Forget the pandemic, say hospital executives. What have you done for us lately?

There was a time, at the peak of the pandemic, when many of us believed that anesthesiologists finally would get the public recognition and respect we’ve earned – at a painful price – for our front-line work in airway management and critical care.

Some anesthesiologists like Ajit Rai, MD, a pain medicine specialist in Fresno, California, even boarded flights to New York last spring to help hospitals overrun with critically ill COVID patients. News reports nationwide celebrated these physicians as “healthcare heroes”.

That was then.

Today hospitals are struggling to maintain their financial stability in the face of the revenue hit they took in 2020 when elective case volumes plummeted. Total knee and hip replacements were down by 53 and 42 percent, respectively, compared with 2019 numbers, and even cardiac catheterization cases were 24 percent fewer. At least 47 hospitals closed or declared bankruptcy in 2020, with more likely to follow.

The American Hospital Association estimates that hospital revenue in 2021 could be down anywhere from $53 billion to $122 billion from pre-pandemic levels. Hospitals are still dealing with supply chain and labor market disruption, paying premium prices for traveling ICU nurses, and facing the high cost of treating resource-intensive COVID patients.

When a hospital is desperate to stay afloat, administrators are going to look anywhere they can for ways to cut costs. Subsidies to anesthesiology groups are in their crosshairs.

Suddenly, an RFP appears

An estimated 85 to 95 percent of hospitals currently subsidize anesthesiology services to some degree. Reasons vary from underutilized OR time to poor third-party payment for trauma or obstetric services. If the anesthesiology department is perceived as thriving financially, a cash-strapped hospital will want to stop the subsidies even if that could make it difficult for the group to attract or retain well-qualified anesthesiologists.

Rather than bothering to negotiate with the existing group, hospital executives may take the quicker, easier route of putting out an RFP, or request for proposals, to attract bids from anesthesia practice management firms such as NorthStar, NAPA, Vituity, or Envision. These companies advertise their ability to improve efficiency and outcomes while reducing hospital costs. They promise to “align the interests” of the anesthesia department and the hospital while eliminating the need for subsidies.

Sometimes the corporate acquisition of an anesthesia practice is friendly, with a lucrative buyout for the senior partners in the group. Today, though, less amicable transitions are occurring more often. If the current group loses the bid for the contract, the anesthesiologists have no certainty that they’ll be invited to keep practicing at the same location, whether they were full partners or not.

Turmoil in Michigan

In August 2020, Beaumont Health signed an agreement for NorthStar Anesthesia to begin providing services at its Detroit-area hospitals, including the flagship 1098-bed teaching hospital in Royal Oak. News reports noted that many (perhaps up to 50 percent) of the anesthesiologists and nurse anesthetists left as a result of the new NorthStar contract, and some surgeons and other specialists resigned too. Cardiologists protested to no avail, expressing “serious concerns that NorthStar will not be able to provide the quality of cardiac anesthesia services that we have received for several decades.”

The death under anesthesia of a colonoscopy patient in January 2021 spotlighted the ongoing turmoil in Beaumont Royal Oak anesthesia services, as anesthesiologists and nurse anesthetists were brought in from other campuses or hired as locum tenens contractors to cover cases. To advocate directly with NorthStar for “safe staffing ratios and greater patient safety measures”, Beaumont’s remaining nurse anesthetists voted overwhelmingly on March 30 to unionize.

Abrupt changes in care model

When anesthesia contracts change hands, changes in the care model often follow.

At Cedars-Sinai Medical Center in Los Angeles, a physician-only private group delivered anesthesiology services for decades. When the hospital took over recently and “transitioned” anesthesiology into an academic department, a number of the anesthesiologists were not offered employment in the new entity. Instead, Cedars-Sinai is now recruiting nurse anesthetists, offering pay sufficient to lure them from other employers in a market where the average yearly pay for a nurse anesthetist is more than $199,000.

A recent letter from Richard Keddington, the CEO of Watertown Regional Medical Center in Wisconsin, was widely circulated on Twitter after it announced that the hospital, under the guidance of Envision Healthcare, “is moving to a 100% CNRA [sic] model in our anesthesia department.” Mr. Keddington went on to say that “the literature is clear that care quality and outcomes are just as good with CRNAs…You shouldn’t see much of a change.” Any responses from the internist, the emergency physician, and the orthopedic surgeon who first received this missive haven’t been made public as of this writing.

Wisconsin and California are among the 19 states that have “opted out” of the federal physician supervision requirement for nurse anesthetists. However, since March 2020, a “temporary” waiver by CMS of the federal supervision requirement has been in effect for all 50 states. The decision hasn’t been made yet whether the temporary waiver will become permanent; the period for submitting comments to the Federal Register ended in December. If I had to bet, I would wager that CMS will make the waiver permanent despite our objections.

The “zone coverage” model gains traction

Even if state law or hospital bylaws mandate physician supervision of nurse anesthesia practice, there is nothing to prevent an anesthesiologist from overseeing more than four cases at a time as long as there is no billing claim that “medical direction” was given. Typically, claims submitted for more than four anesthetizing locations use the “QZ” billing modifier to indicate “unsupervised CRNA” practice even though an anesthesiologist may have been available for assistance or rescue.

The Anesthesia Business Consultants newsletter opined even before the pandemic, in the fall of 2019:  “While the alternative to physician-only anesthesia care used to be medical direction, now unsupervised CRNA care, the QZ model, is gaining popularity. In fact, new models of delivery such as the zone model are being developed to restrike the traditional relationship between doctor and nurse. The zone model assumes that a physician oversees, not medically directs, a squad of CRNAs.”

Will hospital financial woes continue?

Though elective surgery has resumed, financial strain may plague most hospitals for some time to come. CMS has started to eliminate the Inpatient Only (IPO) list of 1700 procedures for which it pays only when they are performed in the hospital inpatient setting. What this means is that money-making procedures including total hip arthroplasty likely will move to free-standing ambulatory surgery centers if the patient is relatively fit, leaving hospitals with the older, sicker population.

Many health system administrators know little and care less about what we do every day, or what so many of us did to help our patients and our colleagues survive the terrible COVID surges of last spring and this winter. We can expect more corner-suite interest in cutting anesthesia subsidies and signing deals with practice management corporations.

It’s possible that nurse anesthetists eventually could price themselves out of the market, or tarnish their image with unacceptable complication rates in their independent practice. We can predict with confidence a downward trend in what insurers are willing to pay anesthesiologists for our services. If these market forces converge, it may once again make sense from a hospital’s point of view for anesthesiologists to do cases personally rather than cover nurse anesthetists in “zones” that grow ever larger.

Only time will tell us how anesthesiology practice and American healthcare are going to evolve. Only this is certain: we would be foolish to think that anyone’s gratitude will last longer than yesterday’s news.

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This article and image appeared originally in the June 2021 issue of the ASA Monitor

If you think about scope-of-practice creep at all, you may think immediately of the advocacy efforts so many physicians have made to preserve physician-led care and discourage independent practice by nurse anesthetists or physician assistants.

You may not have paid as much attention to the current momentum to grant independent practice to nurse practitioners, or NPs, nationwide.

In addition to the District of Columbia, 28 states allow NPs full practice authority to treat and prescribe without formal oversight. Half of these states grant NPs full practice authority as soon as they gain their licenses; the other half allow it after the NP practices with physician oversight for a period of time.

My home state, California, is one of the states that has always required physician oversight. Last fall, however, Governor Newsom signed a bill, Assembly Bill 890, that will allow NPs to practice independently after they have completed a three-year transition period, practicing under physician supervision.

That was when I started to worry.

Preop assessments that make us laugh or cry

No doubt everyone who practices anesthesiology or surgery has encountered preoperative medical assessments, H & Ps, or “clearance” notes that have been so far off the mark they’re laughable. I’m not just talking about the three-word “cleared for surgery” note scrawled on a prescription pad. I recall in particular:

A consultation at a VA hospital that “cleared” my cirrhotic patient with massive ascites and coagulopathy for his inguinal hernia repair under spinal anesthesia but not general.

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            How the ACGME and ABA are infantilizing resident training

Not long ago, my patient in a complex thoracic case developed progressive bradycardia followed by a malignant-looking multifocal atrial arrhythmia that didn’t generate any blood pressure.

“Get out some epinephrine!” I said to my resident, who was standing closer than I was to the drug cart. The resident quickly drew up a milligram of epi, but then paused. I could almost see the thought bubble overhead: “Should I print out a label? Put a tamper-proof cap on the syringe?”

The resident – perhaps spurred on by the look in my eyes – made the right call, pushing epi immediately into the IV line and not stopping first to clean the injection port with alcohol for 15 seconds. The patient responded right away with return of sinus rhythm and a blood pressure consistent with life.

This brief but intense drama led me to ponder (not for the first time) whether the protocols and rules that infuse our days are improving safety or leading to paralysis when decisions must be made. Sometimes you have to act as you think best, accepting the possibility that your action may be vulnerable to criticism.

Even if you follow the protocol today, tomorrow it may change. Wearing masks all the time at the start of the COVID pandemic was considered a bad idea – until it wasn’t. On average, 20% of the recommendations in clinical practice guidelines don’t survive intact through even one review – on the next updated version, they’re downgraded, reversed, or omitted.

Today’s resident education process isn’t helping residents face the inevitable ambiguity of medical decision-making. No wonder residents get rattled when they find that one attending does things far differently from another. The ACGME and ABA are turning residency training into an infantilizing experience. Residents are used to studying to the test, and on the test there’s only one right answer.

Anesthesiology trivial pursuit

I don’t envy residents today. When I peer over their heads in the OR to see what they’re looking at on the computer screen, it’s often a multiple-choice question in preparation for the ABA basic exam, which looms over their first two years like an executioner’s axe. Never once has the question had any relevance to the patient or the case. The question itself seems to be part of an anxiety-ridden trivia game, geared toward testing the ability to prep for the test, not the gain of medical knowledge with any connection to patient care.

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Every death related to anesthesia is a tragedy; even more so when a minor procedure such as a colonoscopy leads to a completely unexpected death. Everyone knows that open heart surgery carries a mortality risk, but few of us walk into the hospital for a colonoscopy thinking that death is a plausible outcome.

We know so few facts at this point about what happened on January 21 at Beaumont Royal Oak Hospital in Michigan. The patient who died, sources say, was a 51-year-old man who walked into the hospital for a routine colonoscopy. He was obese, with a BMI of 39, and suffered from obstructive sleep apnea, a common problem, where people snore heavily and their breathing may obstruct intermittently while they’re sleeping. Author Charles Dickens described a portly gentleman’s sleep apnea perfectly in The Pickwick Papers:

“His head was sunk upon his bosom, and perpetual snoring, with a partial choke occasionally, were the only audible indications of the great man’s presence.”

Sleep apnea is a risk factor for anesthesia complications, especially airway obstruction, but every anesthesiologist is taught how to recognize and manage it. With the obesity epidemic in America today, sleep apnea is part of daily reality in anesthesiology practice.

According to recent reports in Deadline Detroit by journalist Eric Starkman, who has reported extensively on problems at Beaumont Health, the patient was intubated by a nurse anesthetist who ordinarily worked at another Beaumont Hospital. At the end of the procedure, the nurse anesthetist removed the breathing tube, and the patient began to “thrash around”. It isn’t clear from reports if he was trying unsuccessfully to breathe or wasn’t breathing at all. The nurse anesthetist called for help from an anesthesiologist, and an emergency back-up team was summoned, but the patient went into cardiac arrest and couldn’t be resuscitated.

How could this happen?

We’re not likely to learn further details any time soon, as NorthStar Anesthesia has refused to comment. NorthStar took over the contract for anesthesiology services at Beaumont in 2020, leading to the resignation of a number of experienced anesthesiologists and nurse anesthetists who had worked there for years. Prominent surgeons, specialists, and nurses also resigned, according to reports, concerned that extreme cost-cutting measures would compromise patient care. Senior cardiologists wrote a letter in September, according to Deadline Detroit, expressing “serious concerns that NorthStar will not be able to provide the quality of cardiac anesthesia services that we have received for several decades.”

“We oppose the concept that any Beaumont physicians can be considered replaceable commodities, or that corporate leadership can assume that we would blindly accept another group of physicians to care for our patients with life-threatening cardiac conditions,” the cardiologists’ letter stated.

In the context of this upheaval at Beaumont, we can ask these questions.

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I originally wrote this column just before Thanksgiving one year, and then updated it in 2012 after the tragic massacre of the Newtown first-graders. Now COVID-19 — and all the losses and grief that 2020 has brought — makes it only too relevant once again. For families who have lost a child, each holiday brings fresh grief, hurdles to face, and mourning for celebrations that will never happen.

The glittering commercialism and noisy cheer of any American holiday can be stressful for most of us. But for the parent who’s lost a child during the past year, facing the first of many holidays with an empty place at the table can make already unbearable grief so much worse.

No one in modern America expects a child to die.  Children only die in nineteenth century novels and third-world countries, or so we’d like to think.

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