How to Prove Your Group’s Worth 2023

Value enhancement in the preoperative setting is achieved primarily through cost avoidance. Anesthesiologist-led preoperative clinic visits reduce unnecessary preoperative testing, saving time and reducing cost. They identify key comorbid conditions that impact perioperative outcomes, and through interdisciplinary communication with other specialties and service lines, they help ensure that all appropriate labs, studies, and consultations are performed and issues are addressed. They also ensure that the procedure is performed at the most appropriate facility for the patient’s medical condition(s). Ultimately, these factors all work together to decrease day-of-surgery cancellations and delays, which translates into real value for practice groups and health care centers.

While recognizing and evaluating these preoperative conditions is important, anesthesiologists do not stop there. Optimization of modifiable comorbidities underlies even greater value. Chronic disease states, including diabetes, anemia, hypertension, congestive heart failure, chronic pain syndromes, and social determinants of health, all play a role in perioperative complications, discharge disposition, and hospital length of stay. The preoperative clinic identifies patients at greater risk for higher opioid requirements, thus providing education on alternative pain control modalities, multimodal therapy increasing pain control success, and improving patient satisfaction with shorter hospital stays. By identifying and addressing these factors early, patients’ quality of care is improved, and their perioperative journeys can be streamlined.

The preoperative clinic also plays a significant role when it comes to patient education. Patients receive information regarding a multitude of issues, including, but not limited to, pain management and expectations, anemia prevention strategies, counselling on the benefits of smoking cessation, and medication reconciliation and day-of-surgery medication recommendations, all of which can impact the patient’s perioperative experience dramatically.

The preoperative evaluation is a crucial aspect of the patient’s surgical experience, providing support and optimization for this episode of care and education for the patient. Expansion through telehealth will increase the number of patients reached and thus educated. This step definitely provides value to all stakeholders; for example, decreased out-of-pocket costs for patients and hospitals (by avoiding unnecessary testing), improved utilization for surgeons and hospital administrators (fewer delays/day-of-surgery cancellations, shorter length of stay), and increased patient satisfaction through a streamlined episode of care experience.

An anesthesiologist’s value is often equated to the number of ORs that can be staffed by a particular individual, whether that be one or more, depending on the anesthesia care team model. As the practice of anesthesia has become increasingly safe, the perceived value has transitioned from primarily patient safety to patient throughput. While safe anesthesia care has become an expectation, quality intraoperative care still stands apart and has a major impact on both patient outcomes and a health system’s bottom line. Anesthesiologists are active stakeholders and contribute to a high level of quality care through multiple glidepaths.1

Advanced monitoring tools and techniques such as point-of-care testing (e.g., ultrasound, electroencephalography, and thromboelastography) allow for rapid intraoperative patient assessment. Early detection and analysis help ensure appropriate and timely care for any complications or emergencies that may occur during surgery. Furthermore, use of these technologies can drive down costs by limiting the need for expensive imaging, decreasing waste by promoting cost-efficient medication use, and limiting unnecessary or inappropriate transfusions.

Anesthesiologists’ intraoperative management decisions have long-lasting effects, influencing surgical complication rates, unplanned admissions, hospital length of stay, speed of return to normal function, and mortality. Use of evidence-based practices such as goal-directed fluid management, lung-protective ventilation strategies, opioid-sparing pain management techniques, and guideline-driven approaches to postoperative nausea and vomiting prophylaxis are just a few of the many ways anesthesiologists can impact a patient’s perioperative course. Standardized multidisciplinary protocols (i.e., Enhanced Recovery After Surgery) work by layering best practice strategies together to help achieve the overarching health care goals of improved care and decreased cost. As health care payment transitions from traditional fee-for-service to value-based care models (i.e., comprehensive care for joint replacement), adherence to evidence-based best practice will become even more critical for group practices and health care systems.

Anesthesiologists are natural problem-solvers. This ingenuity can be applied within the surgical suite to improve OR throughput with techniques such as parallel processing and by improving the efficiency of postanesthesia care unit (PACU) discharges to avoid backups in the OR.2 At a professional level, this emphasis on quality improvement can be seen clearly through the establishment of organizations such as the Anesthesia Patient Safety Foundation, which was established to address anesthetic complications from human error, and the standardization of intraoperative monitoring. The Anesthesia Quality Institute is home to the largest anesthesia registry in the country, which allows group practices to track patient outcomes, compare themselves to national benchmarks, and identify areas for improvement. Health care systems will only be able to achieve the “triple aim” (improved patient care and experience, improved population health, and reduced health care costs) through a continued focus on a culture of quality improvement, with anesthesiologists leading the way.

While many administrators and anesthesiologists focus on demonstrating value in the preoperative and intraoperative phases of care, the postoperative phase should not be ignored with regard to demonstrating value-based care provided by anesthesiologists. There are multiple avenues through which anesthesiologists can enhance the patient care experience, improve quality, and ensure patient safety in the postoperative phases of care.

While ERAS protocols typically focus upon preoperative optimization and intraoperative multimodal regimens and coordinated care pathways, the postoperative phase of care is extremely germane to providing additional value-based care. Anesthesiologists may develop multidisciplinary order sets for the PACU that ensure optimal timely delivery of pain medications and additional active processes (oral intake, physical mobilization, rapid extubation, glucose management, etc.) to facilitate discharge to home or the ward. Use of anti-emetics and supplemental adjuvant nonopioid agents also diminishes untoward effects that may delay discharge.

While regional blockade may be incorporated into ERAS protocols, occasionally a particular regional block may fail and require an additional procedure. The availability and provision of regional pain services in the PACU by an anesthesiologist will facilitate rapid recovery and timely discharge. Anesthesia group coordination to maintain an available anesthesiologist to manage PACU events may appear to be a costly undertaking, but there are multiple ways to combine this with other duties (i.e., breaks, OB coverage, floor “runner”, etc.) to make this cost-effective.

As alluded to in the previous section, many patients experience acute pain in the PACU and may require prolonged pain management after being admitted to the hospital after a surgical procedure. While the need for a repeat regional block has been discussed, some patients may require complex medication management that consists of both nonopioid and opioid agents; multimodal adjuvant “cocktails” are extremely beneficial as they minimize side-effects by utilizing multiple agents at smaller doses. Additionally, patients may also require active management of an indwelling regional block catheter or neuraxial catheter. Creation of anesthesia-led pain management teams should be efficiently coordinated to overlap with the provision of other services to yield value-based care with positive fiscal impact.

Patients with complex pain syndromes or postoperative pain management tolerance will require a plan for transition to home care consisting solely of oral medications. In coordination with the surgical team, anesthesiologists can play an active role in determining their path for pain management that will facilitate timely discharge, as well as avoiding readmissions.

The PACU remains one of the most highly variable sectors of anesthesia care with regard to staffing models, availability, safety, and fiscal viability. While the majority of functions that an anesthesiologist may perform in the PACU setting are not reimbursable, it is imperative to create a paradigm that allows for physician participation, while understanding the fiscal impact of workforce allocation to this sector. Most medical centers or ambulatory surgery centers coordinate PACU anesthesiologist participation with other roles such as “board runner,” carrying the code beeper, attending to acute and chronic pain management issues, and acting as additional OR personnel during emergency situations.

Multiple studies have demonstrated that rapid resolution of pain issues or timely response to emergency situations in the PACU lead to positive short- and long-term patient outcomes. Anesthesiologists explicitly act as specialty consultants themselves, and thereby can assess and diagnose complex underlying medical issues in the PACU. Many PACU patients are either too unstable to be discharged home or to the ward; therefore, anesthesiologist involvement can facilitate planning and transition to the intensive care unit or coordinate consultations with specialists for further specialty care prior to discharge. The role of anesthesiologists as medical consultants is often overlooked and should always be highlighted as a means of optimizing patient care, safety, and evidence-based synergy between the surgical team and other consultants.

Within all anesthesiology practice environments (independent private practice, employed models, or academia), administrative involvement is key to establishing the specialty as a key stakeholder within the health care system. Administrative opportunities are vast, including opportunities for clinical leadership, health system administration, and practice management. In each, the anesthesiologist adds a unique perspective and enhances their value beyond the OR.

Clinical practice opportunities may involve department leadership, beginning with section or division specialty leads (e.g., liaison to GI services), and ranging up to major clinical leadership positions (e.g., departmental chair). The central clinical perspective of an anesthesiologist allows for a unique clinical value add, especially when delivered in a team-based approach. Health system administration can often be an alternative avenue to direct clinical leadership, and this can specifically involve areas such as management of surgical services or involvement in the hospital C-suite. In each case, again, the “middleman” aspect of an anesthesiologist allows for opportune navigation of challenging issues. Lastly, involvement in one’s own practice, i.e., “running the business,” can ultimately filter to a system value add. By strengthening the model of anesthesia delivery, a practice can enhance operational throughput and quality of care.

Although anesthesiologists are often considered “providers” in the perioperative space, there is immense potential value in the variety of roles they serve in the health care system. This value begins early in the preoperative clinics they staff, continues with the quality care provided in the intra- and postoperative settings, and extends itself into the fabric of health care administration. The challenge for our specialty is promoting and translating the groundbreaking work into something understandable and appreciated by the other system stakeholders. Defining our value at a granular level is the first step in addressing this challenge.