This issue of Anesthesiology contains four articles and an editorial suggesting that the future practice of anesthesiology must address microeconomic issues. Unlike macroeconomics, which embraces social and political factors affecting a marketplace, microeconomics essentially contemplates the allocation decisions of individual consumers or firms within the marketplace. As applied to anesthesia care, microeconomics includes consideration of the costs of providing care in light of the consequent patient benefits. Sperry [1] provides a lucid discussion of the principles of microeconomic analysis. These principles are basic to the anesthetic practice-related discussion of cost analysis by Watcha and White. [2] Lubarsky and colleagues [3,4] present two examples of cost savings using approaches similar to those we have used for decades to study physiologic and pharmacologic issues. The editorial by Fisher and Macario [5] places these articles in a perspective that challenges us to realize that microeconomic issues must become an integral part of our practice.
It is fitting that this issue of the journal that is devoted to economic considerations also examines the macroeconomic forces that have brought this medical specialty to a defining moment. The significance of these macroeconomic forces has compelled respected anesthesiologists to suggest that the specialty must respond to the new health care environment by reorienting our self-identification, [6] embracing already existing extra-operating room activities, [7] and recognizing that an evolutionary process has begun. [8] Despite these recent credible and sobering admonitions, it is my experience that most anesthesiologists continue to lament that the new economic environment unfairly demeans the specialty's merits and, therefore, they ask “Why must we change our practice?” To intelligently address this important question, we must review the macroeconomic forces that have created the harsh realities of the emerging health care marketplace.
After World War II, the United States developed a socioeconomic ethic spawned by an invincible national confidence in our ability to accomplish whatever goals we set. That society embraced the economic philosophy of John Kenneth Galbraith, [9] who advocated that economic growth could best be sustained by directing resources more toward providing better public services and less to producing consumer goods. This “social engineering” credo led to a public determination to build a health care system that would provide ultimate care for every citizen regardless of cost, a national goal that went unchallenged for nearly 40 years.
The federal government initiated the social engineering of health care by funding programs intended to enhance delivery of health care services. Legislation fostered the establishment and expansion of hospitals, the training of new physicians, and physician specialization. Funding of the National Institutes of Health produced a technological and pharmacologic explosion that created more effective (and expensive) diagnostic and treatment regimens. Once programs were established to develop factors essential to delivering health care, the government instituted legislation to enhance access to health care services. Of greatest significance were the Medicare program and federal taxation policies encouraging corporations to provide employee health insurance.
These social engineering initiatives resulted in a health care system with the highest quality in the world. Notable economic consequences included (1) the establishment of a society that expected high-quality health care at no personal cost, (2) an overabundance of beds in hospitals that were guaranteed profits by a “cost-plus” reimbursement system that encouraged hospital admissions and procedures, and (3) physicians that were reimbursed by insurance on a “usual and customary” fee schedule that guaranteed a profit for every patient visit and every procedure. Simply put, the practice of medicine and the delivery of health care became a risk-free economic enterprise completely independent of marketplace forces.
This economically risk-free environment had an important effect on the developing specialty of anesthesiology. In the early years, explosive and poorly controllable anesthetic agents in conjunction with limited monitoring capabilities required extraordinary clinical acumen, skill, and vigilance to minimize anesthetic-related complications and deaths. These patient care and economic realities fostered an environment in which anesthesiologists appropriately defined themselves as physician specialists whose value was encompassed within the direct administration of anesthesia. This role definition is commonly called the “M.D. anesthetist paradigm.”
Practitioners in the specialty of anesthesiology rapidly developed a knowledge and skill base that, combined with sophisticated anesthetic agents and monitors, allowed them to provide a consistently safer operating room environment. By the mid-1960s, patient care justification for the M.D. anesthetist paradigm had eroded to a point in which the “anesthesia care team” concept was adopted to recognize the value of the anesthesiologist as the direct supervisor of nonphysician anesthetists. Concomitantly, the specialty expanded the definition of its scope of practice to include physician responsibilities beyond the administration or supervision of anesthesia in the operating room. Although this expanded physician scope of practice became a reality in many academic centers and training programs, there were no private practice economic forces to challenge the M.D. anesthetist paradigm. Simply put, until recently, there were no compelling reasons for anesthesiologists to expand their practice because the M.D. anesthetist paradigm continued to result in the safe delivery of anesthesia, a lucrative practice, and confined clinical responsibilities.
By the late 1970s, an evolving global economy began to encroach on U.S. corporate profits and jobs. Economic and political thought became dominated by the views of Milton Friedman, [10] which castigated the federal government's ability to cure social ills and touted the free marketplace as the answer to this problem. The business community's growing mistrust of the federal government's ability to control spiraling healthcare costs made employee health benefits an important concern. It became inevitable that the private sector would initiate “managed care” programs encompassing a multiplicity of schemes that apply the principles of marketplace economics to the nation's health care system.
We are now experiencing the abrupt application of marketplace forces to the health care industry. This means we must learn to compete with physicians, hospital administrators, managed care administrators, and insurers for health care dollars. Because essentially all of these persons assess our value in relation to the M.D. anesthetist paradigm, they perceive us as far too expensive in light of the limited services we render. In a marketplace environment, the validity of the perception is irrelevant! The perception that we are too expensive for the services we render must be addressed.
A basic rule of the marketplace is that when a service is perceived to be overpriced, either the price must be lowered or value must be added to the service for the same price. To maintain our fair share of health care dollars, we must increase the value of our services to patients, other physicians, hospitals, managed care administrators, and insurers. For example, we must ensure appropriate preoperative anesthetic assessment with minimal extraneous consultation, minimal laboratory testing, and only essential diagnostic procedures. This will add value to our services by providing a safe, satisfying, and less anxiety-producing experience for the patient; improve surgeon satisfaction by having us assume the responsibility for assuring minimal delays and cancellations; attract managed care insurers by making sure that only essential consultations, laboratory work, and diagnostic procedures will be obtained; and improve hospital administration satisfaction through more efficient operating room use. Other examples of adding value to our services are minimizing ambulatory anesthesia recovery time, minimizing the cost of the anesthetic agents we use, decreasing admissions to the intensive care unit by managing extended recovery rooms, providing care in the intensive care unit, and providing acute pain management to minimize hospital stay, minimize complications, and improve patient satisfaction.
Our primary mission remains that of the nonsurgical intraoperative physician and leader of the anesthesia care team. Our secondary mission must now be to ensure that anesthesiology becomes, and is perceived as, the practice of perioperative medicine. We must continue to provide high-quality physician services in the operating room and embrace the mission of providing the extra-operating room physician services that are now included in our scope of practice and that we are uniquely qualified to provide. Although it may be difficult for the marketplace to differentiate between the value of an M.D. anesthetist and a nurse anesthetist, the difference in value between a perioperative physician and a nurse anesthetist is obvious.
Global economic forces has thrust our specialty into a defining moment. We are abruptly compelled to fulfill expanded physician responsibilities that are already included in our scope of practice. This de facto expansion of responsibilities will add value to our services and serve to maintain our fair share of health care dollars.
Why must the practice of anesthesiology change? It's economics, doctor!
Barry A. Shapiro, M.D., M.M.(M.B.A.)
Department of Anesthesiology; Northwestern University Medical School
Passavant Pavilion, Suite 360; 303 East Superior Street; Chicago, Illinois 60611–3053
