From September 2019 to August 2020, the author served as a senior economist on the Council of Economic Advisers, a government agency charged with providing economic analysis and advice to the President of the United States and senior government officials. Working with the Council yielded many useful lessons on how anesthesiologists can influence healthcare policy. First, because the President has wide latitude over many areas of health policy that directly impact patient care and anesthesiologists’ working environment, anesthesiologists should focus their efforts on influencing policymakers within the executive branch of government in addition to influencing lawmakers. Second, policymakers are busy and typically do not have a technical background, so anesthesiologists must learn how to communicate with them succinctly and at an appropriate level. Finally, because policymakers often need analysis quickly, anesthesiologists must meet these needs even if the underlying analysis is rougher and less precise that what would normally be needed for peer review.

Editor’s Perspective What We Already Know about This Topic In the United States, anesthesia groups derive revenue from insurers and “direct payments” or “institutional support” from hospitals Direct payments can represent a significant portion of group revenue and may enable the provision of services to patients covered by public insurers, which disproportionately represent low-resource and underserved populations The magnitude or characteristics of direct hospital payments to nonacademic private practice anesthesia groups is not well understood What This Article Tells Us That Is New Among 240 nonacademic California hospitals analyzed between 2002 and 2014, more hospitals made direct payments to an anesthesia group in 2014 than in 2002 and the median payment increased Hospitals where public insurers accounted for a larger fraction of anesthesia revenues were increasingly more likely to make direct payments to private anesthesia groups Direct payments to private anesthesia groups are becoming increasingly important, particularly for hospitals providing care to underserved populations Background In addition to payments for services, anesthesia groups in the United States often receive revenue from direct hospital payments. Understanding the magnitude of these payments and their association with the hospitals’ payer mixes has important policy implications. Methods Using a dataset of financial reports from 240 nonacademic California hospitals between 2002 and 2014, the authors characterized the prevalence and magnitude of direct hospital payments to anesthesia groups, and analyzed the association between these payments and the fraction of anesthesia revenue derived from public payers ( e.g. , Medicaid). Results Of hospitals analyzed, 69% (124 of 180) made direct payments to an anesthesia group in 2014, compared to 52% (76 of 147) in 2002; the median payment increased from $242,351 (mean, $578,322; interquartile range, $72,753 to $523,861; all dollar values in 2018 U.S. dollars) to $765,128 (mean, $1,295,369; interquartile range, $267,006 to $1,503,163) during this time period. After adjusting for relevant covariates, hospitals where public insurers accounted for a larger fraction of anesthesia revenues were more likely to make direct payments to anesthesia groups (β = 0.45; 95% CI, 0.10 to 0.81; P = 0.013), so that a 10–percentage point increase in the fraction of anesthesia revenue derived from public payers would be associated with a 4.5–percentage point increase in the probability of receiving any payment. Among hospitals making payments, our results (β = 2.10; 95% CI, 0.74 to 3.45; P = 0.003) suggest that a 1–percentage point increase in the fraction of anesthesia revenue derived from public payers would be associated with a 2% relative increase in the amount paid. Conclusions Direct payments from hospitals are becoming a larger financial consideration for anesthesia groups in California serving nonacademic hospitals, and are larger for groups working at hospitals serving publicly insured patients.

Editor’s Perspective What We Already Know about This Topic The need for long-duration nonopioid pain relief after total knee arthroplasty has driven multimodal analgesic regimens, some of which include the administration of liposomal bupivacaine It is unclear whether the use of liposomal bupivacaine is reliably associated with improvements in clinical or resource outcomes What This Manuscript Tells Us That Is New Retrospective analysis of a national observational data set showed that liposomal bupivacaine use for total knee arthroplasty is increasing Liposomal bupivacaine use was not associated with clinically meaningful reductions in inpatient opioid use, opioid-related complications, or resource utilization in patients who received modern pain management including a peripheral nerve block Background Although some trials suggest benefits of liposomal bupivacaine, data on real-world use and effectiveness is lacking. This study analyzed the impact of liposomal bupivacaine use (regardless of administration route) on inpatient opioid prescription, resource utilization, and opioid-related complications among patients undergoing total knee arthroplasties with a peripheral nerve block. It was hypothesized that liposomal bupivacaine has limited clinical influence on the studied outcomes. Methods The study included data on 88,830 total knee arthroplasties performed with a peripheral nerve block (Premier Healthcare Database 2013 to 2016). Multilevel multivariable regressions measured associations between use of liposomal bupivacaine and (1) inpatient opioid prescription (extracted from billing) and (2) length of stay, cost of hospitalization, as well as opioid-related complications. To reflect the difference between statistical and clinical significance, a relative change of −15% in outcomes was assumed to be clinically important. Results Overall, liposomal bupivacaine was used in 21.2% (n = 18,817) of patients that underwent a total knee arthroplasty with a peripheral nerve block. Liposomal bupivacaine use was not associated with a clinically meaningful reduction in inpatient opioid prescription (group median, 253 mg of oral morphine equivalents, adjusted effect −9.3% CI −11.1%, −7.5%; P < 0.0001) and length of stay (group median, 3 days, adjusted effect −8.8% CI −10.1%, −7.5%; P < 0.0001) with no effect on cost of hospitalization. Most importantly, liposomal bupivacaine use was not associated with decreased odds for opioid-related complications. Conclusions Liposomal bupivacaine was not associated with a clinically relevant improvement in inpatient opioid prescription, resource utilization, or opioid-related complications in patients who received modern pain management including a peripheral nerve block.

Editor’s Perspective What We Already Know about This Topic Both nurse anesthetists and anesthesiologist assistants work together with physician anesthesiologists as part of care teams It is unknown whether the specific anesthesia care team composition (physician anesthesiologist plus nurse anesthetist or anesthesiologist assistant) is associated with differences in perioperative outcomes What This Article Tells Us That Is New Using national claims data for 443,000 Medicare beneficiaries, the influence of care team composition on inpatient mortality, inpatient length of stay, and inpatient spending was evaluated There were no significant differences in mortality, length of stay, or inpatient spending between the care team models Background In the United States, anesthesia care can be provided by an anesthesia care team consisting of nonphysician providers (nurse anesthetists and anesthesiologist assistants) working under the supervision of a physician anesthesiologist. Nurse anesthetists may practice nationwide, whereas anesthesiologist assistants are restricted to 16 states. To inform policies concerning the expanded use of anesthesiologist assistants, the authors examined whether the specific anesthesia care team composition (physician anesthesiologist plus nurse anesthetist or anesthesiologist assistant) was associated with differences in perioperative outcomes. Methods A retrospective analysis was performed of national claims data for 443,098 publicly insured elderly (ages 65 to 89 yr) patients who underwent inpatient surgery between January 1, 2004, and December 31, 2011. The differences in inpatient mortality, spending, and length of stay between cases where an anesthesiologist supervised an anesthesiologist assistant compared to cases where an anesthesiologist supervised a nurse anesthetist were estimated. The approach used a quasirandomization technique known as instrumental variables to reduce confounding. Results The adjusted mortality for care teams with anesthesiologist assistants was 1.6% (95% CI, 1.4 to 1.8) versus 1.7% for care teams with nurse anesthetists (95% CI, 1.7 to 1.7; difference −0.08; 95% CI, −0.3 to 0.1; P = 0.47). Compared to care teams with nurse anesthetists, care teams with anesthesiologist assistants were associated with non–statistically significant decreases in length of stay (−0.009 days; 95% CI, −0.1 to 0.1; P = 0.89) and medical spending (−$56; 95% CI, −334 to 223; P = 0.70). Conclusions The specific composition of the anesthesia care team was not associated with any significant differences in mortality, length of stay, or inpatient spending.

What We Already Know about This Topic Prompt availability of dantrolene is important for treating malignant hyperthermia and has resulted in lowered mortality rates Maintaining a malignant hyperthermia cart and full treatment dose of dantrolene is expensive, particularly for locations with low incidence of malignant hyperthermia, such as labor-and-delivery units What This Article Tells Us That Is New Cost-benefit analysis showed that the costs associated with maintaining a malignant hyperthermia cart with a full dantrolene supply within 10 min of a maternity unit exceeded the benefits Modeling suggested that a more cost-effective approach would be to keep just an initial dose of dantrolene on the maternity unit, with a central supply of dantrolene available within 30 min Background The Malignant Hyperthermia Association of the United States recommends that dantrolene be available for administration within 10 min. One approach to dantrolene availability is a malignant hyperthermia cart, stocked with dantrolene, other drugs, and supplies. However, this may not be of cost benefit for maternity units, where triggering agents are rarely used. Methods The authors performed a cost-benefit analysis of maintaining a malignant hyperthermia cart versus a malignant hyperthermia cart readily available within the hospital versus an initial dantrolene dose of 250 mg, on every maternity unit in the United States. A decision-tree model was used to estimate the expected number of lives saved, and this benefit was compared against the expected costs of the policy. Results We found that maintaining a malignant hyperthermia cart in every maternity unit in the United States would reduce morbidity and mortality costs by $3,304,641 per year nationally but would cost $5,927,040 annually. Sensitivity analyses showed that our results were largely driven by the extremely low incidence of general anesthesia. If cesarean delivery rates in the United States remained at 32% of all births, the general anesthetic rate would have to be greater than 11% to achieve cost benefit. The only cost-effective strategy is to keep a 250-mg dose of dantrolene on the unit for starting therapy. Conclusions It is not of cost benefit to maintain a fully stocked malignant hyperthermia cart with a full supply of dantrolene within 10 min of maternity units. We recommend that hospitals institute alternative strategies ( e.g ., maintain a small supply of dantrolene on the maternity unit for starting treatment).

Background In 2001, the Centers for Medicare and Medicaid Services issued a rule allowing U.S. states to “opt out” of the regulations requiring physician supervision of nurse anesthetists in an effort to increase access to anesthesia care. Whether “opt out” has successfully achieved this goal remains unknown. Methods Using Medicare administrative claims data, we examined whether “opt out” reduced the distance traveled by patients, a common measure of access, for patients undergoing total knee arthroplasty, total hip arthroplasty, cataract surgery, colonoscopy/sigmoidoscopy, esophagogastroduodenoscopy, appendectomy, or hip fracture repair. In addition, we examined whether “opt out” was associated with an increase in the use of anesthesia care for cataract surgery, colonoscopy/sigmoidoscopy, or esophagogastroduodenoscopy. Our analysis used a difference-in-differences approach with a robust set of controls to minimize confounding. Results “Opt out” did not reduce the percentage of patients who traveled outside of their home zip code except in the case of total hip arthroplasty (2.2% point reduction; P = 0.007). For patients travelling outside of their zip code, “opt out” had no significant effect on the distance traveled among any of the procedures we examined, with point estimates ranging from a 7.9-km decrease for appendectomy (95% CI, −19 to 3.4; P = 0.173) to a 1.6-km increase (95% CI, −5.1 to 8.2; P = 0.641) for total hip arthroplasty. There was also no significant effect on the use of anesthesia for esophagogastroduodenoscopy, appendectomy, or cataract surgery. Conclusions “Opt out” was associated with little or no increased access to anesthesia care for several common procedures.

Background: Markets for physician services are becoming increasingly concentrated, with many areas being dominated by a few groups. Antitrust authorities are concerned that increasing concentration will lead to inappropriately high payments for physician services from private insurers. The authors examined the association between market concentration and private insurer payments for anesthesia services. Methods: The authors obtained data on average payments from private insurers for five commonly used anesthesia Current Procedure Terminology codes for physicians located in 229 counties in the United States between 2002 and 2010. The authors calculated a measure of market concentration (the Herfindahl–Hirschman Index [HHI]) for anesthesiologists in each county using Medicare claims data. The authors then estimated the association between market concentration and private insurer payments using a difference-in-differences approach to minimize confounding. Results: Private insurer payments to anesthesiologists in more concentrated markets were not significantly different from payments in less concentrated markets. Compared with the 25% of counties with the least concentration (counties with an HHI in the 0th to 25th percentile), payments in counties in the 25th to 50th percentile of HHI were approximately 0.51% less (95% CI, −2.3 to 1.3%, P = 0.95), whereas payments in counties in the 50th to 75th percentile of HHI were approximately 2.8% less (95% CI, −6.7 to 1.4%, P = 0.41) and payments in counties in the 75th to 100th percentile were approximately 3.1% less (95% CI, −8.1 to 1.2%, P = 0.32). Conclusion: Increasing market concentration of anesthesia groups is not associated with significantly greater payments from private insurers. Abstract In a review of payments from private insurers for five commonly billed anesthesia codes in 229 counties in the United States from 2002 through 2010, payments to anesthesiologists in more concentrated markets were not significantly different from payments in less concentrated markets. Supplemental Digital Content is available in the text.