Where Is Our Specialty Going In The Future?

1. Where Is Our Specialty Going In The Future? Mark J. Lema, M.D., Ph.D. Professor and Chair of Anesthesiology University at Buffalo, SUNY Roswell Park Cancer Institute President-Elect American Society of Anesthesiologists

2. Do you think the work force shortage of anesthesiologists will continue for the next 5-10 years? • Yes • No 0 / 10

3. Which of the following concerns you most about our specialty’s future? • Non-anesthesiologists doctors thinking they are equal and cheaper • Propofol administration by untrained personnel • Impending crisis in academic anesthesiology • Complacency about the importance of PAC donations • The perception we are overpaid for what we do 0 / 10

4. Physician Shortage Predicted To Spread • COGME has reversed its 1980’s position that there will be a physician surplus. • Adopted Salsberg study which estimates a need for 3000 more (15%↑) graduating physicians by 2015. • Projected number of MDs in 2020 – 972,000 Projected needed by 2020 – 1,060,000 • Medical school graduates have remained constant at 15-16,000 since 1980 while US population has increased by 24% and is also ‘graying’. Am Med News 47(1):1-2, 1/5/04

5. The Lingering Costs Of Med Ed Source: AAMC 2003 Graduation Questionnaire, Am Med News 1/26/04

6. A possible reason for the reduced interest in a medical career.

7. Factors Which Worsen Efficiency of Team Coverage • Off-site anesthesia • Office-based anesthesia • Remote site anesthesia • Demand for dedicated subspecialists • Obstetrical suite coverage • Multiple hospital coverage • Anesthesiologist-CRNA mistrust • Personality conflicts • Boutique surgical schedules

8. Work Force Projections • No reliable data but consensus of academic chairs and ASA leadership suggests that ther will be about a 10 – 15% workforce shortage for the next 5-10 years. • No new training programs have appeared and a few have closed.

9. Realities Of A Changing Health Care System It’s broken – “What is perhaps most disturbing is the absence of real progress toward restructuring health care systems to address both quality and cost concerns, or toward applying advances in information technology to improve administrative and clinical processes … the last quarter of the 20th century might best be described as the ‘era of Brownian motion in health care.’’’ IOM 2001

10. The Realities Of A Changing Health Care System • Who’s Overseeing the transition? • Not the government – CMS and DEA are not like the FAA and FCC. • Technology (medical science development) and market competition drive changes in health care just like in business. • U.S. Government is acting more like an anchor than a rudder during this transition (HIPAA, BBA ’97) Regarding health care reform, no one is in long run control and health care systems throughout the U.S. operate like silos. *Regarding health care reform, no one is in long run control and health care systems throughout the U.S. operate like silos.

11. “ The future practice of surgery is medicine”1 • If the future of surgery is medicine, what is the future of anesthesiology? • Medicine or obsolescence • SURGICAL TRENDS SINCE MID-90’s Minimally invasive surgery (VATS) Radiologic procedures (Gamma Knife) ‘Medicalization’ of surgery (Urology) Office-based procedures using non-anesthesia professionals 1 - Jeff Bauer PhD, health futurist, personal comm.

12. The Operating Room of the Future1 • History – delivery of surgical care was stable (but not optimal) through the mid-1990’s. • What changed the status quo? • The rapid growth of minimally invasive procedures blurring the line between interventional radiology and surgery 1 - Wright J, Bauer J. TEWS – White Paper 12/2002

13. Threats to Our Current Mode of Anesthetic Practice • Unexpected advances in anesthetic drugs or delivery systems. • Minimalist surgical procedures. • Proceduralists oversee CSNs to give office anesthetics. • Non-Anesthesiologist MDs (ICU, ER) perform anesthesia. • CRNA independent practice expands anesthesia workforce. • Single payer system controls (reduces) anesthesia fees. • Loss of base + time units billing in favor of flat fees. • Shorter work hours for residents places greater demand for staff. • Life-style issues for new generation of MDs (♂ or ♀ ) will limit their productivity (estimated 15% reduction). • Increasing number of women in the workforce may reduce overall productivity per MD by 25% and needs to be factored into supply equations.

14. The “Dis-location” of U.S. Medicine – The Implications of Medical Outsourcing1 • Digitizing health care will render many activities borderless (radiology, laparoscopy) • Has become a cost-cutting effort to offset skyrocketing health care costs • eICU has off-site MDs in Australia with TV monitors advising local staff, writing orders, running codes • Outsourcing will allow patients to obtain services from best provider, not limited to best in town 1 -Wachter, RM NEJM 354 (7):661,2/16/06

15. Wachter – Medical Outsourcing • “ In the digitally globalized world, the painful truth is that the only durable protection against the outsourcing of services is to provide the highest quality of care at the lowest cost.” For anesthesiologists, ‘outsourcing’ may come from ICU and ER MDs anesthetizing patients in their domains. • 4 certainties: • Outsourcing will grow • Traditional relationships will change • New ethical, legal, and quality standards will develop • It will be controversial Wachter SM, NEJM 534 (7):661,2006

16. Shattuck Lecture - Health Care in 2005 • U.S. Health care spending is the highest in the industrialized world. • 15% of GDP (est. 19% by 2015) • Today’s average health insurance premium: • >$9000 yearly per family (21% of mean income) • >$5500 is spent yearly per person in U.S. • Despite high cost of care, Americans at best receive only 55% of recommended care for common conditions. • It takes 17 years for MDs to adopt basic research findings into clinical practice. • - Frist, WH. NEJM 2005; 352(3):267-272.

17. Shattuck - A Glimpse into the Future • Health Savings Accounts allow patients to select MDs from Internet profiles. • Patients own a personal electronic health record which is implantable and updatable. • Email, videoconferencing, home monitoring reduce the need to travel great distances for care. • Universal access to patients’ health records form anywhere in the U.S. makes emergency care safe and efficient. • New therapies include nanobot technology, minimally invasive surgery, combination sustained released medical pill pumps • - Frist, WH. NEJM 2005; 352(3):267-272.

18. Changes In Our Practice Are Inevitable and Imminent • Practice – lesser trained personnel will likely predominate health care delivery to reduce costs. • Hospitals – will become inpatient ICU facilities where surgical and medical care are fused. Many specialties will compete for hospital care. • Payment – reduced payment for services will change supervisory ratios and the ability of MDs to provide solo care.

19. Key Anesthesia Issues 2005 -2010 • Future Paradigms of Anesthesia Practice • Workforce Size • Clinical Practice Arrangements • Our Public Images • Payment Restructuring • Academic Anesthesiology –Teaching Rule • CRNA/AANA Interactions • Status Of Anesthesiologists’ Assistants • Lema’s Top Ten List

20. Future Practice • Will market forces narrow our role to strictly operating room care? • We must demonstrate our value to society and to our colleagues in a changing health care market that emphasizes non-MD provision of care • What happens if the need for highly trained anesthesiologists is reduced by others providing propofol/LMA and by minimally invasive surgery? • Competition from other MDs and non- MD providers will intensify and force us to show that we are the best and most economical. • Should pain medicine, perioperative care and critical care be required to position us as leaders in these areas? • ASA, ABA, SAAC/AAPD, FAER will continue to strategize to reshape anesthesia training to prepare our specialty for the inevitable changes to come.

21. Workforce Size - Expand, Reduce or Right-size? • Society must decide on the value of having highly trained anesthesia professionals perform anesthesia for routine diagnostic and lesser surgical procedures. • Our growth (shrinkage) depends both on the affordability and the availability of our services. • Perceptions persist that we are overpaid and can be replaced by non-anesthesia or other MD personnel. • Our value in the OR must be addressed through public image enhancement campaigns and our daily interactions with patients, colleagues and administrators.

22. Clinical Practice Arrangements • Will society value the anesthesia care team model and be willing to pay for it? • Will the evolving surgical/medical advances require the need for an ACT in the current ratios? • Will there simply be competition among all providers for the smaller, ‘safer’, routine cases? • Will MD supervision or medical direction become similar to an ICU physician overseeing a ward of ICU nurses?

23. Clinical Practice - Realities • Conscious sedation nurses (CSNs) are becoming more popular for simple procedures because they are less expensive than either CRNAs or MDs and are more easily controlled by the proceduralist. • ASA is fighting to preserve anesthesia coverage for high-risk endoscopy but will have a hard time convincing payers that propofol for everyone is safer – this care is too expensive ($64M) and will lead to a marked reduction in payment. • We must be both medically and financially prepared to expand our supervision beyond 4:1 and consider an ICU-type medical direction (10:1). • ASA is evaluating alternative payment structures to avoid last-minute adverse payment changes by CMS/payers.

24. Public Image • Everyone feels safe when there is an experienced pilot in the cockpit even though the plane flies itself. (Good Public Image) • Policymakers want to eliminate anesthesiologists and even CRNAs now that we’ve made anesthesia 20x safer. (Bad Public Image) • ASA needs to change this perception through the media but it’s incumbent on every anesthesiologist to earn the respect of colleagues every day in every OR.

25. Payment Restructuring • ASA needs to be proactive and look at alternative methods of payment that acknowledge our perioperative services and our expertise in complex cases (stratify fees so that PRACTICE guides payment). • There is something wrong with our current payment structure when recent graduates want to immediately practice in ambulatory centers because payment and QOL are favorable instead of initially serving in hospital-based settings where surgical and anesthetic innovations occur. • With Medicare slowly becoming the dominant payer, our RVS will become a liability. Alternative payment structures need to be developed and vetted for anticipated future changes. Moreover, P4P will be tied to payment and quality measures will factor into the equation.

26. Anesthesia mortality in 1900 Anesthesia mortalityin1970 today

27. Academic Anesthesiology • Anesthesiology’s Curriculum needs a total restructuring. • Critical care, perioperative care and pain medicine emphasis seem to be essential skills the new medicine paradigm. • Current emphasis in operative services is likely to doom our specialty (or markedly reduce salaries). • Research in Outcomes and Safety are needed to show our value to patients, colleagues and payers.

28. ASA/AANA Interactions • It’s unlikely that relationships will improve unless both sides are willing to offer compromise solutions. • Neither side feels significantly threatened to the point where they wish to change current interactions by offering concessions. • ASA/AANA can agree on some core issues that protect patient safety and maintain payment structures. • Both sides have agreed to be respectful of the other specialty’s attempts to advance their respective issues and will refrain from personal attacks or stating misinformation.

29. Anesthesiologist’s Assistants • Support for AAs within ASA is mixed. • Ohio case where AAs are suing OMA over scope of practice issues further clouds the picture. • AANA is taking advantage of this case by lobbying to limit AAs scope of practice at the state level. • Program expansion beyond 3 programs is modest (3-5), and the numbers graduating each year (55→76+) are inconsequential when compared with MDs (1200) and CRNAs (2000). • Any expanded support for AAs will require HOD action.

30. Lema’s Top Ten List of Concerns • Anesthesia awareness and the media’s attention • CRNAs thinking that they’re equal and cheaper • Non-anesthesiologist doctors thinking they’re equal and cheaper • The perception that we’re overpaid for what we do • The misconception by the membership at large that we don’t need to change • Propofol administration by untrained personnel • Impending crisis in academic anesthesiology • Complacency about the importance of PAC donations (we are no longer #1 among MD subspecialties) • SGR fix and CMS Teaching Rule Change • Properly preparing us for the future changes in health care

31. My Vision of the Future • Extensive surgical trauma will disappear for elective surgery • Procedures will become tedious and uneventful; critical incidents will become rare; anesthesia will become routine • Putting all our eggs into the surgical anesthesia basket may be specialty suicide (or at best the need for surgical anesthesiologists will markedly decline) • Non-physician mid-level providers will be overseen by MDs in an ICU type arrangement using standard anesthesia protocols • Perioperative, Pain, Critical Care and Hospitalist medicine will become the domain of the future anesthesiologist • Salaries may decrease or will cease to escalate to align with safer surgical procedures • Future practice paradigms are not about whether we will survive as a specialty but to what we will evolve.

32. Another Plausible Prediction For The Future • MD shortages will forestall any efforts to restructure health care. • Supply and demand principles will prevail and ‘boutique medical care’ will become a prominent part of our delivery systems for those who can afford it. • The government will be forced to spend $100 billions for Medicare/caid to keep doctors in low income settings. • Medical education will be heavily subsidized for those who choose public health service time. • The ‘silo system’ of care will predominate and doctors will be recruited like sports players to more affluent health care communities.

33. One Concept Is Clear Spiraling health care costs are crippling this nation’s ability to complete on a flat global playing field (Friedman). Any windfall benefits to MDs will abruptly end as technology and payers find innovative ways to eliminate the high cost providers. It’s better to be part of the solution than part of the problem – MDs are best suited to lead the health care reform.

34. Future Changes Begin Now – Get Involved and Stay Involved! American Anesthesiology – Advancing Safe Patient Care for 21st Century Medical Practice