Short-selling Private Practice

Today is a remarkable day for me. I’m officially leaving private practice after almost 18 years, to return to academic medicine with a faculty position in a highly regarded California department of anesthesiology.

Why would I do that?

There are many positive reasons. I believe in the teaching mission of academic medicine:  to train the anesthesiologists of the future, and the scientists who will advance medical care. I enjoy teaching. The years I’ve spent at the head of the operating room table, anesthetizing patients every day, have given me a great deal of hands-on experience (and at least some wisdom) that I’m happy to pass along to the next generation.

But the other, more pragmatic reason is this. I’ve lost confidence in the ability of private-practice anesthesiology in California to survive in its prevalent form — physician-only, personally provided anesthesiology care.

MD-only:  A viable model?

California is an outlier among all other states in its ratio of physicians to non-physicians in the practice of clinical anesthesia. Nationally, there are slightly more non-physicians — including nurse anesthetists (about 47,000) and anesthesiologist assistants (about 1,700) — than physician anesthesiologists (about 46,000) in the workforce, according to 2015 National Provider Identifier (NPI) data.

But in California, there are about 5,500 physician anesthesiologists and only 1,500 nurse anesthetists in the workforce, while anesthesiologist assistants can’t yet be licensed here at all. Though some other states, chiefly in the western half of the U.S., also have more physicians than nurses in the anesthesia workforce, none tops California’s ratio of more than 3.5 to 1.

It’s hard to see how such a physician-skewed model of anesthesia care can continue to be financially viable, no matter how much affection I have for it. I genuinely love safeguarding my patients through anesthesia for complex surgical procedures, from beginning to end. But there’s no way that it makes sense for many of the tasks involved to be performed directly by a physician. If the Institute of Medicine advocates for nurses to practice “to the full extent of their education and training” in order to provide cost-effective care, it stands to reason that physicians ought to work at the top of their licenses too.

Many of the daily tasks involved in MD-only, personally-provided anesthesia care could and should be delegated to nurses, pharmacists, and technicians. Easy examples include starting IVs, drawing up medications, labeling syringes, and monitoring a patient’s blood pressure. Surgeons don’t perform these tasks during surgery, intensive care physicians don’t perform them in ICUs, and hospitalists don’t perform them on the inpatient wards. And we haven’t even mentioned other routine tasks such as changing the suction tubing on the anesthesia machine between cases — a duty that is well within the skill set of the OR clean-up crew. It makes no fiscal sense, in our cost-conscious time, for physicians to be performing these tasks personally.

Logically, it’s an appropriate use of physician anesthesiologist skills to decide, for example, if a patient’s heart condition has been adequately optimized prior to proceeding with surgery. If there’s a problem during anesthesia with a sudden change in blood pressure, an abnormal heart rhythm, or any other severe medical problem, a physician is the logical person to diagnose the problem and prescribe treatment. The duty of the nurse or any other non-physician practitioner is to monitor the patient, administer prescribed care, and alert the physician to any new problems.

The new multidisciplinary world

The best solution to cost-effective medical care is the use of teams. The American Society of Anesthesiologists (ASA) endorses the concept of the anesthesia care team, a model in which a physician anesthesiologist supervises anesthesiologist assistants, residents, and/or nurse anesthetists in the delivery of anesthesia care, just as an intensive care physician supervises a clinical team in the care of multiple patients.

A January 6, 2016, editorial in JAMA, written by two anesthesiologists and a surgeon, describes how the concept of  “captain of the ship” has become antiquated in an era of complex perioperative care requiring multiple specialists. “When done properly,” the authors believe, “multidisciplinary team-based care is the key to good health care delivery.” That care is likely to involve “intensivists, fellows, residents, midlevel professionals, nurses, pharmacists, physical therapists, nutritionists, and others.” All right, fine; that statement seems inarguable, and may even qualify as old news.

The real surprise in the JAMA article, though, is this. The authors advocate changing the administrative structure in which the teams work. They favor “institutes, centers, or other consolidations that focus on a specific disease process, e.g., a heart institute that houses cardiac surgery, cardiology, cardiac anesthesiology, and cardiac ICU.” In other words, a traditional department structure — such as a private, MD-only anesthesiology practice — would have no place in this brave new multidisciplinary world. The remarkable fact to me is that two out of three of the authors of this editorial (Michael Nurok, MBChB, PhD, and Bruce Gewertz, MD) hail from Cedars-Sinai Medical Center, where I worked up until today.

Is there any hope for physician-only anesthesia groups?

It may be that the MD-only anesthesiology practice is about to become an endangered species. In the last few years, we have witnessed numerous examples of formerly successful practices succumbing to market forces they didn’t expect. In 2011, for instance, New York-based Somnia Anesthesia Services won the contract to provide anesthesiology services at Kaweah Delta Medical Center in Visalia, California, displacing the physician-only group that had held the contract for 16 years. Somnia brought in a new chief of anesthesiology from outside, and proceeded to recruit nurse anesthetists to complete the switchover to a more cost-effective care team model.

The Kaiser Permanente system, California’s largest nonprofit health plan, for decades has staffed its operating rooms and procedure locations according to an anesthesia care team model. The major academic medical centers in California, including the University of California hospitals, Loma Linda University, Stanford University, and the University of Southern California, all utilize the care team model with physician anesthesiologists supervising residents and nurse anesthetists. Without fanfare, these programs are all teaching their residents how to practice anesthesiology in a team-based environment.

Yet it’s too early to ring the death knell for California’s private anesthesiology groups. The smart ones are already making changes to increase the likelihood of their survival. They are getting more involved outside the operating room, in the overall management and financial success of their hospitals.

In the San Francisco Bay area, Keith Chamberlin, MD, MBA, a physician anesthesiologist, has led the formation of an Accountable Care Organization (ACO) at Marin General Hospital, and is currently the President of the ACO’s Board of Directors.

In Pasadena, anesthesiologist Rick Bushnell, MD, MBA, is leading Huntington Memorial Hospital in a Perioperative Surgical Home project designed to improve the patient experience and outcome. As Dr. Bushnell explained recently in the Anesthesia Business Consultants Communique, the physician anesthesiologists will focus their attention “on the most complicated 20 percent of patients,” seeing them both preoperatively and after discharge in order to prevent costly readmissions.

“If our specialty is to maintain its relevance,” Dr. Bushnell said, “as anesthesiologists we must assume more responsibility. We must extend and improve our management to include the complete perioperative process, a continuum from the moment of decision to operate to the completion of recovery.” The anesthesiologists work with “intervention teams” of nurses, physician assistants, nurse practitioners, and nurse anesthetists, as he explained in his article, to improve post-op and post-discharge surveillance and intervention on the hospital floor, in the home setting, in the emergency department, and in the post-discharge clinic.

Would care be even cheaper without physicians?

Certainly health care would be cheaper if we didn’t utilize physicians at all, and simply allowed non-physician practitioners — nurse practitioners, nurse anesthetists, physician assistants — to practice independently. But that idea carries its own risks. Perhaps it has some merit for primary care in underserved areas. The acute-care environment of the operating room, however, is different and much more hazardous.

In my opinion, the answer to rising health-care costs is not to give non-physicians such as nurse anesthetists the regulatory authority to practice medicine without a license, and to administer anesthesia without consulting with or accepting advice from a physician anesthesiologist. Patients want a fully licensed physician in charge of their care, just as they want a lawyer — not a paralegal — managing their legal affairs, and an experienced, fully qualified pilot flying the jet plane.

I’m placing my bet on the likelihood that California’s anesthesia practices will continue to move away from physician-only, one-to-one anesthesia care, and more in the direction of the anesthesia care team model. The CSA’s efforts to gain the right for anesthesiologist assistants to work in California, it seems to me, will give us an excellent additional option for expanding the anesthesia care team. It will be fascinating, and possibly alarming, to watch how the anesthesia marketplace in California continues to evolve.

Karen Sibert is an anesthesiologist in Los Angeles.

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  1. Important questions. I imagine that the use of non-physician staff will increase in many different specialties. Non-physician staff are seen as more docile, more willing to comply with rules, mandates, safety protocols, etc. and, of course, less costly overall. Physicians will have a hard time making the case that outcomes are worse (or at least, making the case to those who control the job market).