The medical specialty of anesthesiology is founded on patient experience and patient safety. Having major surgery would be a very different experience without anesthesia. Before the advent of safe anesthesia techniques, the world of surgery was basically limited to amputations and other attempts at life-saving maneuvers. Dr. Bigelow’s publication describing the safe administration of ether changed everything, and the New England Journal of Medicine called this the most important article in its history. With this article, the science and clinical practice of anesthesiology, as well as the modern era of surgery, were born. Understanding and appreciating the rich history of anesthesiology will help guide the future direction of this specialty. Physician anesthesiologists have the skills necessary to take the quality of perioperative medicine to the next level, combat the opioid epidemic, and redesign the surgical experience,
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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 Medicine
Chief, Anesthesiology and Perioperative Care
Veterans 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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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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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.org
2. http://www.hospitalcompare.hhs.gov
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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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• 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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MIPS Payments in 2019
EVERYONE who isn’t part of an APM will be
subject to MIPS
Quality
Resource use
Clinical Practice
Improvement
Activities
EHR meaningful
use
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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;120:1163
Kain, et al. A&A 2014;118:1126
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Out of the Operating Room
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
FY11 FY12 FY13 FY14 FY15
NUMBEROFENCOUNTERS
ANESTHESIA OUT-OF-OR ENCOUNTERS FY11-15
Total
419 PRE/POST
420 PAIN
427 REGIONAL
434 NON-OR/APS
441 PHONE
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Mariano, Walters, Kim, Kain. A&A 2015;120:1163
Walters, Mariano, Clark. Pain Med 2015;16;1666
Walters, 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)
Initial stages of PSH implementation
Today’s discussion is in line with available publications. More of a case report of our experience at VA Palo Alto rather than research article.
Not a “one-size fits all” – no single ideal PSH model