MANAGED CARE AND THE ANESTHESIOLOGIST'S ROLE IN CRITICAL RESOURCE MANAGEMENT

Abstract

Dramatic changes in the funding and organization of American medical care that have evolved following the failure of the key health care proposal put forth during the first Clinton administration can go unnoticed by anesthesiologists. After rejection of a federal plan, an industrial, or business model of health care has rapidly evolved with dramatic impact upon anesthesia providers. Governmental and private third parties have either negotiated or unilaterally reduced fees paid for anesthesia services. Young anesthesiologists and nurse anesthetists report that they have found jobs more difficult to find in their preferred employment location and at income levels that are below expectation. Anesthesia group practices and departments have delayed hiring replacements for departing staff. A number of residency programs have deleted training positions that were funded from faculty practice income as that income diminished. Many hospitals have mounted cost-cutting campaigns and focused attention upon surgical time, surgical support services, and surgical decision making. Individual practitioners have found that drug and equipment access has become more tightly controlled with a consequent simplification or standardization of drug menus available for anesthetic use. Surgeons and referring physicians face more hurdles as they attempt to move patients through hospitals and outpatient centers for either elective or urgent surgery. Finally, it has become increasingly difficult to investigate, develop, and introduce “new” procedures, monitors, and therapy. Unlike the most recent cycle of health care expansion, dating from the 1960s, that was fueled by the creation of federally funded programs and the ideal of providing top-flight care for all, together with the physician entrepreneur-driven development of evolving medical specialties, technologies, and therapies, health care in the closing decade of the twentieth century is characterized by the demands of business, a more reliable, cost-controlled health care product. Health care is to be purchased in known quantities and must fit a competitive, industrial model for a service industry. The anesthesiologist has more at stake in this process than future expectations of earning less for his/her efforts, and access to fewer or less expensive drugs and equipment. Rapidly evolving changes are taking place in three major components of the health industry—the for-profit managed care insurance segments, physician management organizations, and hospital networks. These components demonstrate the breadth and depth of this process. There are indications that the profit-based industrial model may reshape the delivery of medical care as we know it, transforming the roles of many involved in the process as well as the expectations of patients and the public. Although anesthetists from other countries see these processes as a parochial issue from the United States, there is evidence that other parts of the world are exploring an industrial risk-sharing health care management model. The model provides a profit incentive as a solution to rising health costs, whether incurred in an egalitarian social system like that of Finland32 and Canada18 or in a more traditionally indemnity-funded system like that in Switzerland.23 At a time when change seems inevitable and cost has become a primary determinant of the therapeutic options available to health care providers,31 anesthesia intensivists, anesthesia educators, anesthesia services administrators, and anesthesia pain consultants alike must examine and husband the resources available for patient care. Surgical resource management has become a fundamental element of the health care organization's economic viability both in the United States and elsewhere.19 Hospitals, multispecialty physician organizations, and physician-hospital organizations will focus more attention upon issues like scheduling efficiency, surgical support costs, and surgical practice styles. Anesthesiologists can play a pivotal role in the health care organization's operative care by virtue of their education, training, and experience. They have a working proximity to the problems and a proven ability to prevent costly medical complications, by increasing efficient operative throughput and minimizing the physiologic impact and medical costs of operative stress in the postoperative period. In the United States, anesthesiologists have pioneered the concept of resource-based surgical anesthesia cost. Although others may compete for control of the process, no other physician has such an immediate understanding and day-to-day involvement in the assessment and management of operative risk and outcome. Will the anesthesiologist become the primary, perioperative physician, a surgical gate keeper, and lead the health care organization's efforts to manage perioperative processes by facilitating surgical care and allocating critical surgical resources? An examination of the background of these issues and critical resource management strategies that anesthesiologists can employ, suggests that this aspect of perioperative medicine is one scenario for the specialty's future.