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Anesthesiology:Past, Present, and Future
Edward R. Mariano, M.D., M.A.S.Professor of Anesthesiology, Perioperative and Pain Medicine
Stanford University School of MedicineChief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care System
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Financial Disclosures
• Halyard Health, B Braun – Unrestricted educational program funding paid to my institution
The contents of the following presentation are solely the responsibility of the speaker without input from any of the above companies.
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Short Trip Down Memory Lane
1998
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Why Anesthesiology?
“Once a hot specialty, anesthesiology cools as insurers scale back” Anders G. Wall Street Journal. March 17, 1995.
http://www.apnewsarchive.com/1995/Numb-and-Number-Once-a-Hot-Specialty-Anesthesiology-Cools-As-Insurers-Scale-Back/id-0ff8af6e9ab84b8a994aa4f123c6dc74
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An Unpopular Specialty
1995 1996 1997 1998 1999 2000 2001 2002 20030
200400600800
100012001400160018002000
Anesthesiology Residency Graduates Nationwide
USA International
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People Forgot
• Why does anesthesiology exist?–Patient experience–Patient safety
• It’s just “going to sleep,” right??
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Anesthesiology’s History
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http://www.woodlibrarymuseum.org/history-of-anesthesia/
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The Patient Experience
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To Err is HumanAnesthesiology’s contributionsto patient safety
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To Err is Human
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AnesthesiologyToday
Where Are We Now?
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The Problem
http://www.cms.gov
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The “Triple Aim”
Berwick et al., Health Aff (Millwood) 2008;27:759Vetter et al., Anesth Analg 2014;118(5):1131
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Anesthesia Quality?
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Emphasis on Patient Experience
• Patients are surveyed using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)1
• 32 questions• Publicly reported 4 times a year2
• HCAHPS is administered to a random sample of adult inpatients between 48 hours and six weeks after discharge
1. http://www.hcahpsonline.org2. http://www.hospitalcompare.hhs.gov
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If Anesthesiologists Are Anonymous
Anesthesia is Just a Commodity
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Evolution of Anesthesia Practice
• Traditional private practice models are changing– Horizontal integration: merging of small and large
groups to form mega-groups; some are funded by private equity or venture capital
– Vertical integration: acquisition of smaller practices into larger groups (ie, ACOs)
• California law prohibits the corporate practice of medicine (physician employees) except VA
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In the News
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In the News
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MEDNAX Coming Soon?
http://www.mednax.com/newsroom/
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• There are 135 VA facilities with anesthesia services.• Veterans are complex patients with many illnesses.• There is no shortage of anesthesiologists in VA.• The national VA anesthesia handbook is pro-team.
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www.safevacare.org
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Medicare Access & CHIP Reauthorization Act (MACRA)
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https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html
BUDGET NEUTRAL
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MIPS Payments in 2019
EVERYONE who isn’t part of an APM will be subject to MIPS
QualityResource useClinical Practice Improvement Activities EHR meaningful use
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The Future of Anesthesiology
Where Is This Specialty Going?
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Anesthesia Services
Anesthesia Services: Care Team or MD only
In OR
Surgery Centers
Clinic-Based
Hospital Out-of-
OR
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Anesthesia Services
Anesthesia Services: Care Team or MD only
In OR
Surgery Centers
Clinic-Based
Hospital Out-of-
OR
Who will be on this team?Physician Anesthesiologists?Nurse Anesthetists?Anesthesiologist Assistants?
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Anesthesiologist Assistants
AB 890 (2015-16)
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Non-Anesthesia Services
Non-Anesthesia
Services
Perioperative Medicine(Surgical Home)
Telehealth
Palliative Care
Critical CareMedicine
Care Coordination
Pain Management
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Perioperative Surgical Home
“a patient-centered, physician anesthesiologist-led, multidisciplinary team-based practice model
that coordinates surgical patient care throughout the continuum from the decision to
pursue surgery through convalescence.
Mariano, et al. A&A 2015;120:1163Kain, et al. A&A 2014;118:1126
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Perioperative Surgical Home
Anesthesiology 2015;123:A23
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Out of the Operating Room
FY11 FY12 FY13 FY14 FY150
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
ANESTHESIA OUT-OF-OR ENCOUNTERS FY11-15
Total419 PRE/POST420 PAIN427 REGIONAL434 NON-OR/APS441 PHONE
NUM
BER
OF
ENCO
UNTE
RS
PSH
Out of ORRegional
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Mariano, Walters, Kim, Kain. A&A 2015;120:1163Walters, Mariano, Clark. Pain Med 2015;16;1666Walters, et al. Semin CV Anes 2016;20:133
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Does PSH Fit into MACRA?
• Participants in Advanced Alternative Payment Models are exempt from MIPS:
• The following ARE expected to qualify:– Comprehensive ESRD Care– Comprehensive Primary Care– Medicare Shared Savings Program ACOs– Oncology Care Model
• NOT Comprehensive Care for Joint Replacement (yet)
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We Must Continuously Improve
Federal Register May 3, 2007
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Who Are Our Partners?
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Anesth Clinics 2014;32:853
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The Newest Subspecialty
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Rethink Residency Training?
Growing demand for these new hospital positions:• Chief Safety Officer• Chief Patient Experience Officer• Chief Improvement Officer
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Design, Improvement, and Medicine
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