33. Eichhorn JH: Patient perspective personalizes patient safety. APSF Newsletter 2005; 20: 61

34. Cox W: The five A's: What do patients want after an adverse event? J Healthcare Risk Management 2007; 27: 25

35. Semo JJ: Our hospital wants to employ us: Now what? Proceedings of the American Society of Anesthesiologists 2008 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2008, p 48

36. Practice management: Compliance with Medicare and other payor billing requirements. Park Ridge, IL, American Society of Anesthesiologists, 1997

37. Locke J: The net collections fallacy and other performance metric myths. Proceedings of the American Society of Anesthesiologists 2003 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2003, p 141

38. Managed Care Reimbursement Mechanisms: A Guide for Anesthesiologists. Park Ridge, IL, American Society of Anesthesiologists, 1994

39. Contracting Issues: A Primer for Anesthesiologists. Park Ridge, IL, American Society of Anesthesiologists, 1999

40. Willett DE: Exclusive contracts: Update on legal issues. Proceedings of the American Society of Anesthesiologists 2001 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2001, p 8

41. Scott SJ, Blough GG: Exclusive contracts: Survey of hospital contracts. Proceedings of the American Society of Anesthesiologists 2001 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2001, p 9

42. Practice Management: Managed Care Contracting. Park Ridge, IL, American Society of Anesthesiologists, 1996

43. Bierstein K: Pros and cons of exclusive contracts. ASA Newsletter 2006; 70(8): 36

44. Everett PC: Securing a hospital stipend: The business-like approach. Proceedings of the American Society of Anesthesiologists 2003 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2003, p 189

45. Semo JJ: Hospital stipend negotiations: Practical and legal issues. Proceedings of the American Society of Anesthesiologists 2004 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2004, p 51

46. Laden J, Monea M: Preparing the financial case for hospital support. Proceedings of the American Society of Anesthesiologists 2008 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2008, p 258

47. Rodin MA: Conflicts in managed care. N Engl J Med 1995; 332: 604

48. Adessa A: The vulnerability and potential extinction of independent, hospital-based practices. Proceedings of the American Society of Anesthesiologists 2008 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2008, p 65

49. Hetrick WD: Health care reform: Implications for the anesthesiologist. Adv Anesth 1995; 12: 1

50. Epstein AM, Lee TH, Hamel MB: Paying physicians for high-quality care. N Engl J Med 2004; 350: 406

51. Hannenberg AA: Progress report: Quality incentives in anesthesiology. Proceedings of the American Society of Anesthesiologists 2008 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2008, p 57

52. The HIPAA Privacy Rule in Anesthesia and Pain Medicine Practices. Park Ridge, IL, American Society of Anesthesiologists, 2003

53. Semo JJ: HIPAA privacy: What you need to know, what you need to do. Proceedings of the American Society of Anesthesiologists 2003 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2003, p 96

54. Semo, JJ: HIPAA privacy update. Proceedings of the American Society of Anesthesiologists 2004 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2004, p 123

55. Johnson JF: Questions to ask your billing software vendor. Proceedings of the American Society of Anesthesiologists 2003 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2003, p 130

56. Sexton J, Makary M, Tersigni, et al: Teamwork in the operating room. Anesthesiology 2006; 105: 877

57. Lingard L, Regehr G, Orser B, et al: Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 2008; 143: 12

58. Mazzei WJ: OR management. Proceedings of the American Society of Anesthesiologists 2001 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists ASA, 2001, 12-1

59. Malhotra V: Practical issues in OR management: The obvious and the not so obvious. Proceedings of the American Society of Anesthesiologists 2004 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2004, p 43

60. Pollard JB, Zboray AL, Mazze RI: Economic benefits attributed to opening a preoperative evaluation clinic for outpatients. Anesth Analg 1996; 83: 407

61. Fischer SP: Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology 1996; 85: 196

62. Schubert A: Implications of a changing anesthesia workforce. Proceedings of the American Society of Anesthesiologists 2008 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2008, p 297

63. Blough GG, Scott SJ: Creative scheduling for anesthesiologists: Physician retention in a tight market. Proceedings of the American Society of Anesthesiologists 2003 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2003, p 71

64. Schubert A: Anesthesiology resident class sizes and graduation rates. ASA Newsletter 2007; 71(12): 24

65. Abouleish AE, Prough DS, Zornow MH, et al: Designing meaningful industry metrics for clinical productivity for anesthesiology departments. Anesth Analg 2001; 93: 309

66. Abouleish AE, Prough DS, Whitten CW, et al: Comparing clinical productivity of anesthesiology departments. Anesthesiology 2002; 97: 608

67. Abouleish AE, Prough DS, Barker SJ et al.: Organizational factors affect comparisons of clinical productivity of academic anesthesiology departments. Anesth Analg 96: 802, 2003

68. Abouleish AE: Working hard: Hardly working; comparing clinical productivity of anesthesiology groups. Proceedings of the American Society of Anesthesiologists 2004 Conference on Practice Management. Park Ridge, IL, American Society of Anesthesiologists, 2004, p 195

69. Calmes SH: Anesthesiology Demographics: Women's Changing Specialty Choices and Implications for Anesthesiology Workforce Shortage. ASA Newsletter 2001; 65(8): 22

70. Tuman KJ, Ivankovich AD: High cost, high tech medicine—are we getting our money's worth? J Clin Anesth 1993; 5: 168

71. Johnstone RE, Martinec CL: Costs of anesthesia. Anesth Analg 1993; 76: 840

72. Eddy DM: Applying cost-effectiveness analysis: The inside story. JAMA 1992; 268: 2575

73. Baum JA: Low flow anaesthesia: The sensible and judicious use of inhalation anaesthetics. Acta Anaesthiol Scand 1997; 111: 264

74. Szocik JF, Learned DW: Impact of a cost containment program on the use of volatile anesthetics and neuromuscular blocking drugs. J Clin Anesth 1994; 6: 378

75. Barclay LP, Hatton RC, Doering PL, et al: Physicians' perceptions and knowledge of drug costs: Results of a survey. Formulary 1995; 30: 268

76. Johnstone R, Jozefczyk KG: Costs of anesthetic drugs: Experiences with a cost education trial. Anesth Analg 1994; 78: 766

Editors: Barash, Paul G.; Cullen, Bruce F.; Stoelting, Robert K.; Cahalan, Michael K.; Stock, M. Christine