PREOPERATIVE EVALUATION IN PRIVATE PRACTICE ANESTHESIA

The “Preoperative Evaluation” chapter in our Bible, Miller’s Anesthesia, is 80 pages long—one of the longest chapters in the book. As a double-boarded anesthesiologist and internal medicine doctor, preoperative evaluation has been my area of interest and expertise for decades. It’s almost June, and hundreds of anesthesia residents are about to graduate from residency programs. Are they more likely to continue in university practice or in community/private practice? Per the Anesthesia Quality Institute, in 2009 the majority of 41,693 anesthesiologists in the United States worked outside of academic centers.  While 43% worked in an academic medical center, 35% worked in a community hospital, 11% worked in a city/county hospital, and 6% worked solely in an ambulatory surgery center. In 2024 most academic medical centers utilize a preoperative anesthesia evaluation clinic to prepare and screen patients prior to surgery, but do community and private practice anesthesiologists commonly employ a preoperative anesthesia clinic in their practices?

No. Read on and I’ll explain why.

The concept of an anesthesia preoperative clinic originated at Stanford University Medical Center, as reported by my colleague Stephen Fischer MD in his landmark 1996 paper in Anesthesiology, “Development and effectiveness of an anesthesia preoperative evaluation Clinic in a teaching hospital.”  Dr. Fischer’s clinic existed within the hospital footprint, and was staffed by both residents and a faculty member. His clinic resulted in 87.9% fewer same-day case cancellations and $112 per patient savings in preoperative labs ordered. The paper also stated, “As it exists at Stanford, the anesthesia preoperative evaluation clinic may not be suitable in its entirety for all academic departments, private individuals, and groups that administer anesthesia.” Miller’s Anesthesia makes a similar statement regarding preoperative evaluation clinics: ”Anesthesia departments at hospitals with many medically complex surgical patients may benefit from the establishment of a formal preoperative evaluation facility with multiple examination rooms, dedicated staffing, and a full time operational system. The establishment of a successful preoperative evaluation clinic requires commitment, collaboration, and support from several hospital disciplines.”

Private practices didn’t rush to adopt the preoperative anesthesia clinic model, mainly because of the costs involved. Such a clinic requires office space, salaried employees, and at least one staff anesthesiologist on site, and reimbursement for these expenses is uncertain. Per the American Society of Anesthesiologists (ASA): “Compensation for pre-anesthesia evaluation, including the immediate pre-anesthesia assessment (history, physical exam with airway assessment, NPO status, and other pertinent elements), is incorporated into the anesthesia base units and is not separately billable.” Anesthesia services for surgeries are paid for based on the “base value + time” methodology, which is described in the ASA Relative Value Guide. Reimbursement for preoperative evaluation is already accounted for in the base value for each case.

The ASA also states, “For some patients undergoing surgery or procedures requiring anesthesia care, it may be medically necessary to optimize underlying medical conditions, perform care coordination, and/or develop medical optimization transition or bridging orders for patient safety and optimal outcomes. These services for patients with complex medical co-morbidities may fall outside the scope of the pre-anesthesia evaluation and the pre-operative history and physical examination. In these circumstances, when the work is separate and distinct, the anesthesiologist can report this work with the appropriate Evaluation and Management (E/M) code. This service must be distinct and separate from the pre-anesthetic evaluation.”

Thus billing for additional anesthesia preoperative assessment in a clinic setting is not always reimbursable. Because the viability of a preoperative clinic depends on the ratio between reimbursement and costs, if reimbursement is not greater than the overhead of office space and staffing, a clinic will be too expensive to maintain. The publication “Setting up and Functioning of a Preanesthesia Clinic” states, “The most limiting factors for implementation of a functioning Preanesthesia clinic are lack of finance and shortage of anesthetists to run the clinic. Lack of finance is a frequently reported problem, especially in a private setup where the anesthetists often work on a fee per case basis.”

Problematic issues with an anesthesia preoperative evaluation clinic in private practice include:

• Who’s going to pay for the office space, the administrative staff, and the clinical professional staff?
• Anesthesiologists in private practice earn their maximal income by doing anesthetics, not by seeing patients in clinic.
• If you staff one Full Time Employee (FTE) anesthesia MD to the clinic or to a Zoom clinic, you have to hire one more MD in your company.
• There is a current nationwide shortage of anesthesiologists.
• Patients don’t like going to an additional preoperative appointment.
• Patients don’t meet the person who’s going to do the anesthetic.

How is preoperative assessment performed in private and community practice? Non-anesthesiologist physicians provide a larger percentage of the consultations. In community medicine, there are financial motivations for these MDs to do preoperative assessment. The incentives align as follows:

• Primary care doctors have an economic incentive to do preoperative assessment history and physicals. They get paid to do this.
• Surgeons have an economic incentive to prepare patients properly for the day of surgery. Same-day cancellations and same-day delays penalize the surgeon financially. Surgeons are motivated to contact appropriate consultations with anesthesiology, as well as cardiologists and pulmonologists.
• Anesthesiologists and surgeons work together, via cell phone, personal communication, or electronic communication, to answer preoperative questions well ahead of the day of surgery.
• Private practice surgeons, anesthesiologists, and primary care doctors are fully trained and experienced. They’re not partially-trained residents working in an academic medical center. Fully-trained MDs typically they make assessments which are accurate and reliable.

Anesthesiologists pride themselves on being perioperative physicians—providing medical care prior to, during, and after surgical procedures. How does a private practice/community practice anesthesiology group provide preoperative consultations without providing a brick and mortar clinic? In the most common model, each anesthesia group will have a Primary Consultant Anesthesiologist who will answer the questions surgeons have regarding preoperative workup. Surgeons have the cell phone number of this MD and can call him/her well in advance of surgery.

This Primary Consultant Anesthesiologist is usually:

1. A leader in the anesthesia group
2. A senior clinician
3. Trusted and respected by the surgeons
4. The individual who makes out the daily anesthesia staffing schedule.

This individual has access to the internet and on-line textbooks if there is a question regarding preoperative diagnosis and treatment.

In private practice, anesthesiologists educate surgeon colleagues regarding which medical problems require extra preoperative scrutiny. These co-morbidities include:

1. Morbid obesity
2. Any functional deficit: shortness of breath or chest pain
3. Any unstable cardiac history
4. Any recent pulmonary history
5. End-stage renal disease
6. Extremes of age
7. Any airway abnormality
8. Significant obstructive sleep apnea

If a surgeon has a patient with any of these conditions, the surgeon contacts the anesthesia group to ascertain whether the patient is safe and ready for the surgical procedure. Once contacted, the Primary Consultant Anesthesiologist has multiple choices. He or she may:

1. Approve the case as is, or
2. Require a primary care provider see the patient and write a clearance note on the chart, or
3. Require a cardiologist or other consultant write a clearance note on the chart, or
4. Telephone the patient themselves to interview the patient, or
5. Schedule the patient to come to an anesthetizing location for an in-person interview and physical examination, or
6. Postpone the case, or
7. Cancel the case.

If the Primary Consultant Anesthesiologist refers the case to an internal medicine doctor or a cardiologist for preoperative clearance, there are two questions he or she wants answered on the chart: 1) Are there any further diagnostic tests needed prior to anesthesia? and 2) Are there any further therapeutic interventions needed prior to anesthesia? Anesthesiologists are not asking for advice regarding how, when, or where to do the anesthetic, but rather whether these two questions are satisfied. If the case was originally scheduled at an ambulatory surgery center, but is found to be too high a risk for that setting, the Primary Consultant Anesthesiologist may move the case from a surgery center to a hospital setting. Sixty-four percent of surgeries in America are done as outpatients, but as the Baby Boomer population grows older with increasing comorbidities, the decision of surgery center versus hospital becomes an important fork in the road. Over the past 22 years as the Medical Director of a freestanding ambulatory surgery center one mile from Stanford University Hospital, I make these decisions daily. A freestanding ambulatory center lacks the support systems of an acute care hospital—we lack intensive care units, full laboratory services, arterial blood gas analysis, X-ray services, and respiratory therapists. It’s critical to triage difficult patients to the hospital prior to initiating surgical procedures on them. How does the Medical Director of a freestanding surgery center make these triage decisions? Our system looks like this:

1. A medical assistant (MA) makes a preoperative call 48 hours in advance to every patient.
2. This preoperative caller has a standardized list of questions to ask, and a list of conditions which identify outlying patients as needing Medical Director approval.
3. The preoperative caller will then contact the Medical Director regarding all patients whose interview or medical records indicate problems which need Medical Director approval.
4. The Medical Director then decides on each patient, 48 hours in advance, as to whether their criteria make them an appropriate case for the surgery center.

Which is the most important screening criteria: the medical comorbidities of the patient, or the procedure proposed to be done? The answer is: the proposed procedure. In an ambulatory center we would never perform a craniotomy, open heart surgery, liver transplant, or lumbar fusion. Procedures like these require a hospital, regardless of the preoperative health of the patient. The type of surgery is more important than the medical comorbidities. An ASA III patient with a disease which is a constant threat to life, such as heart failure, dialysis, or morbid obesity, could safely be a candidate for a minor surgery such as fixing a hammer toe under local anesthesia. Procedures appropriate for a freestanding surgery center include those which don’t require a hospital admission, such as arthroscopies of knees or shoulders, tonsillectomies, cataract surgeries, colonoscopies, laparoscopies, foot or hand surgeries, and plastic surgeries.

If you’re one of the 57% of anesthesiologists who works outside of an academic university system, more likely than not you’ll manage preoperative assessment without an anesthesia preoperative clinic, using some version of the methods described above. And . . . for your best interests and the best interests for your patients, remain very familiar with those 80 pages in the “Preoperative Evaluation” chapter in Miller’s Anesthesia.