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Anesthesiology:Past, Present, and Future

Edward R. Mariano, M.D., M.A.S.Professor of Anesthesiology, Perioperative and Pain Medicine

Stanford University School of MedicineChief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care System

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Financial Disclosures

• Halyard Health, B Braun – Unrestricted educational program funding paid to my institution

The contents of the following presentation are solely the responsibility of the speaker without input from any of the above companies.

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Short Trip Down Memory Lane

1998

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Why Anesthesiology?

“Once a hot specialty, anesthesiology cools as insurers scale back” Anders G. Wall Street Journal. March 17, 1995.

http://www.apnewsarchive.com/1995/Numb-and-Number-Once-a-Hot-Specialty-Anesthesiology-Cools-As-Insurers-Scale-Back/id-0ff8af6e9ab84b8a994aa4f123c6dc74

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An Unpopular Specialty

1995 1996 1997 1998 1999 2000 2001 2002 20030

200400600800

100012001400160018002000

Anesthesiology Residency Graduates Nationwide

USA International

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People Forgot

• Why does anesthesiology exist?–Patient experience–Patient safety

• It’s just “going to sleep,” right??

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Anesthesiology’s History

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http://www.woodlibrarymuseum.org/history-of-anesthesia/

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The Patient Experience

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To Err is HumanAnesthesiology’s contributionsto patient safety

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To Err is Human

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AnesthesiologyToday

Where Are We Now?

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The Problem

http://www.cms.gov

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The “Triple Aim”

Berwick et al., Health Aff (Millwood) 2008;27:759Vetter et al., Anesth Analg 2014;118(5):1131

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Anesthesia Quality?

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Emphasis on Patient Experience

• Patients are surveyed using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)1

• 32 questions• Publicly reported 4 times a year2

• HCAHPS is administered to a random sample of adult inpatients between 48 hours and six weeks after discharge

1. http://www.hcahpsonline.org2. http://www.hospitalcompare.hhs.gov

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If Anesthesiologists Are Anonymous

Anesthesia is Just a Commodity

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Evolution of Anesthesia Practice

• Traditional private practice models are changing– Horizontal integration: merging of small and large

groups to form mega-groups; some are funded by private equity or venture capital

– Vertical integration: acquisition of smaller practices into larger groups (ie, ACOs)

• California law prohibits the corporate practice of medicine (physician employees) except VA

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In the News

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In the News

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MEDNAX Coming Soon?

http://www.mednax.com/newsroom/

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• There are 135 VA facilities with anesthesia services.• Veterans are complex patients with many illnesses.• There is no shortage of anesthesiologists in VA.• The national VA anesthesia handbook is pro-team.

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www.safevacare.org

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Medicare Access & CHIP Reauthorization Act (MACRA)

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https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html

BUDGET NEUTRAL

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MIPS Payments in 2019

EVERYONE who isn’t part of an APM will be subject to MIPS

QualityResource useClinical Practice Improvement Activities EHR meaningful use

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The Future of Anesthesiology

Where Is This Specialty Going?

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Anesthesia Services

Anesthesia Services: Care Team or MD only

In OR

Surgery Centers

Clinic-Based

Hospital Out-of-

OR

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Anesthesia Services

Anesthesia Services: Care Team or MD only

In OR

Surgery Centers

Clinic-Based

Hospital Out-of-

OR

Who will be on this team?Physician Anesthesiologists?Nurse Anesthetists?Anesthesiologist Assistants?

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Anesthesiologist Assistants

AB 890 (2015-16)

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Non-Anesthesia Services

Non-Anesthesia

Services

Perioperative Medicine(Surgical Home)

Telehealth

Palliative Care

Critical CareMedicine

Care Coordination

Pain Management

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Perioperative Surgical Home

“a patient-centered, physician anesthesiologist-led, multidisciplinary team-based practice model

that coordinates surgical patient care throughout the continuum from the decision to

pursue surgery through convalescence.

Mariano, et al. A&A 2015;120:1163Kain, et al. A&A 2014;118:1126

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Perioperative Surgical Home

Anesthesiology 2015;123:A23

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Out of the Operating Room

FY11 FY12 FY13 FY14 FY150

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

ANESTHESIA OUT-OF-OR ENCOUNTERS FY11-15

Total419 PRE/POST420 PAIN427 REGIONAL434 NON-OR/APS441 PHONE

NUM

BER

OF

ENCO

UNTE

RS

PSH

Out of ORRegional

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Mariano, Walters, Kim, Kain. A&A 2015;120:1163Walters, Mariano, Clark. Pain Med 2015;16;1666Walters, et al. Semin CV Anes 2016;20:133

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Does PSH Fit into MACRA?

• Participants in Advanced Alternative Payment Models are exempt from MIPS:

• The following ARE expected to qualify:– Comprehensive ESRD Care– Comprehensive Primary Care– Medicare Shared Savings Program ACOs– Oncology Care Model

• NOT Comprehensive Care for Joint Replacement (yet)

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We Must Continuously Improve

Federal Register May 3, 2007

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Who Are Our Partners?

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Anesth Clinics 2014;32:853

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The Newest Subspecialty

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Rethink Residency Training?

Growing demand for these new hospital positions:• Chief Safety Officer• Chief Patient Experience Officer• Chief Improvement Officer

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Design, Improvement, and Medicine

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