SAMBA Residents Talks eNewsletter - September, 2005

Welcome to our first issue of SAMBA Residents Talks, the only electronic newsletter prepared exclusively for residents, at no charge. Residents, who subscribe to SAMBA Residents Talks, will also receive a copy of the SAMBA electronic newsletter "SAMBA Talks."

INTERVIEW DR. DOUG MERRIL- TOP

The following is an interview with Dr. Doug Merrill, Staff Anesthesiologist at Virginia Mason Medical Center in Seattle WA on August 5, 2005. Dr. Merrill has exposure to private practice settings as well as with different size groups. He frequently gives talks to SAMBA and the ASA on the business aspects of anesthesia.

From what I’ve understand, you’ve been out in the real world and perhaps you can give the resident some idea what’s it is like to be in a real outpatient surgery center.

M: “I think probably the most significant difference in private practice from the experience gained by a resident during training is the setting of a freestanding ambulatory surgery center. All aspects of that practice are different, based upon distance from hospital services as well as attitudes. Incentives for efficiency and production are different from the hospital. This is true for surgeons as well as anesthesiologists and staff at the ASC. Most often, this leads to a closer alignment of goals between surgeon, anesthesiologist and staff than is true in the hospital."

"The economics of private practice ambulatory surgery are completely different, in that someone at the ASC is able to tell you at the drop of a hat exactly how much what you do there costs the ASC and how much it earns, as well. This is rarely true at a major teaching hospital. That’s a huge difference, as economics become a much bigger driver of care models in the freestanding arena than they are in a hospital. In reality, if you practice in a smaller community after training, you may find that the finance department of the local hospital is also able to more closely monitor costs and income than is true in the major medical centers in which most residencies exist. Economics will be a much larger part of your workplace life in private practice.”

It is constantly been said that ambulatory anesthesia saves money. Who saves the money – the patient?

M: “Any therapy that is applied in the outpatient setting can be done more economically than in the hospital. It takes fewer people to accomplish the same event, and labor is 35 plus percent of the cost of most surgical care. In the ASC, someone somewhere is taking a look at the costs and really all you have to do to reduce cost is to measure it. For instance, if you look at your anesthesia drug costs frequently you’ll start discovering what drugs cost the most. And it’s impossible for you to not think about that when you administer them."

"In the hospital there is frequently a disconnection between how much things cost and the price that is paid for them. That’s less true in the outpatient center and the other aspect is that, despite DRGs (diagnosis related group – a billing method), if we keep the patient in the hospital an extra day we often get paid more. In the outpatient ambulatory surgery center you get paid a set price for whatever procedure you’re going to do, no matter how long it takes you or how much you spend on it. There is a healthcare economy still in place in ambulatory surgery. There, cost and income are still tied, to a degree. That is no longer true in most of healthcare, particularly it is not true in the environment of the teaching hospital."

Does that mean that patients pay less in the ambulatory setting?

M: “Absolutely. If a free market is operant, then in most ambulatory care there is greater competition for price. For most plastic surgery procedures, for instance, the patient will know in advance how much they will pay, and in general it’ll be less than half of what they will pay in the hospital. There won’t be any add-on costs afterward. In many communities there is significant competition between ambulatory centers and that serves to keep costs lower.”

I would think they would choose to pay less.

M: “The economics of ambulatory care are pretty clearly in the favor of the patient. With careful attention to detail, they can also be in the favor of the practitioners and facility.”

Now what happens when you need to admit a patient?

M: “It depends upon the acuity. There are some patients we admit for pain control. The patient is medically stable in that situation and we transfer them to the appropriate care facility, which can sometimes be a non-hospital setting, and the transfer can be by car. In other instances it’s a medical problem and those patients need to be transferred to a hospital, which can be an emergent ambulance drive if there is a significant medical issue. If it’s a surgical issue where perhaps there is more drainage than the surgeon anticipated and observation but not intervention is indicated, then it may be a non-emergent transfer to the hospital."

"At the end of the year the state, Medicare, JACHO, or AAAHC (Accreditation Association for Ambulatory Health Care) looks at how many transfer your center did and why they were done. And what they don’t want to see is that you repeatedly transferred people to the hospital after surgery if you knew in advance they would need to be monitored in the hospital - as it constitutes fraud. So, to take an extreme example, if you routinely performed surgery on patients with obstructive sleep apnea for uvulo-palatoplasty and then sent all or most of them to the E.R. to be admitted over night, it would be wrong. For one thing, it mean that you are taking the price of the procedure as if you were planning to provide the patients outpatient surgery, but then hitting the patient and his insurance company with the cost of an overnight hospitalization. In addition, it cherry picks the most lucrative portion of the patient’s care, the surgery, and sticks the hospital with the less profitable portion. Finally, the least safe time for a patient after surgery is in an ambulance transferring to an emergency room. No one should do that routinely.”

This brings us to how patients coming for ambulatory surgery are getting sicker and sicker. I hear about the sleep apnea, the morbidly obese, and even thoughts of gastric bypass. At what point are we going to say doing these patients are not feasible?

M: “Well, I think there are three factors that allow us to take care of sicker patients. One is that the anesthetics and monitoring are so much safer, but that’s not changing as rapidly as it was 15 years ago. Nonetheless, there are little permutations that help each year. For instance, increased attention to use of regional anesthesia has helped greatly.
However, recently the more significant change is the extent to which surgeons can accomplish impressive surgical interventions with so much less brutalization of the body. An easy example is laparoscopic cholecystectomy, which has brought about a difference in outcome from the previously required five or seven-day hospitalization and made it into a fairly comfortable same-day surgery. Back surgery, shoulder and knee surgery and bariatric surgery are other examples. Finally, in terms of medical care, although patients may be older and have more significant medical illness, more optimal use of medications such as beta-blockers are making such illness less significant in terms of peri-operative risk and morbidity."

"However, there is still a wall and that wall is a negative answer to this question: ‘Is the patient sufficiently medically stable to allow care at home that is just as safe as that which would be provided in the hospital?’ When a post-surgical patient can be as safe at home as he or she would be in the hospital, then they can have their procedure in the outpatient surgery center. It is a pretty straightforward litmus test.”

Sounds fair. We mentioned earlier regarding surgeons and other people having some financial incentive. You are the medical director here. How does the anesthesiologist fit in all of this?

M: “Most of the time the anesthesiologist is not a shareholder. The reason is that in most settings, corporate law requires that a physician must contribute business to the ambulatory center to be a shareholder in that ambulatory surgery center. So, usually the only way the anesthesiologist gains that capability is if they provide pain management services there."

"On the other hand, the medical director post is often a salaried position and is paid to take hours out of the day to work on policy and procedures and to sit at the end of the day until the last patient is gone. These are jobs that must be done by a physician and the medical director is normally is an anesthesiologist who is on site frequently or –better yet- all the time.”

So how is life at the center?

M: “In terms of lifestyle, if you’re in a single setting and that’s all you do it is nice because typically it’s five or six days a week and there is no call. Most people are not in that situation. Most ambulatory centers are staffed by a group of physicians who also work in the hospital. So to be a member of that group you have to do inpatient work and take call, in addition to any time that you spend in the surgery center."

"Every once in a while you’ll see a subset of people in a group who only do ambulatory surgery, but they are generally more senior members trying to transition out of call. The other thing to keep in mind is that a lot of times younger and more recently trained people are not as excited about an ambulatory-only career because they do not want to end up in a setting where they don’t keep up their skills with different types of cases, such as cardiac, obstetrics, neurosurgery or trauma. That’s a significant consideration for any anesthesiologist. Having said that, we often find that people who move back and forth between a hospital and ambulatory surgery don’t do as good a job at either one of them as do people who are doing only one or the other.”

Then would you recommend a resident to go into ambulatory anesthesia or stay in a hospital to keep their skill level?

M: "I think it’s rare for someone who’s first out of training to go into an ambulatory-only setting, simply because most jobs last only about four or five years and you cannot decide that early in your career to give up some of those skills you so recently worked hard to acquire. You might need them in your next job."

"However, when an anesthesiologist goes into a job and immediately thinks, ‘hey, I love this place, this hospital, and I really like my partners and this kind of work and the hours aren’t so bad…’ well, the chances are in this day and age that all those factors are unlikely to remain unchanged. A spouse’s work may change, home prices may alter; something is bound to change some aspect of whatever you are doing, and you need to remain able to manage such change. So, I would not recommend a just-trained resident go to a place where he or she is only going to perform ambulatory anesthesia. I think you still need to hedge your bets in term of whatever it is you wish to do, whether it’s neurosurgery or hearts or whatever. Having said that, if you love regional anesthesia, if you love pediatrics and don’t care to do OB, neuro, or hearts, then it’s not out of the question. It’s just that you’ll have to realize that you’ll give up something tangible if you do choose to do only ambulatory anesthesia right out of residency."

People only stay with their jobs for only four or five years!?!

M: “The concept used to be that you could go to a place and anticipate you would stay there for your entire career and there are indeed people still do that. But I think if you check in with your residency class 10 years from now you’ll find that on average most people will have had two jobs, at least. The differences are that I think more people now expect that their job will not be as consuming as jobs were in the past."

"As well, people are more mobile as there are more two-professional families. You have to be ready to move if your spouse has a career that may require it. That is also one of the great positives about anesthesiology: it is a career that has more mobility available to it than many other specialties offer. We tend not to need to build a practice, but rather can expect to eat well pretty quickly after we move to a new location. Although, I would like to note that the transition from one job to another is usually more difficult than you expect."

"One last reason that we are more mobile these days is that our specialty is so understaffed that any job that you go into is going to be harder than you would like: call duty is going to be more frequent than you would like, late days are going to be more frequent than you would like. You are likely to work late on days and on weekends when you are not on call. And I think as people work very hard they keep their ears open more and if there is a better job that comes along, they’re going to jump on it. Now we have ambulatory surgery centers, which is the definition in my mind of a ‘better job.’ In the past, perhaps paying attention to what else is out there was moot because nothing was any better than what you were already doing. So, yes, people are going to be more mobile as our profession develops further and as outpatient surgery becomes almost 80% of what we do, the sub-specialty of ambulatory anesthesiology will be both a cause and a benefactor of our overall specialty’s mobility.”

Do you feel that residents should have a rotation in an ASC (ambulatory surgery center) prior to graduation? If a resident wants to go into private practice at an ASC, should he/she do a fellowship in Ambulatory Anesthesia?

M: "Yes, I believe it is imperative that residents are exposed to this atmosphere in training. I think it is important that they see the venue that will be a large part of most of their lives in the years to come. It is usually significantly different in pace and in the approach of the other professionals to both the patients and the procedures than what is seen in the teaching, usually tertiary hospitals where they spend most of their time. I think a fellowship is important if a resident is likely to be in a position early in his or her career to be considered for a medical directorship. It is not frequent that new graduates are given that opportunity, so I believe this accounts for the slow development of this type of fellowship program. It is a valuable learning experience for anyone going into outpatient anesthesia, but so few of our residents know in advance that they are going to such a specialized situation."

Do you do most cases yourself or do you supervise CRNAs? Does the role of supervisor change from ASC to that in teaching hospitals?

M: "In private practice I did all my own cases. However, I know many excellent and high-efficiency private ASCs that use the anesthesia team approach. And yes the role is different. You are in the position of herding people who feel they ‘know how to do it.’ Unfortunately, they often know how to do it expensively and slowly. So, you have to be more diplomatic but still with a firmness that will get the job done. Some doctors are just not going to be able to make the adjustments needed to be adept in the outpatient setting. You have to be able to help them come to that conclusion as amicably as possible."

CONTIBUTE TO OUR ENEWSLETTER - TOP

Anyone is free to contribute to the SAMBA newsletter. Topics should be relevant to residents and ambulatory anesthesia; for example, sleep apnea and obesity – at what point (or BMI) do we say it’s not worth it, billing and how that works from a resident’s perspective, etc. Much of the newsletter is written in an interview style, and hopefully easy to read and understand. The aim of the newsletter is to have a monthly publication of one or two topics and to promote discussion via e-mail and forum.

OPENINGS FOR SAMBA RESIDENT COMPONENT- TOP

Currently we are looking for people who are interested in the SAMBA resident component. Duties involve submission of articles, recruitment of other residents, and newsletter editing. Please contact Robert Hsiung for further information.

SAMBA MID YEAR MEETING- TOP

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