New Health Care Paradigms – Trouble or Opportunity?
Ronald G. Pearl, M.D., Ph.D.
Dr. Richard K. and Erika N. Richards Professor
Chairman, Department of Anesthesiology, Perioperative and Pain Medicine
Stanford University School of Medicine
The American health care system is in the process of a major transformation. Currently, the
United States spends 2.6 trillion dollars, over 17% of its gross domestic product, on health care
with a per capita expenditure more than twice the average of other developed countries but
without evidence of improved quality or outcomes. Health care now represents approximately
one-fourth of the government budget and costs have been rising faster than inflation. Although
the passage of the Patient Protection and Affordable Care Act in 2010 is often viewed as the
pivotal event driving health care reform, the reality is that many of the ongoing changes in health
care are driven by payers who are searching for new paradigms to decrease costs and share
financial risk. This syllabus will review the current status of new health care paradigms and then
focus on the potential role of the cardiothoracic anesthesiologist.
Fee-for-service reimbursement developed in the 1930s to preserve the autonomy of physicians in
health care decisions (Kane, 2008) and remains the dominant method of payment. The fee-forservice systems rewards providers (both physicians and hospitals) for quantity of services rather
than for quality and has resulted in a fragmented care delivery system with limited coordination
of care among providers and with marked variation in resource use. An example of the problem
of the fee-for-service methodology is that hospitals increase their profitability when Medicare
patients have surgical complications (Eappen, 2013). The initial change away from a pure feefor-service system has been to modify the payment, either on the basis of meeting specific
process performance metrics (such as antibiotic prophylaxis, glucose control, and temperature
management) or by not paying for certain hospital-acquired conditions such as central line
associated blood stream infections or wrong site surgery. These initial modifications have been
expanded to a larger value-based purchasing approach where payments may be modified on the
basis of patient outcomes or patient satisfaction scores. These approaches have often involved
payment withholds which are then distributed to the higher-performing institutions.
Unfortunately, such systems which reward specific process measures may produce negative
consequences, such as promoting erroneous practices (perioperative beta-blockade), excess
inappropriate care, inappropriate resource allocation, and creating incentives to avoid high risk
patients (O’Brien, 2013). Many studies have not demonstrated improved outcomes with
increased implementation of process measures.
The general lack of success of value-based purchasing based on process measures has therefore
evolved to payments for an episode of care such as coronary artery bypass surgery. For Medicare
payments, hospitals have received such diagnosis-related group (DRG)-based payments since
1983, but the current methodology for episode of care payments invovles two major expansions.
First, the episode of care is defined not just as the hospitalization but also includes the 30 days
after discharge, creating incentives for improved coordination and communication throughout
this period. Second, the hospital and physician payments (Medicare Part A and B) may be
bundled together into a single payment, as initially recommended by the MedPAC 2008
commission (Kane, 2008). That commission also recommended the development of the medical
home with a monthly capitation payment for providing comprehensive, continuous care of
complex patients. Approximately two-thirds of Medicare beneficiaries with 3 or more common
conditions see at least 10 physicians per year, and the current fee-for-service system promotes
fragmented, uncoordinated care without adherence to best-practice guidelines. In selected
demonstration projects, the medical home concept has improved outcomes with decreased costs
(Milstein, 2013). Importantly, the medical home concept is financially viable only with
appropriate risk-adjustment payments.
The fee-for-service reimbursement system emphasizes high-cost management of acute disease,
and the bundled payment and medical home approaches focus on value-based payment
(decreased cost and improved outcomes) for individual patients. The final stage in the evolution
of health care is the development of accountable care organizations (ACOs) which provide
payments for the care of entire populations. Although systems such as Kaiser Permanente
function effectively as ACOs, the development of ACOs among academic health care systems
has only begun and has faced major financial, cultural, and organizational barriers (Tallia, 2012).
By definition, ACOs incorporate concepts of bundled payments and the medical home with a
strong emphasis on processes of care including adherence to evidence-based guidelines and
pathways, coordinated patient-centered care, and cross-subsidization among specialties.
The American Society of Anesthesiologists has strongly advocated for the development of the
Perioperative Surgical Home (PSH) as a future model for the role of the anesthesiologist
(http://www.periopsurghome.info/). The goal of the PSH is to achieve the triple aim of better
health, better healthcare, and decreased costs. It is a response to anticipated changes in health
care paradigms and emphasizes patient-centric, physician-led collaborative care with shared
decision making and continuity of care for the surgical patient. It incorporates the cost-effective
use of non-physician providers. The goal is to align incentives, prevent fragmented and variable
care, and avoid preventable harm throughout the preoperative, intraoperative, and postoperative
period. It emphasizes involvement of the anesthesiologist from the time surgery is first planned
and includes early patient assessment and the use of evidence-based clinical protocols for
preoperative testing and medical optimization. The intraoperative period uses best practice
protocols to decrease variation. The postoperative period focuses on integrated care, optimal pain
management, use of protocols and pathways, and coordination of discharge planning and postdischarge management. The ASA is funding a learning collaborative to develop and disseminate
models for the PSH.
There are approximately 500,000 cardiac surgeries performed annually in the United States, and
the costs and outcomes dramatically vary among centers for the same procedure. The indications
for CABG and valve procedures are well-defined. Implantable cardioverter defibrillators (ICDs),
cardiac resynchronization therapy, and heart transplant are cost-effective in appropriate
populations, and the improving results with LVAD insertion for destination therapy will likely
make this a cost-effective procedure in the near future (Kazi, 2013; Miller, 2013). As a result of
the increased age of the population, cardiac surgery procedures will continue to increase
(Etzioni, 2011). Based on their high prevalence, high cost, and high rate of complications,
cardiac surgery procedures are commonly viewed as an area of potential cost savings in health
care reform. Cardiac anesthesiologists can play important roles in this process.
Cardiac anesthesiologists are most intensively involved in the intraoperative management of the
cardiac surgery patient. The operating room is remarkable for its complexity and the need for
seamless communication and coordination between the anesthesiologist, the surgeon, the
perfusionist, and nursing. The FOCUS (Flawless Operative Cardiovascular Unified Systems)
initiative of the Society of Cardiovascular Anesthesiologists (SCA) Foundation is designed to
develop guidelines to decrease human error in the operating room and thereby improve outcomes
(http://scahqgive.org/flawless-operative-cardiovascular-unified-systems/). In addition to using
superb anesthesia skills and intraoperative decision-making, cardiac anesthesiologists can add
value to the intraoperative management of the patient through outstanding communication,
adherence to guidelines (e.g., central line insertion bundles), standardization of care, choice of
monitoring, and choice of an anesthetic technique to optimize the postoperative course. Since
intraoperative care significantly alters postoperative complications, anesthesiologists should also
be involved in the development of pathways which include intraoperative glucose control and
atrial fibrillation prophylaxis. Adoption of blood transfusion guidelines, point-of-care
coagulation testing, and antibiotic prophylaxis can improve value by decreasing costs and
improving outcomes. As part of the cardiac surgery team, the cardiac anesthesiologist can help
prevent adverse events (Martinez, 2013).
Cardiac anesthesiologists can also add value by appropriate preoperative assessment and
optimization, including collaboration with cardiac surgeons and cardiologists through attendance
at catheterization conference and early preoperative assessment. However, the major area in
which cardiac anesthesiologists can expand their value is in the postoperative period. In many
institutions, cardiac anesthesiologists are responsible for the postoperative management of the
cardiac surgery patient in the intensive care unit. As cardiac surgery has moved towards more
minimally invasive procedures and patients have become older and more complex, the
postoperative management of patients has assumed an increasingly important role. Even without
additional fellowship training in critical care, anesthesiologists are able to treat the major issues
which occur in the ICU, such as hemodynamic instability, arrhythmias, bleeding, respiratory
failure, delirium, and pain. These problems may continue after discharge from the ICU, and
cardiac anesthesiologists can extend their value by collaborating with cardiac surgeons,
cardiologists, hospitalists, nurses, and mid-level providers in the management of the cardiac
surgery patient throughout their hospital course, including coordination of care. With their skills
in echocardiography and resuscitation, cardiac anesthesiologists can also add value to the
institution by developing a service for medical and non-cardiac surgery patients with
hemodynamic instability. Finally, cardiac anesthesiologists can add value through careeffectiveness research and implementation of protocols.
Selected References:
Eappen S, Lane BH, Rosenberg B, Lipsitz SA, Sadoff D, Matheson D, Berry WR, Lester M,
Gawande AA. Relationship between occurrence of surgical complications and hospital finances.
JAMA. 2013; 309:1599-1606.
Etzioni DA, Starnes VA. “The epidemiology and economics of cardiothoracic surgery in the
elderly.” Cardiothoracic Surgery in the Elderly. New York: Springer, 2011. 5-24.
Kane NM. Traditional fee-for-service Medicare payment systems and fragmented patient care:
the backdrop for non-operating room procedures and anesthesia services. Anesthesiol Clin. 2009;
27:7-15.
Kazi DS, Mark DB. The economics of heart failure. Heart Fail Clin. 2013; 9:93-106.
Martinez EA. Quality, patient safety, and the cardiac surgical team. Anesthesiol Clin. 2013;
31:249-268.
Miller LW, Guglin M, Rogers J. Cost of ventricular assist devices: can we afford the progress?
Circulation. 2013; 127:743-748.
Milstein A, Shortell S. Innovations in care delivery to slow growth of US health spending.
JAMA. 2012; 308:1439-1440.
O'Brien JM Jr, Kumar A, Metersky ML. Does value-based purchasing enhance quality of care
and patient outcomes in the ICU? Crit Care Clin. 2013; 29:91-112.
Tallia AF, Howard J. An academic health center sees both challenges and enabling forces as it
creates an accountable care organization. Health Aff. 2012; 31:2388-2394.