In medicine, reimbursement drives change in clinical practice faster than evidence. Bundled payments from Medicare since the development of Accountable Care Organizations (ACOs) epitomize a heightened value of measurable outcomes. The Merit Based Incentive Payment System (MIPS) directs physicians to report outcomes. Based on these data, bundled payments to practices may be altered (1). Anesthesiologists are uniquely situated to help reduce cost, improve efficiency, deploy protocols for enhanced recovery, all while ensuring that patient safety is held to the utmost importance.
In healthcare economics, value is defined as quality divided by cost. The unique challenge of computing and comparing value lies in the subjective nature of quality. While variables like length of stay, mortality after 30 postoperative days, reoperation, and surgical site infections are measurable, attainable values, they fail to capture all aspects of care. Furthermore, billing departments and clinical administration are distinct entities, and only recently are collaborative efforts attempting to bridge this historical artifact. Moreover, physicians of earlier generations were raised in a “cost-blind” pedagogy. Medical schools and residency programs are now integrating economics and encouraging containment of cost into medical plans.
While increasing quality is desirable for patients and providers alike, this hurdle often comes with greater cost in the form of new technologists, training personnel, and clinical uncertainties. Moreover, few novel strategies have shown improvement in the already exceptional safety margin of the delivery of anesthesia care. Instead, practices often focus on cost containment. Personnel comprise the lion’s share of OR operating costs for most institutions. French et al found that nearly 80% of OR cost was from personnel. Thus, optimizing staffing ratios is an obvious source for improvement in some practices. However, some novel incentives have been developed. For instance, some practices link provider bonuses to lean usage of volatile anesthetics by encouraging lower gas flows (2). Providers should be familiar with emerging strategies for cost containment.
The most studied tactic to contain cost and improve value is represented by Enhanced Recovery After Surgery (ERAS™), which has shown promise since its original implementation in colorectal surgery. These pathways stress the importance of early ambulation, neuraxial and regional anesthesia where appropriate, antiemetics, and decreased postoperative fasting times as a bundled package. These concepts have been similarly employed to other surgical populations, including thoracic, pelvic, urologic, spine, and breast surgeries (3). While the mechanisms why ERAS™ pathways expedite recovery are not entirely understood, their implementation has become widespread. The success of ERAS™ is due to the multidisciplinary effort in modulating the perioperative trajectory for standard surgical encounters. Yet, anesthesiologists and anesthesia providers should continue to treat each patient and condition with consideration and not blindly yield to pathways when extenuating circumstances arise.
Criticisms of value-based care arise when groups or practices are unfairly penalized for inevitable, uncontrollable complications. For instance, the acute kidney injury (AKI) rate after cardiothoracic surgery is approximately 30%. The multifactorial nature of AKI has been investigated in many prospective studies. Patient, anesthetic, and procedural factors all contribute (4). However, managing blood glucose levels with intravenous or subcutaneous insulin is a controllable outcome which is known to complicate cardiac surgery. The core measures upon which reimbursement is based will continue to drive improvements in anesthetic care for a multitude of patients.
- Serdiuk AA, et al. Aligning Anesthesiology and Perioperative Services with Value-Based Care: Proceedings of the Annual Meeting of the Association of Anesthesia Clinical Directors (AACD). J Clin Anesth. 2018; 50:76-77.
- Beverly A et al. Enhanced Recovery After Surgery: Evidence for Delivering Value-based Care. Int Anesthesiol Clin. 2017;55(4):78-89.
- French KE, et al. Value based care and bundled payments: Anesthesia care costs for outpatient oncology surgery using time-driven activity-based costing. Healthc (Amst). 2016;4(3):173-80.
- Kolarczyk LM, et al. Defining Value-Based Care in Cardiac and Vascular Anesthesiology: The Past, Present, and Future of Perioperative Cardiovascular Care. J Cardiothorac Vasc Anesth. 2018;32(1):512-521.