Financial and Operational Analysis for Non–Operating Room Anesthesia

Market Trends

Some argue that fee-for-service fuels much of U.S. health care spending and results in excessive usage, but it is also important to recognize that the same financial incentive also propels medical advances. In the 1990s, minimally invasive surgical techniques led to a growth in ambulatory surgeries. Fast-forward 20 years to 2013, the next set of innovations prompting changes is minimally invasive procedures performed outside the operating room.

These nonsurgical procedures are appealing. From the patient’s perspective, it means a less invasive approach and faster recovery. It also appeals to the patient who is too sick to undergo a traditional surgical treatment. From the hospital’s perspective, minimally invasive procedures mean shorter length of stays, higher volume, less overhead cost, and of course the satisfaction of making medical advancements. While market forces are at work, as long as there is a demand, there will be a supply to meet. As a result, the demand for anesthesia outside the operating room also has grown. And yet, many practices may be in a difficult situation if they are unable to staff these procedures efficiently. The failure to properly manage these procedures creates erratic coverage and unhappy proceduralists.

New Customers

The operating room has traditionally served as the anesthesiologist’s home. Anesthesiologists are increasingly perceived as natural masters of operating room management as they make strides in leadership, efficiency, scheduling, and cost effectiveness. Customers traditionally have included patients, surgeons, and hospital management. With the rise of non–operating room anesthesia (NORA) cases, the specialty now has an additional set of nonsurgical customers that demand and value anesthesiologists’ services.

Unlike surgeons, proceduralists such as medical interventionists and radiologists have different needs. For example, they do not perform painful procedures that require multimodal postoperative pain management. In addition, they and the nurses around them are often unused to working with anesthesiologists and thus unfamiliar with their particular needs. Given that NORA cases are often short procedures, they demand faster room turnover and rapid recovery.

An Opportunity

As the aging population grows older and sicker, it is inevitable that the number of procedures performed outside the operating room will continue to increase in the next decade. The chart in Figure 21-1 shows the large increases in the population aged 65 and older from 3.1 million people in 1900 to 35 million in 2000 and projected to 72 million in 2030.

Table 21-1 illustrates the dramatic increase in anesthesia professional participation in the two most common NORA procedures, esophagogastroduodenoscopy and colonoscopy. By 2015, anesthesia services will be involved in over half of these procedures.

The anesthesiology community is adjusting its practice to meet the NORA demand. Without appropriate preprocedural and postprocedural care, cancellation and rescheduling from unanticipated medical complexity will certainly rise. Thus early risk stratification of patients and planned anesthesia service can greatly improve efficiency and reduce cost. Most surgical patients currently undergo a preoperative assessment by a member of the anesthesia team. In contrast, the evaluation of patients for NORA procedures may be lacking despite the fact that some of these patients are ill enough to be hospitalized. The anesthesia group needs to work with the hospital and proceduralists to ensure that proper infrastructure is in place to optimize scheduling and provide safe care of these patients. The question “Is it safe for proceduralists with minimal training in airway and pharmacology to perform the procedure, manage comorbidities, and supervise administered sedation?” is often raised. Everyone wants to avoid the use of unplanned anesthesia on an emergency basis.

When tallied together, the costs of procedural cancellation, emergent anesthesia usage, and unforeseen hospitalizations are expensive and should be minimized. Thus it is important that anesthesiologists take a leadership role by creating appropriate policies and systems of care to preemptively avoid complications and delays and improve efficiency.

Competitors

Many providers such as registered nurses, dentists, and oral surgeons deliver sedation that might be considered competition to anesthesiologists. However, many NORA cases require deep sedation or general anesthesia, in particular patients with complex comorbidities or those who previously failed routine sedation. Because of difficulty in coordination of services or resources, some hospitals may elect to outsource contracts with an outside anesthesia group to provide consistent and reliable services. This represents a loss of business for the existing group. Thus when faced with the question “Can you provide coverage to our new location outside the operating room?” the answer should be yes, “Let’s get together and discuss how we can optimally do this for everyone involved.”

Barriers to Entry

The addition of anesthesia service is perceived to add time and cost. As a result, many proceduralists have historically been reluctant to ask for coverage. In addition, unfamiliarity with anesthesia care also causes reluctance.

From an anesthesia perspective, cultural and operational barriers exist to practicing outside the comfort zone of the surgical suite. Traditionally, anesthesiologists reside in the operating room. Most find experiences outside the operating room to be unpleasant because of ergonomically unfavorable physical space, poor ancillary support, lack of backup equipment, distance from the recovery room, and dealing with a new set of providers who may not understand anesthesiologists’ approach to safe care. In regard to staffing, too few anesthesiologists are available to provide guaranteed coverage to all of the subspecialists. This lack creates delays and frustration, especially when dealing with add-on cases. Financially speaking, proceduralists may find it more economically favorable to rely on sedation nurses for most of their cases and use emergent anesthesia on demand. This situation may worsen when procedure reimbursements are bundled into one case payment.