State of anesthesiology

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AKMD_1984

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great summary of current challenges. Explains why anesthesiologists are flocking to locums/prn/independent setups or atleast incorporating that in their practices.

We all know the issues

What’s the solution?

Direct hospital employment?

What needs to happen to stop the hemorrhage?

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I came across this article because I was trying to understand and look at “downstream revenue” specifically to anesthesiology services.

For orthopedic - it’s around 3million per year per surgeon - average. That seems low to me.

But let’s go with that figure. Can’t perform surgery without anesthesia. In fact can’t even book cases without reliable anesthesia services. Not even talking about quality of care with regional anesthesia - not everyone anesthesiologist is good at these.

We need a study to look at loss of downstream revenue when anesthesiologist is not reliably available.

It needs to be a part of contract negotiations. Too much emphasis is on payor mix, hours, call etc. it makes it easy for the hospital.

Don’t know how we can study this?
 
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Honesty and I read the entire article. I could have cut it down to a few sentences

1. Hospitals administrators are dumb thinking catering for surgeons and procedurists after 5pm and weekends cases is cost effective (it’s not). The threat of the surgeon moving their cases to another hospital system is real but who cares. Unless that surgeon guarantees that hospital at least 3 days full of cases. They aren’t bringing any real consistent revenue you in.

So let the surgeons walk to the competing hospital.

Reward the surgeons who bring consistent cases to your hospital.

It’s very simple

We have these gen surgeons (big surgery group). They bitch and complain their cases aren’t on time. 12/1pm starts when they operate at their surgery center first.

Fine. Go to the competing hospital. Do your inpatient cases there. No one cares. Or move your cases to the main OR and we will give you the 7/730am starts. Nope. It’s easier for them and more profitable to keep the profits to themselves at their outpatient surgery center.
 
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from the gist of the article, it seems that payor mix will worsen as the population ages (ie the proportion of Medicare will be higher).

That’s logical.

At the same time, facility fees for hospitals are rising.

Essentially there is a transfer of revenue from physicians to the hospital.

Hospital revenue is predicated upon completion of service (anesthesia/ surgeon).

-Who’s going to pay for anesthesiologists time on call - already shortages of plus desire for no-call/ no weekends gigs; like ASCs and daytime. Eventually the hospital will. They don’t have a choice.

No way an anesthesia group can be profitable unless you’re a boutique practice etc as the article suggests.

- maybe direct hospital employment isn’t bad after all

Atleast there is stability?
 
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Healthcare continues to **** itself to death . Nothing new
 
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from the gist of the article, it seems that payor mix will worsen as the population ages (ie the proportion of Medicare will be higher).

That’s logical.

At the same time, facility fees for hospitals are rising.

Essentially there is a transfer of revenue from physicians to the hospital.

Hospital revenue is predicated upon completion of service (anesthesia/ surgeon).

-Who’s going to pay for anesthesiologists time on call - already shortages of plus desire for no-call/ no weekends gigs; like ASCs and daytime. Eventually the hospital will. They don’t have a choice.

No way an anesthesia group can be profitable unless you’re a boutique practice etc as the article suggests.

- maybe direct hospital employment isn’t bad after all

Atleast there is stability?
Payor mix will inevitably worsen for a number of reasons; aging population and hospitals building towards service lines that bring in good revenue to them but are not typically high anesthesia reimbursement or time efficient for anesthesia (Cardiac, EP, spine, etc), and outpatient private payors cases being diverted to surgery centers.

So hospital work is fruitless. It’s low paying and high resource/time intensive.

Anesthesia groups will die without a few things;

1.) outpatient/surgery center work subsidizing your hospital work

2.) a stipend to cover the delta between staff/partner income expectation and payor mix or avg $/unit as well as call requirement that costs the most to staff but brings in the least.

So, the choices are; heavily subsidize your hospital work with surgery center work, get a large stipend, or go hospital employed. Unless there’s a paradigm shift.

Alternatively, and I think this is the answer for long term sustainability; argue that all of these surgical services are service lines and they require anesthesia. Want a trauma service so your entire hospital can bill at a higher rate? Cut in anesthesia or you can’t do it. Want a TAVR and other structural heart programs (Watchman etc)? Guess what? You need anesthesia, pay us. You want to recruit a handful of spine surgeons to do 2-3 big spines/day which pay us garbage but bring in $$$ in device/hardware/facility fees? You need us. We have leverage, they can’t create or deliver on any of these service lines without us. And, this is the dirty secret, they don’t understand anesthesia finances/reimbursement, and it would be more expensive for them to employ us on a per doc/CRNA basis than if they simply provided the delta.
 
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[QUOTE="Robotic Wis-Hipple, post: And, this is the dirty secret, they don’t understand anesthesia finances/reimbursement, and it would be more expensive for them to employ us on a per doc/CRNA basis than if they simply provided the delta.[/QUOTE]

But when the Hospital CEO makes the wrong decision and causes chaos in anesthesia services at the hospital and/or massively increased costs to the hospital , no one cares and there is no consequence to the CEO.

Taking call nowadays makes less sense than ever. You can make about the same being per diem with no call. We need some people to take call and do those nonprofitable cases for the sake of the community. But we don’t need every little hospital open all night with a skeleton crew available for an appy.

Especially around me near NYC with so many competing systems, if the public wants a chance at any sort of efficiency these different systems need to start working together to minimize docs needed on call. Instead we are building EP suites in every one of them
 
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There are 2 completing dynamics. There’s a shortage of us, but many healthcare systems are hemorrhaging money. Depending on which dynamic is winning at the time determines our pay.

There's a constant cycle of provider (MD, midlevel, RN) getting paid below market, providers leaving, pay increased above market directly or indirectly through travelers. Until someone leaves nothing changes. It's unstable, but often instability leads to opportunity.

Even at very high hourly rates our pay doesn't come close to the cost of shutting down services. If you're providing great service it won't be appreciated until its gone. If you're the key to a health system providing services that they currently can't they will roll out the red carpet.

A strong group asks for their compensation to be increased 10% to keep up with market conditions. Administrator: no way, there's no money for that, loyalty, greedy doctors... Group dissolves. Hospital can't run ORs. Locums company offers coverage at double what the group charged. Administrator: no problem, when can they start?

I'm thankful to be in high demand. I do wish the average administer had more foresight.
 
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[QUOTE="Robotic Wis-Hipple, post: And, this is the dirty secret, they don’t understand anesthesia finances/reimbursement, and it would be more expensive for them to employ us on a per doc/CRNA basis than if they simply provided the delta.

But when the Hospital CEO makes the wrong decision and causes chaos in anesthesia services at the hospital and/or massively increased costs to the hospital , no one cares and there is no consequence to the CEO.

Taking call nowadays makes less sense than ever. You can make about the same being per diem with no call. We need some people to take call and do those nonprofitable cases for the sake of the community. But we don’t need every little hospital open all night with a skeleton crew available for an appy.

Especially around me near NYC with so many competing systems, if the public wants a chance at any sort of efficiency these different systems need to start working together to minimize docs needed on call. Instead we are building EP suites in every one of them
[/QUOTE]

Agree 100%. I’m no MBA but part of the problem it seems is the way these business dinguses are running hospitals for their motivations.

Every hospital, even different hospitals in the same “system” compete with each other. The business folks want their hospital to be more profitable or more efficient than their in-system colleagues’ hospital. Every department, division, or business entity has to show black in the books so they make insane cuts in areas that make little sense just so they can say each one is in the black. Decisions like cutting anesthesia techs or surgical services and asking offsite RNs to restock the anesthesia equipment or clean their own labs etc. Then they still want the same turnover times and don’t understand why that could be a downstream effect.

The business folks are a huge part of the problem, the admin bloat is at a breaking point. Each hospital is overrun with administrators making decisions that are short term budget positive so they can add a buzzword heavy bullet point on their CV and move up in the chain at another hospital. They’re cannibalizing and skeletonizing the hospitals for personal gain leaving understaffed, wrecked culture husks of their prior glory behind. And this takes years to recoup, not that the administrators that did it would know, as they’re at their next hospital making similar decisions that got them promoted.
 
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They don’t have anesthesia either. And neither does the surgicenter. Anesthesia is one pool and the water level is low.
correct.

and the more important question is who is addressing quality and burnout?
 
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This logic doesn't pan out for other specialties. Yes they can't do the procedure without the anesthetic but the surgeon doesn't get to do the procedure unless the patient is referred by the PCP/specialist who found the problem yet there are strict laws preventing kickbacks to reward the providers who do that work so they are stuck on their RVUs only. The surgeon gets all the credit and the entire team of other providers (from the PCP to the radiologist, pathologist, anesthesiologist) are just SOL under the Stark rules where the only credit they get are for wRVUs. Hospitals of course can circumvent this by moving money around when needed to recruit but then point right back at those rules to keep pay low and protect their margins because rules don't really apply to them.

The entire system needs to collapse and de-emphasize our obsession with surgery. Surgical subspecialists shouldn't be the only reason a hospital can operate in the green. The fact that so many healthcare facilities nearly imploded during COVID when they were full of sick people because taking care of sick people apparently doesn't generate revenue is emblematic of how ****ed our entire healthcare system is but instead of taking that warning shot we just keep going business as usual until the next crisis.
 
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This logic doesn't pan out for other specialties. Yes they can't do the procedure without the anesthetic but the surgeon doesn't get to do the procedure unless the patient is referred by the PCP/specialist who found the problem yet there are strict laws preventing kickbacks to reward the providers who do that work so they are stuck on their RVUs only. The surgeon gets all the credit and the entire team of other providers (from the PCP to the radiologist, pathologist, anesthesiologist) are just SOL under the Stark rules where the only credit they get are for wRVUs. Hospitals of course can circumvent this by moving money around when needed to recruit but then point right back at those rules to keep pay low and protect their margins because rules don't really apply to them.

The entire system needs to collapse and de-emphasize our obsession with surgery. Surgical subspecialists shouldn't be the only reason a hospital can operate in the green. The fact that so many healthcare facilities nearly imploded during COVID when they were full of sick people because taking care of sick people apparently doesn't generate revenue is emblematic of how ****ed our entire healthcare system is but instead of taking that warning shot we just keep going business as usual until the next crisis.

If the administrative burden were lower, would hospitals be able to keep the lights on with medical care?
They’d like us to shuffle money from one specialty to another when we should really cut administration.
 
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If the administrative burden were lower, would hospitals be able to keep the lights on with medical care?
They’d like us to shuffle money from one specialty to another when we should really cut administration.
I have yet to see a locums administrator so my guess is that the supply must be adequate...
 
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definitely agree with above. the system revolving around surgery doesnt make sense. # of surgeries you do doesnt make you a better healthcare system, yet thats how the US healthcare works at the moment
 
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