Like many other specialties, the practice of anesthesiology has suffered as of late due to reimbursement cuts, fear of malpractice and provider shortages. At the same time, technological advances are improving perioperative care and placing a greater emphasis on a complete episode of care. Paul Willoughby, MD, president of the New York State Society of Anesthesiologists, discusses four trends affecting anesthesiology in his state.
1. Practice of "defensive medicine" needs to be reduced. According to Dr. Willoughby, physicians across the United States — including anesthesiologists — practice "defensive medicine" more than they should to avoid being sued. "Ninety percent of all lawsuits occur in America, which allows other practitioners around the world to practice more cost-effective medicine," he says. He says the NYSSA encourages lawmakers to introduce caps on damages for providers that face a malpractice suit and points out that medical malpractice lawsuits suck valuable resources from the healthcare system. "That money could be better used to take care of patients," he says. "The government keeps saying that healthcare costs a lot, but a lot of those costs are generated through defensive medicine to avoid lawsuits."
He says pain practitioners and anesthesia providers can be hurt by contradictory best practice guidelines. "For instance, it's perfectly acceptable to do epidural steroid blocks in patients on non-steroidals. Even the American Society of Regional Anesthesia guidelines show that you can do that," he says. "However, I frequently see pain practitioners taking patients off non-steroidals because they're afraid of being sued for bleeding, which is an incredibly rare event." He says practitioners are unsure of which guidelines to follow when adhering to one set of guidelines, which might put them at risk for a lawsuit.
2. Already low Medicaid reimbursements recently received a one percent cut. According to Dr. Willoughby, Medicaid reimbursements for pain procedures in New York — already lower than the national average at 20 cents on the dollar compared to 33 — just received a one percent cut. "We get very little out of Medicaid and the federal government will be progressively moving people into Medicaid, which is the worst form of reimbursement for physicians," he says.
He says hospital-based anesthesiologists find it particularly difficult not to accept Medicaid patients because of the growing Medicaid population. Whereas ASCs can simply decide to not take Medicaid patients and bypass those reimbursement problems, hospital-based providers will be forced to accepting growing numbers of patients for whom they will be reimbursed very little.
3. Advances in acute pain management have cut costs. Dr. Willoughby says the advent of ultrasound has been a tremendous boon to regional anesthesia. "Years ago, the majority of anesthesiologists were uncomfortable performing peripheral nerve blocks in regional anesthesia," he says. "After the advent of ultrasound, I watched the number of fellowships in acute pain management increase by 300 percent." He says training in residences is also increasing, producing more physicians who are comfortable with performing peripheral nerve blocks. "When you manage acute pain better, you're able to get patients functional and out of the hospital sooner," he says. Quality perioperative care is becoming more and more essential to the practice of anesthesiology, shortening the length of stay for many patients and improving patient satisfaction and quality of life.
4. NYSSA is working with the state department of health to incent anesthesia providers to work in rural areas. The predicted shortage of anesthesiologists and CRNAs in rural areas of New York — similar to the provider shortages seen throughout the country — is not impacting metropolitan areas to the same extent, says Dr. Willoughby. He explains that the NYSSA conducted a survey to look at shortage areas for anesthesia providers and found that rural areas had equal shortages of anesthesiologists and CRNAs. However, Dr. Willoughby pointed out that opting out of the CRNA supervision rule is not the answer. "What's interesting is that every time a state loosens a supervisory requirement of nurse anesthetists and moves toward giving them practice autonomy in the rural area, more CRNAs migrate to the metropolitan areas," he says. "It is important to note that when a non-anesthesiologist physician is put in a position to supervise a CRNA, they are not really supervising the CRNA's technical skills as much as the overall medical care of the patient. If the patient is having a heart attack, a physician, not a nurse, needs to run the code, and if a patient is having an airway problem, an anesthesiologist needs to come to their aid as opposed to a nurse."
Dr. Willoughby says the NYSSA is working with the department of health to find ways to incent anesthesia providers — both anesthesiologists and CRNAs — to practice in rural areas. As with other states, it's difficult. "You want to live near your family, and it's also a question of how much business you really get," he says. "If you're not getting enough business to pay off your student loans, you're going to have a problem." He says firm incentive plans have yet to be established.
Learn more about the New York State Society of Anesthesiologists.
1. Practice of "defensive medicine" needs to be reduced. According to Dr. Willoughby, physicians across the United States — including anesthesiologists — practice "defensive medicine" more than they should to avoid being sued. "Ninety percent of all lawsuits occur in America, which allows other practitioners around the world to practice more cost-effective medicine," he says. He says the NYSSA encourages lawmakers to introduce caps on damages for providers that face a malpractice suit and points out that medical malpractice lawsuits suck valuable resources from the healthcare system. "That money could be better used to take care of patients," he says. "The government keeps saying that healthcare costs a lot, but a lot of those costs are generated through defensive medicine to avoid lawsuits."
He says pain practitioners and anesthesia providers can be hurt by contradictory best practice guidelines. "For instance, it's perfectly acceptable to do epidural steroid blocks in patients on non-steroidals. Even the American Society of Regional Anesthesia guidelines show that you can do that," he says. "However, I frequently see pain practitioners taking patients off non-steroidals because they're afraid of being sued for bleeding, which is an incredibly rare event." He says practitioners are unsure of which guidelines to follow when adhering to one set of guidelines, which might put them at risk for a lawsuit.
2. Already low Medicaid reimbursements recently received a one percent cut. According to Dr. Willoughby, Medicaid reimbursements for pain procedures in New York — already lower than the national average at 20 cents on the dollar compared to 33 — just received a one percent cut. "We get very little out of Medicaid and the federal government will be progressively moving people into Medicaid, which is the worst form of reimbursement for physicians," he says.
He says hospital-based anesthesiologists find it particularly difficult not to accept Medicaid patients because of the growing Medicaid population. Whereas ASCs can simply decide to not take Medicaid patients and bypass those reimbursement problems, hospital-based providers will be forced to accepting growing numbers of patients for whom they will be reimbursed very little.
3. Advances in acute pain management have cut costs. Dr. Willoughby says the advent of ultrasound has been a tremendous boon to regional anesthesia. "Years ago, the majority of anesthesiologists were uncomfortable performing peripheral nerve blocks in regional anesthesia," he says. "After the advent of ultrasound, I watched the number of fellowships in acute pain management increase by 300 percent." He says training in residences is also increasing, producing more physicians who are comfortable with performing peripheral nerve blocks. "When you manage acute pain better, you're able to get patients functional and out of the hospital sooner," he says. Quality perioperative care is becoming more and more essential to the practice of anesthesiology, shortening the length of stay for many patients and improving patient satisfaction and quality of life.
4. NYSSA is working with the state department of health to incent anesthesia providers to work in rural areas. The predicted shortage of anesthesiologists and CRNAs in rural areas of New York — similar to the provider shortages seen throughout the country — is not impacting metropolitan areas to the same extent, says Dr. Willoughby. He explains that the NYSSA conducted a survey to look at shortage areas for anesthesia providers and found that rural areas had equal shortages of anesthesiologists and CRNAs. However, Dr. Willoughby pointed out that opting out of the CRNA supervision rule is not the answer. "What's interesting is that every time a state loosens a supervisory requirement of nurse anesthetists and moves toward giving them practice autonomy in the rural area, more CRNAs migrate to the metropolitan areas," he says. "It is important to note that when a non-anesthesiologist physician is put in a position to supervise a CRNA, they are not really supervising the CRNA's technical skills as much as the overall medical care of the patient. If the patient is having a heart attack, a physician, not a nurse, needs to run the code, and if a patient is having an airway problem, an anesthesiologist needs to come to their aid as opposed to a nurse."
Dr. Willoughby says the NYSSA is working with the department of health to find ways to incent anesthesia providers — both anesthesiologists and CRNAs — to practice in rural areas. As with other states, it's difficult. "You want to live near your family, and it's also a question of how much business you really get," he says. "If you're not getting enough business to pay off your student loans, you're going to have a problem." He says firm incentive plans have yet to be established.
Learn more about the New York State Society of Anesthesiologists.