Physician Shortage Predicted To SpreadPhysician Shortage Predicted To Spread• COGME has reversed its 1980’s position COGME has reversed its 1980’s position
that there will be a physician surplus.that there will be a physician surplus.• Adopted Salsberg study which estimates a Adopted Salsberg study which estimates a
need for 3000 more (15%need for 3000 more (15%↑) ↑) graduating graduating physicians by 2015.physicians by 2015.
• Projected number of MDs in 2020 – Projected number of MDs in 2020 – 972,000 Projected needed by 2020 – 972,000 Projected needed by 2020 – 1,060,0001,060,000
• Medical school graduates have remained Medical school graduates have remained constant at 15-16,000 since 1980 while US constant at 15-16,000 since 1980 while US population has increased by 24% and is population has increased by 24% and is also ‘graying’.also ‘graying’.
Am Med News 47(1):1-2, 1/5/04Am Med News 47(1):1-2, 1/5/04
• 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.
The Realities Of A Changing The Realities Of A Changing Health Care SystemHealth Care System
• Who’s Overseeing the transition?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.
1 - Jeff Bauer PhD, health futurist, personal comm.
• “ “ The future practice of surgery is The future practice of surgery is medicine”medicine”11
• If the future of surgery is medicine, what is If the future of surgery is medicine, what is the future of anesthesiology?the future of anesthesiology?
• Medicine or obsolescenceMedicine or obsolescence
• SURGICAL TRENDS SINCE MID-90’s Minimally invasive surgery (VATS) Radiologic procedures (Gamma Knife) ‘Medicalization’ of surgery (Urology) Office-based procedures using
Threats to Our Current Mode of Anesthetic PracticeThreats to Our Current Mode of Anesthetic Practice
• Unexpected advances in anesthetic drugs or delivery systems.
• Minimalist surgical proceduresMinimalist surgical procedures.• Proceduralists oversee CSNs to give office anesthetics.• Non-Anesthesiologist MDs (ICU, ER) perform anesthesia.Non-Anesthesiologist MDs (ICU, ER) perform anesthesia. • CRNA independent practice expands anesthesia
workforce.• Single payer system controls (reduces) anesthesia fees.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 Shorter work hours for residents places greater demand
for staff.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 Increasing number of women in the workforce may reduce
overall productivity per MD by 25% and needs to be overall productivity per MD by 25% and needs to be factored into supply equations.factored into supply equations.
The “Dis-location” of U.S. Medicine – The The “Dis-location” of U.S. Medicine – The Implications of Medical OutsourcingImplications of Medical Outsourcing11
• 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
Wachter – Medical OutsourcingWachter – 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 highest quality of care at the lowest costquality of care at the lowest cost.” For anesthesiologists, ‘outsourcing’ may come from ICU and ER MDs anesthetizing patients in their domains.
• 4 certainties:4 certainties:– Outsourcing will growOutsourcing will grow– Traditional relationships will changeTraditional relationships will change– New ethical, legal, and quality standards will New ethical, legal, and quality standards will
developdevelop– It will be controversialIt will be controversial
• U.S. Health care spending is the highest in the U.S. Health care spending is the highest in the industrialized world.industrialized world.– 15% of GDP (est. 19% by 2015)15% of GDP (est. 19% by 2015)– Today’s average health insurance premium: Today’s average health insurance premium:
• >$9000 yearly per family (21% of mean income)>$9000 yearly per family (21% of mean income)• >$5500 is spent yearly per person in U.S.>$5500 is spent yearly per person in U.S.
– Despite high cost of care, Americans at best Despite high cost of care, Americans at best receive only 55% of recommended care for receive only 55% of recommended care for common conditions.common conditions.
– It takes 17 years for MDs to adopt basic It takes 17 years for MDs to adopt basic research findings into clinical practice.research findings into clinical practice.
• Health Savings Accounts allow patients to select MDs from Internet profiles.
• Patients own a personal electronic health Patients own a personal electronic health record which is implantable and updatable.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 Universal access to patients’ health records form anywhere in the U.S. makes emergency form anywhere in the U.S. makes emergency care safe and efficient.care safe and efficient.
• New therapies include nanobot technology, minimally invasive surgery, combination sustained released medical pill pumps
Changes In Our Practice Are Changes In Our Practice Are Inevitable and ImminentInevitable and Imminent
• PracticePractice – lesser trained personnel will – lesser trained personnel will likely predominate health care delivery likely predominate health care delivery to reduce costs.to reduce costs.
• HospitalsHospitals – will become inpatient ICU – will become inpatient ICU facilities where surgical and medical facilities where surgical and medical care are fused. Many specialties will care are fused. Many specialties will compete for hospital care.compete for hospital care.
• Payment Payment – reduced payment for – reduced payment for services will change supervisory ratios services will change supervisory ratios and the ability of MDs to provide solo and the ability of MDs to provide solo care.care.
• Future Paradigms of Anesthesia PracticeFuture Paradigms of Anesthesia Practice• Workforce SizeWorkforce Size• Clinical Practice ArrangementsClinical Practice Arrangements• Our Public ImagesOur Public Images• Payment Restructuring Payment Restructuring • Academic Anesthesiology –Teaching RuleAcademic Anesthesiology –Teaching Rule• CRNA/AANA InteractionsCRNA/AANA Interactions• Status Of Anesthesiologists’ Assistants Status Of Anesthesiologists’ Assistants • Lema’s Top Ten ListLema’s Top Ten List
Future PracticeFuture Practice– Will market forces narrow our role to strictly operating room care?Will market forces narrow our role to strictly operating room care?– We must demonstrate our value to society and to our colleagues in We must demonstrate our value to society and to our colleagues in
a changing health care market that emphasizes non-MD provision of a changing health care market that emphasizes non-MD provision of carecare
– What happens if the need for highly trained anesthesiologists is What happens if the need for highly trained anesthesiologists is reduced by others providing propofol/LMA and by minimally reduced by others providing propofol/LMA and by minimally invasive surgery? invasive surgery?
– Competition from other MDs and non- MD providers will intensify Competition from other MDs and non- MD providers will intensify and force us to show that we are the best and most economicaland force us to show that we are the best and most economical.
– Should pain medicine, perioperative care and critical care be Should pain medicine, perioperative care and critical care be required to position us as leaders in these areas?required to position us as leaders in these areas?
– ASA, ABA, SAAC/AAPD, FAER will continue to strategize to reshape ASA, ABA, SAAC/AAPD, FAER will continue to strategize to reshape anesthesia training to prepare our specialty for the inevitable anesthesia training to prepare our specialty for the inevitable changes to come.changes to come.
Workforce Size - Expand, Reduce or Right-size?Workforce Size - Expand, Reduce or Right-size?
– Society must decide on the Society must decide on the valuevalue of having of having highly trained anesthesia professionals highly trained anesthesia professionals perform anesthesia for routine diagnostic perform anesthesia for routine diagnostic and lesser surgical procedures.and lesser surgical procedures.
– Our growth (shrinkage) depends both on the Our growth (shrinkage) depends both on the affordabilityaffordability and the and the availabilityavailability of our of our services.services.
– Perceptions persist that we are overpaid and Perceptions persist that we are overpaid and can be replaced by non-anesthesia or other can be replaced by non-anesthesia or other MD personnel. MD personnel.
– Our value in the OR must be addressed Our value in the OR must be addressed through public image enhancement through public image enhancement campaigns and our daily interactions with campaigns and our daily interactions with patients, colleagues and administrators.patients, colleagues and administrators.
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 ASA is evaluating alternative payment structures to avoid last-minute adverse payment changes by avoid last-minute adverse payment changes by CMS/payers.CMS/payers.
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.
• 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.
ASA/AANA InteractionsASA/AANA Interactions• It’s unlikely that relationships will improve It’s unlikely that relationships will improve
unless both sides are willing to offer unless both sides are willing to offer compromise solutions.compromise solutions.
• Neither side feels significantly threatened to Neither side feels significantly threatened to the point where they wish to change current the point where they wish to change current interactions by offering concessions.interactions by offering concessions.
• ASA/AANA can agree on some core issues ASA/AANA can agree on some core issues that protect patient safety and maintain that protect patient safety and maintain payment structures.payment structures.
• Both sides have agreed to be respectful of Both sides have agreed to be respectful of the other specialty’s attempts to advance the other specialty’s attempts to advance their respective issues and will refrain from their respective issues and will refrain from personal attacks or stating misinformation.personal attacks or stating misinformation.
Anesthesiologist’s AssistantsAnesthesiologist’s Assistants• Support for AAs within ASA is mixed.Support for AAs within ASA is mixed.• Ohio case where AAs are suing OMA over Ohio case where AAs are suing OMA over
scope of practice issues further clouds the scope of practice issues further clouds the picture.picture.
• AANA is taking advantage of this case by AANA is taking advantage of this case by lobbying to limit AAs scope of practice at lobbying to limit AAs scope of practice at the state level.the state level.
• Program expansion beyond 3 programs is Program expansion beyond 3 programs is modest (3-5), and the numbers graduating modest (3-5), and the numbers graduating each year (55each year (55→76+)→76+) are inconsequential when are inconsequential when compared with MDs (1200) and CRNAs (2000).compared with MDs (1200) and CRNAs (2000).
• Any expanded support for AAs will require Any expanded support for AAs will require HOD action.HOD action.
Lema’s Top Ten List of ConcernsLema’s Top Ten List of Concerns1.1. Anesthesia awareness and the media’s attentionAnesthesia awareness and the media’s attention
2.2. CRNAs thinking that they’re equal and cheaperCRNAs thinking that they’re equal and cheaper
3.3. Non-anesthesiologist doctors thinking they’re equal and cheaperNon-anesthesiologist doctors thinking they’re equal and cheaper
4.4. The perception that we’re overpaid for what we doThe perception that we’re overpaid for what we do
5.5. The misconception by the membership at large that The misconception by the membership at large that we don’t need to change we don’t need to change
6.6. Propofol administration by untrained personnelPropofol administration by untrained personnel
7.7. Impending crisis in academic anesthesiologyImpending crisis in academic anesthesiology
8.8. Complacency about the importance of PAC donations Complacency about the importance of PAC donations (we are no longer #1 among MD subspecialties)(we are no longer #1 among MD subspecialties)
9.9. SGR fix and CMS Teaching Rule ChangeSGR fix and CMS Teaching Rule Change
10.10. Properly preparing us for the future changes in health careProperly preparing us for the future changes in health care
• 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 Future practice paradigms are not about whether we will survive as a specialty but to what we will evolve.survive as a specialty but to what we will evolve.
Another Plausible Prediction For The FutureAnother Plausible Prediction For The Future• MD shortages will forestall any efforts to MD shortages will forestall any efforts to
restructure health care.restructure health care.• Supply and demand principles will prevail and Supply and demand principles will prevail and
‘boutique medical care’ will become a prominent ‘boutique medical care’ will become a prominent part of our delivery systems for those who can part of our delivery systems for those who can afford it.afford it.
• The government will be forced to spend $100 The government will be forced to spend $100 billions for Medicare/caid to keep doctors in low billions for Medicare/caid to keep doctors in low income settings.income settings.
• Medical education will be heavily subsidized for Medical education will be heavily subsidized for those who choose public health service time.those who choose public health service time.
• The ‘silo system’ of care will predominate and The ‘silo system’ of care will predominate and doctors will be recruited like sports players to doctors will be recruited like sports players to more affluent health care communities.more affluent health care communities.
Spiraling health care costs are crippling Spiraling health care costs are crippling this nation’s ability to complete on a this nation’s ability to complete on a flat global playing field (Friedman).flat global playing field (Friedman).
Any windfall benefits to MDs will abruptly Any windfall benefits to MDs will abruptly end as technology and payers find end as technology and payers find innovative ways to eliminate the high innovative ways to eliminate the high cost providers.cost providers.
It’s better to be part of the solution than It’s better to be part of the solution than part of the problem – MDs are best part of the problem – MDs are best suited to lead the health care reform.suited to lead the health care reform.
Future Changes Begin Now – Get Future Changes Begin Now – Get Involved and Stay Involved!Involved and Stay Involved!
AmericanAmerican Anesthesiology – Anesthesiology – Advancing Safe Patient Care Advancing Safe Patient Care for 21st Century Medical for 21st Century Medical PracticePractice
