The value of the services that anesthesiologists provide is being examined more closely than ever. Indeed, determining the true value of regional anesthesia can only be done within the context of its many costs, most of which are not monetary.
“‘Value’ is the name of the game in medicine these days,” said Brian E. Harrington, MD, staff anesthesiologist at Billings Clinic Hospital, in Billings, Mont. “Yet I don’t think a lot of anesthesiologists have a great understanding of the concept of value and how we can impact it,” he said during the 21st Annual Jefferson Anesthesia Conference.
Value = Benefit/Cost
“Many anesthesiologists limit their perception of the value of regional anesthesia to its benefits: less pain, faster rehabilitation and better patient satisfaction,” Dr. Harrington said. “But value is actually benefit per cost.”
As health care economist Michael E. Porter, PhD, noted in a New England Journal of Medicine article (2010;363:2477-2481), value should always be defined around the customer. In the case of regional anesthesia, those customers are patients, surgeons, facilities and payors.
For patients, costs are largely not measured in terms of dollars and cents, but instead comfort and pain control. A study by Dove et al (Reg Anesth Pain Med2011;36:332-335) found that patients’ two greatest concerns regarding regional anesthesia were seeing and hearing the surgery. In another study of patients’ perceptions of regional anesthesia (Reg Anesth Pain Med 2014;39:48-55), researchers found that significant pain during regional blocks was, unsurprisingly, associated with significant dissatisfaction.
“So when you think about how you can decrease the costs of regional anesthesia to the patient, it has a lot to do with ensuring their comfort and making sure they’re getting the level of sedation they desire,” Dr. Harrington said.
Surgeons, who represent the next customer base, also don’t tend to view regional anesthesia as a financial proposition. “When you look at why surgeons might not want regional, it’s not necessarily because they don’t think it’s in the best interests of the patients,” Dr. Harrington told Anesthesiology News. “It’s more likely that they think it slows down the operating room. So that’s the cost to them.”
Since regional anesthesia has the potential to increase turnover times, clinicians need to do everything they can to prevent that from happening. Indeed, as was shown by Masursky et al (Anesth Analg2011;112:440-444), turnover times (measured to be 36 minutes in their operating room) are perceived quite differently by anesthesiologists (30 minutes) and surgeons (46 minutes). “This study really illustrates the importance of avoiding even the perception of slowing things down with regional anesthesia,” Dr. Harrington said.
The Old Bottom Line
Unlike patients and surgeons, facilities are acutely aware of the fiscal bottom line when it comes to determining value. “For facilities, the cost of regional anesthesia would most likely be the equipment and supplies they need to provide for us to do our jobs,” Dr. Harrington noted. Unfortunately, most anesthesiologists are likely unaware of the cost associated with the tools they use every day. “This emphasizes how important it is for regional anesthesiologists to make themselves aware of supply costs and properly document regional techniques so that facilities get reimbursed for our using, say, an ultrasound machine.”
Yet if money is important for facilities, it’s paramount for the regional anesthesiologists’ fourth customer: the payors. “While payors have allowed us to perform regional anesthesia without having a great deal of proof that it actually works, I think those days are rapidly coming to an end,” Dr. Harrington said. “So if we want to be leaders in perioperative pain management, we need to be aware of the literature and try to be discerning when it comes to doing things that are well worth the cost, not just because we can bill for it.”
Toward Value-Based Regional Anesthesia
Given these various perspectives, Dr. Harrington said the trick to providing value-based regional anesthesia begins with thoughtful consideration of the benefits and costs of regional techniques, a process that should include general agreement with surgeons. Patients need to be engaged on a personal level, including a meaningful discussion of expectations regarding the technique. Patient consent should include reassurance about serious risks and realistic counseling on minor ones.
Regional anesthesiologists also need to avoid real or perceived operating room delays, administer adequate sedation, have an awareness of current supply costs and provide necessary documentation. Intraoperatively, sensitivity in draping and screening, minimizing background noise and personalized sedation will help meet patients’ needs. Finally, Dr. Harrington recommended that postoperative care should include structured anesthesia follow-up, comanagement of neuropathies and accurate billing.
“That’s a lot of angles, but as anesthesiologists we don’t want to forget any of our customers,” he added. “We want to satisfy all of them as best we can.
“In the end, providing value-based regional anesthesia means looking at the big picture and trying to come up with a system within each individual practice location,” he added. “Sure, everyone works within their own unique environment, but there are a lot of things each of us can do within our environments to maximize value.”
Colin J.L. McCartney, MBChB, PhD, chair of anesthesiology at the University of Ottawa, in Ontario, agreed that true value can only be determined in the context of cost. “Health care systems around the world are focusing increasingly on the Institute for Healthcare Improvement’s Triple Aim of improving the patient experience of care, the health of populations and reducing the per-capita cost of health care,” he noted. “Regional anesthesia can add value in all of these areas.” According to Dr. McCartney, regional anesthesia can influence value through increased efficiency, reduced readmission rates, reduced mortality and other potential beneficial effects on other outcomes.