We sincerely thank Abouleish et al. and Flynn et al  for their interest in and comments on our review article.  Whereas our manuscript emphasized the virtually universal, multidisciplinary application of the American Society of Anesthesiologists (ASA; Schaumburg, Illinois) Physical Status Classification System to patient care and research, Abouleish et al. and Flynn et al. highlight the fact that it is also used for purposes that go far beyond the original intent of its developers. Indeed, we agree with the thoughtful insights of both letters noting the considerable economic implications of the ASA Physical Status Classification System to both clinicians and medical facilities.

The authors  provide vivid illustrations with specific examples of the potential financial impact of misclassification of ASA Physical Status—perhaps far greater than we suggested in our original review.  Although economics was not the primary focus of our article, the financial impact of the ASA Physical Status system is real, and any future changes to the classification system involve a complex set of stakeholders (ASA members and leadership, Centers for Medicare & Medicaid Services [Baltimore, Maryland], the Current Procedural Terminology, which is a product of the American Medical Association [Chicago, Illinois], and the AMA Relative Value Unit Update Committee). As noted by Flynn et al. “The ASA Physical Status score is a key variable in mathematical models used by the Centers for Disease Control and Prevention [Atlanta, Georgia] National Healthcare Safety Network to risk-adjust surgical site infection rates at U.S. acute care hospitals.” Because it is considered a “key variable” in models with profound impact on both quality assessment and billing, we believe that minimizing the variability behind this key variable should be a high priority.

Thus, the best route to appropriate and fair compensation for services for both clinicians and medical facilities is to embrace education and adopt future processes (e.g., technology assist ) that optimize the accuracy and reproducibility of the ASA Physical Status classification by all providers, and efforts to optimize interrater reliability should continue or even be enhanced by the ASA and other leading organizations.

However, given the long-term design and intent of the ASA Physical Status system, it is not clear that any changes to this system that aim to directly impact economics—as distinct from the society’s 80-yr-long (and continuing) efforts to improve accuracy and reproducibility and provide a valuable tool for its clinicians—are desirable. We should make changes based on a need for clinical improvement and let the economic process evolve in parallel. That effort is best led by the ASA with other key stakeholders as we consider any future refinements to our classic ASA Physical Status system.