OBAMACARE AND ANESTHESIA

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Key questions in our specialty in 2014 related to Obamacare and anesthesia. This article was originally published in 2014, when Barack Obama was the President of the United States. A key question in our specialty at that time was “How will ObamaCare affect anesthesiology?” The following essay represents my thoughts as of 2014, prior to the Trump presidency.

I don’t have a crystal ball, but based on what I’ve read, what I’ve observed, and what I’m hearing from other physicians, these are my predictions on how ObamaCare will change anesthesia practice in the United States:

  1. There will be more patients waiting for surgery. Millions of new patients will have ObamaCare cards and coverage. A flawed premise of ObamaCare is that a system can cover more patients and yet spend less money.
  2. Reimbursement rates will be lower. How many anesthesiologists will sign up for Medicaid or Medicare-equivalent rates to care for patients? Large organizations such as university hospitals, Kaiser, Sutter, and other HMO-types will likely sign up for the best rate they can negotiate. As a result, their physicians will have increased patient numbers and lower reimbursement for their time. The insurance plans that patients purchase will have higher deductibles, and most patients will have to pay more out of pocket for their surgery and anesthesia. This will lead to patients delaying surgery, and shopping around to find the best value for their healthcare dollar.
  3. Less old anesthesiologists. Older anesthesiologists will retire early rather than work for markedly reduced pay.
  4. Less young anesthesiologists. The pipeline of new, young anesthesiologists will slow. Young men and women are unlikely to sign up for 4 years of medical school,  4 – 6 years of residency and fellowship, and an average of $150,000 of student debt if their income incentives are severely cut by ObamaCare.
  5. More certified nurse anesthetists (CRNAs). It seems apparent that ObamaCare is interested in employing cheaper providers of medical services. CRNAs will command lower salaries than anesthesiologists. The premise to be tested is whether CRNAs can provide the same care for less money. Expect to see wider use of anesthesia care teams and of independent CRNA practice. Expect the overall quality of anesthesia care to change as more CRNAs and less M.D.’s are employed.
  6. A two-tiered system. Anesthesiologists who have a choice will not sign up for reduced ObamaCare rates of reimbursement. Surgeons who have a choice will not sign up for reduced ObamaCare reimbursement. Expect a second tier of private pay medical care to exist, where patients will choose non-ObamaCare M.D.’s of their choice, and will pay these physicians whatever the physicians charge. This tier will provide higher service and shorter waiting times before surgery is performed. This tier will likely be populated by some of the finest surgeons–surgeons are unwilling to work for decreased wages. A subset of anesthesiologists will work in this upper tier of medical care, and these anesthesiologists will earn higher wages as a result.
  7. Will the Accountable Care Organization (ACO) model stumble as the Health Maintenance Organization (HMO) model did in the 1990’s? ObamaCare provides for the existence of ACO’s, which are hospital-physician entities designed to provide comprehensive health care to patients in return for bundled payments. In this model the surgeon, the anesthesiologist, and the hospital (i.e. nurses, pharmacy, and the medical device industry) will divide up the bundled surgical payment. In this model it’s essential that an anesthesiologist leader has a strong presence at the negotiating table. A worrisome issue with the ACO model, as it was with the HMO model, is the flow of money. Physicians will no longer be working for their patients, but will be working for the ACO. The  primary incentive will be to be paid by the ACO, rather than to provide the best care possible.
  8. Anesthesia leadership skills will change. The physician leader of each anesthesia group must be a powerful and effective politician and economic strategist. These traits are not taught during anesthesia residency, and these traits have nothing to do with being an outstanding clinician.
  9. What about the Perioperative Surgical Home (PSH)? The American Society of Anesthesiologists is proposing the model of the PSH, in which anesthesiologists will assume leadership roles managing patient care in the preoperative, intraoperative, and postoperative arenas. This is a desirable goal for our specialty. No physician is better equipped than an anesthesiologist to supervise patients safely through the perioperative period with the highest standards of quality and cost-control. The Perioperative Surgical Home is designed to work with the model of the Accountable Care Organization. How these systems of the Perioperative Surgical Home and the Accountable Care Organization will evolve remains to be seen. It will be the role for individual anesthesia physician leaders in each hospital to seize the new opportunities.  Rank and file anesthesiologists will likely follow their leadership.

10. Consolidation of anesthesia groups. Small anesthesia groups will likely merge into bigger groups in an effort dominate a clinical census, and therefore to negotiate higher reimbursement rates. In November, 2013, the 100-physician Medical Anesthesia Consultants Medical Group, Inc, of San Ramon, California was acquired by Sheridan Healthcare Inc, a 2,500-physician services company based in Florida. Per Sheridan’s CEO, John Carlyle, the acquisition “provides a platform that will accelerate our expansion in the California marketplace.” This was the largest merger in Northern California anesthesia history.

11. Requirement of more anesthesia clinical metrics. Government and insurance payors will require more metrics to document that the provided clinical care was excellence. A typical required metric may be a high percentage of patients who received preoperative antibiotics prior to incision, or a low percentage of patients free from postoperative nausea and vomiting. Each anesthesia groups will need to establish computerized data-capturing systems to present this information to payors. The effort to tabulate these metrics will be another incentive for anesthesia groups to merge into larger clinical entities.

In summary:  More patients, more cases, less money, more bureaucracy, less money, more CRNA providers, and less money. These are the challenges ObamaCare presents to anesthesiologists. Stay tuned. Legions of patients with ObamaCare cards will be knocking on hospital doors. The government is expecting enough anesthesiologists to sign up for ObamaCare contracts to make the new system successful. It’s impossible to tell what behaviors ObamaCare will incentivize. Each anesthesiologist has the benefit of 25+ years of education, and each anesthesiologist will make intelligent choices regarding their career and their time.

Bob Dylan once sang, “I ain’t gonna work on Maggie’s Farm no more.”

Time will tell if ObamaCare is Maggie’s Farm for physicians.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

ROBOT ANESTHESIA

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Will robots replace anesthesiologists? I am the Medical Director of a surgery center in California that does 5,000 gastroenterology endoscopies per year.  In 2013 a national marketing firm contacted me to seek my opinion regarding an automated device to infuse propofol. The device was envisioned as a tool for gastroenterologist/nursing teams to use to administer propofol safely for endoscopy procedures on ASA class I – II patients.

 

The marketing firm could not reveal the name of the device, but I believe it was probably the SEDASYS®-Computer-Assisted Personalized Sedation System, developed by the Ethicon Endo-Surgery, Inc., a division of Johnson and Johnson.  The SEDASYS System is a computer-assisted personalized sedation system integrating propofol delivery with patient monitoring. The system incorporates standard ASA monitors, including end-tidal CO2, into an automated propofol infusion device.

The SEDASYS system is marketed as a device to provide conscious sedation.  It will not provide deep sedation or general anesthesia.

Based on pharmacokinetic algorithms, the SEDASYS infuses an initial dose of propofol (typically 30- 50 mg in young patients, or a smaller dose in older patients) over 3 minutes, and then begins a maintenance infusion of propofol at a pre-programmed rate (usually 50 mcg/kg/min).  If the monitors detect signs of over- sedation, e.g. falling oxygen saturation, depressed respiratory rate, or a failure of the end-tidal CO2 curve, the propofol infusion is stopped automatically.  In addition, the machine talks to the patient, and at intervals asks the patient to squeeze a hand-held gripper device.  If the patient is non-responsive and does not squeeze, the propofol infusion is automatically stopped.

As of February, 2013, the SEDASYS system was not FDA approved. On May 3, 2013, Ethicon Endo-Surgery, Inc. announced that the Food and Drug Administration (FDA) granted Premarket Approval for the SEDASYS® system, a computer-assisted personalized sedation system.  SEDASYS® is indicated “for the intravenous administration of 1 percent (10 milligrams/milliliters) propofol injectable emulsion for the initiation and maintenance of minimal to moderate sedation, as identified by the American Society of Anesthesiologists Continuum of Depth of Sedation, in adult patients (American Society of Anesthesiologists physical status I or II) undergoing colonoscopy and esophagoduodenoscopy procedures.”  News reports indicate that SEDASYS® is expected to be introduced on a limited basis beginning in 2014.

Steve Shaffer, M.D., Ph.D., Stanford Adjunct Professor, editor-in-chief of Anesthesia & Analgesia, and Professor of Anesthesiology at Columbia University, worked with Ethicon since 2003 on the design, development and testing of the SEDASYS System both as an investigator and as chair of the company’s anesthesia advisory panel.

Dr. Shafer has been quoted as saying, “The SEDASYS provides an opportunity for anesthesiologists to set up ultra-high throughput gastrointestinal endoscopy services, improve patient safety, patient satisfaction, endoscopist satisfaction and reduce the cost per procedure.” (Gastroenterology and Endoscopy News, November 2010, 61:11)

In Ethicon’s pivotal study supporting SEDASYS, 1,000 ASA class I to III adults had routine colonoscopy or esophagogastroduodenoscopy, and were randomized to either sedation with the SEDASYS System (SED) or sedation with each site’s current standard of care (CSC) i.e. benzodiazepine/opioid combination.  The reference for this study is Gastrointest Endosc. 2011 Apr;73(4):765-72. Computer-assisted personalized sedation for upper endoscopy and colonoscopy: a comparative, multicenter randomized study. Pambianco DJ, Vargo JJ, Pruitt RE, Hardi R, Martin JF.

In this study, 496 patients were randomized to SED and 504 were randomized to CSC. The area under the curve of oxygen desaturation was significantly lower for SED (23.6 s·%) than for CSC (88.0 s·%; P = .028), providing evidence that SEDASYS provided less over-sedation than current standard of care with benzodiazepine/opioid.  SEDASYS patients were significantly more satisfied than CSC patients (P = .007). Clinician satisfaction was greater with SED than with CSC (P < .001). SED patients recovered faster than CSC patients (P < .001). The incidence of adverse events was 5.8% in the SED group and 8.7% in the CSC group.

Donald E. Martin, MD, associate dean for administration at Pennsylvania State Hershey College of Medicine and chair of the Section on Clinical Care at the American Society of Anesthesiologists (ASA), expressed concerns about the safety of the device.  Dr. Martin (Gastroenterology and Endoscopy News, November 2010, 61:11) was quoted as saying, “SEDASYS is requested to provide minimal to moderate sedation and yet the device is designed to administer propofol in doses known to produce general anesthesia.”

Dr. Martin added that studies to date have shown that some patients who had  propofol administered by SEDASYS experienced unconsciousness or respiratory depression (Digestion 2010;82:127-129, Maurer WG, Philip BK.). In the largest prospective, randomized trial evaluating the safety of the device compared with the current standard of care, five patients (1%) experienced general anesthesia with SEDASYS. The ASA also voiced concern that SEDASYS could be used in conditions that do not comply with the black box warning in the propofol label, namely that propofol “should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure.”

Anesthetists, emergency room doctors, and trauma helicopter nurses are trained in the administration of general anesthesia. Gastroenterologists and endoscopy nurses are almost never experts in airway management.  For this reason, propofol anesthetics for endoscopy are currently the domain of anesthesiologists and nurse anesthetists.

In my phone conversation regarding the automated propofol-infusion system, I told the marketing company’s representative that in my opinion a machine that infused propofol without an airway expert present could be unsafe.  The marketing consultant responded that in parts of the Northeastern United States, including New York City, many GI endoscopies are done with the assistance of an anesthesia provider administering propofol.  If SEDASYS were to be approved, the devices could replace anesthesiologists.

In the current fee-for-service model of anesthesia billing, anesthesiologists and CRNA’s bill insurance companies or Medicare for their professional time.  If machines replace anesthesiologists and CRNA’s, the anesthesia team cannot send a fee-for-service bill for professional time.  The marketing consultant foresaw that with the advent of ObamaCare and Accountable Care Organizations, if a health care organization is paid a global fee to take care of a population rather than being paid a fee-for-service sum, then perhaps the cheapest way to administer propofol sedation for GI endoscopy would be to replace anesthesia providers with SEDASYS machines.

A planned strategy is to have gastroenterologists complete an educational course that would educate them on several issues.  Key elements of the course would be: 1) anesthesiologists are required if deep sedation is required, 2) SEDASYS is not appropriate if the patient is ASA 3 or 4 or has severe medical problems, 3) SEDASYS is not appropriate if the patient has risk factors such as morbid obesity, difficult airway, or sleep apnea, and 4) airway skills are to be taught in the simulation portion of the training.  Specific skills are chin life, jaw thrust, oral airway use, nasal airway use, and bag-mask ventilation.  Endotracheal intubation and LMA insertion are not to be part of the class.  If the endoscopist cannot complete the procedure with moderate sedation, the procedure is to be cancelled and rescheduled with an anesthesia provider giving deep IV sedation.

Some anesthesiologists are concerned about being pushed out of their jobs by nurse anesthetists.  It may be that some anesthesiologists will be pushed out of their jobs by machines.

I’ve been told that the marketing plan for SEDASYS is for the manufacturer to give the machine to a busy medical facility, and to only charge for the disposable items needed for each case. The disposable items would cost $50 per case. In our surgery center, where we do 5,000 cases per year, this would be an added cost of $25,000 per year. There would be no significant savings, because we do no use anesthesiologists for most gastroenterology sedation.

There have been other forays into robotic anesthesia, including:

1) The Kepler Intubation System (KIS) intubating robot, designed to utilized video laryngoscopy and a robotic arm to place an endotracheal tube (Curr Opin Anaesthesiol. 2012 Oct 25. Robotic anesthesia: not the realm of science fiction any more. Hemmerling TM, Terrasini N. Departments of Anesthesia, McGill University),

2) The McSleepy intravenous sedation machine, designed to administer propofol, narcotic, and muscle relaxant to patients to control hypnosis, analgesia, and muscle relaxation. (Curr Opin Anaesthesiol. 2012 Dec;25(6):736-42. Robotic anesthesia: not the realm of science fiction any more. Hemmerling TM, Terrasini N.)

3) The use of the DaVinci surgical robot to perform regional anesthetic blockade. (Anesth Analg. 2010 Sep;111(3):813-6. Epub 2010 Jun 25. Technical communication: robot-assisted regional anesthesia: a simulated demonstration. Tighe PJ, Badiyan SJ, Luria I, Boezaart AP, Parekattil S.).

4) The use of the Magellan robot to place peripheral nerve blocks (Anesthesiology News, 2012, 38:8)

Each of these applications may someday lead to the performance of anesthesia by an anesthesiologist at geographical distance from the patient.  In an era where 17% of the Gross National Product of the United States is already being spent on health care, one can question the logic of building expensive technology to perform routine tasks like I.V. sedation, endotracheal intubation, or regional block placement.  The new inventions are futuristic and interesting, but a DaVinci surgical robot costs $1.8 million, and who knows what any of these anesthesia robots would sell for?  The devices seem more inflationary than helpful at this point.

Will robots replace anesthesiologists?  Inventors are edging in that direction.  I would watch the peer-reviewed anesthesia journals for data that validates the utility and safety of any of these futuristic advances.

It will be a long time before anyone invents a machine or a robot that can perform mask ventilation.  SEDASYS is designed for conscious sedation, not deep sedation or general anesthesia.  Anyone or anything that administers general anesthesia without expertise in mask ventilation and all facets of airway management is courting disaster.

NOTE: In March of 2016, Johnson & Johnson announced that they were going to stop selling the SEDASYS system due to slow sales and company-wide cost cutting. The concept of Robot Anesthesia will have to wait for some future development, if ever, if it is to ever become an important part of the marketplace.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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*

Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited