Update on the Perioperative Surgical Home
There is a sharp debate on whether the Perioperative Surgical Home (PSH) should represent the future of our profession. It has been estimated that two-thirds of all hospital costs are directly related to surgical care. In US, this amounts to approximately $180 billion per year on inpatient surgical procedures in nonfederal hospitals alone. According to the Institute for Healthcare Improvement, the “Triple Aim” for health care is to (1) Improve the patient experience, (2) Improving the health of the population, and (3) Reducing health care costs.
The embodiment of these goals is seen in the Affordable Care Act of 2010, in which Accountable Care Organizations (ACOs) will hold multiple providers jointly responsible for achieving quality targets and reductions in per capita cost of care. These changes may not be fully implemented for another 5 years. But Medicare and Medicare have already begun to link reimbursements to performance and financial accountability in its Bundled Payment for Care Improvement Initiative.
In response to these challenges, the Council on Continuous Professional Development of Anesthesiologists introduced the Perioperative Surgical Home (PSH). Conceived in 2011, the PSH was modeled after the Patient-Centered Medical Home (PCMH), a program endorsed by the Institute of Medicine to improve coordination of care and patient satisfaction while reducing cost in complex medical patients. The PSH is a patient-centered, physician (hopefully anesthesiologist)-led, multidisciplinary team-based practice model that coordinates surgical patient care from the time of decision for surgery to recovery.
In May 2015, Anesthesia and Analgesia published 6 Open Mind articles and 4 editorials on the PSH, and the list of authors reads like a who’s who of anesthesia.
On the PRO side:
1. Zeev Kain of University of California at Irvine et al states a case for disruptive innovation, the replacement of an old produce or service with new. Citing the inadequacies of slow, incrementally changing models such as the failed mini-computer business, the PSH needs to be more of a widespread, transformative change. Its central tenets include an emphasis on integration, collaboration, coordination, clinical pathways, safety, and cost-reduction. Such cost-savings may result from reduced variability, adherence to clinical pathways, and reductions in preoperative testing, length of hospitalization, and rate of readmission (unnecessary testing has been estimated to cost $18 billion/yr). The anesthesiologist need not personally deliver all aspects of patient care, but organize, coordinate, and oversee the process. According to the authors, as we any great organization, anesthesiologists must be willing to change most everything except their core values (Anesth Analg 2015;120(5):1155-57).
2. Edward Marino from Stanford University et al discusses the advantages of using the VA Healthcare System as a platform to test the PSH since (1) It has a history of innovation, (2) Employees are salaried, and (3) Reimbursements are already not fee-for-service (Anesth Analg 2015;120(5):163-66).
3. Lynne Ferrari from Boston Children’s Hospital/Harvard Medical School et al, notes the lack of recommendations on the PSH applied to pediatric patients. Given the successes of the PCSH model applied to pediatric patients, it makes sense that a Pediatric PSH model be considered, especially for children with special needs. As with the adult PSH, it will be essential to collect data on clinical, cost, functional, and satisfaction outcomes will be the key to determine successes and failures (Anesth Analg 2015;120(5):167-70).
4. Thomas Vetter of the University of Alabama, reiterating the need to include pediatric patients on the PSH “bus,” predicts that different iterations of the PSH will likely be implemented, depending on local infrastructure and internal/external political and economic forces. For instance, variants such as the Enhanced Recovery After Surgery (ERAS) are already accepted by many surgeons, due, in part, to its early adoption by European surgical colleagues. The 5 factors that influence the diffusion of innovation – relative advantage, compatibility, complexity, triability, and obvervabilty – will determine whether the entire health system chooses to accept the PSH model (Anesth Analg 2015;120(5):974-77).
5. Mark Warner from the Mayo Clinic in Rochester, MN and Jeffrey Apfelbaum from the University of Chicago et al reject the burning platform analogy to describe our current state, and instead portray our profession as one of stability, health, yet in constant flux, and the need to adapt merely an imperative to change – “before we have to.” In response to Prielipp’s challenge that anesthesiologists are insufficiently trained to perform the tasks required by PSH, they suggest that not every anesthesiologist in a group needs to be formally trained in perioperative medicine. Instead only a few members need to become the local PSH champions. They also disagree with Prielipp’s recommendations to increase the anesthesiology training to 5 years due to fiscal realities. And based on conversations with large consortia and small groups, their impression is the PSH model has been well received (Anesth Analg 2015;120(5):1149-51).
On the CON side:
1. Richard Prielipp of the University of Minnesota and Douglas Coursin of University of Wisconsin emphasizes the critical nature of the perceived crisis to our profession. Quoting Karen Domino’s 2014 ASA Rovenstein lecture, “The clock is ticking. The time to act is now.” Prielipp asks vitally important questions: (1) Will the PSH really add value, increase patient-centeredness, and provide better treatment for patients? (2) Are anesthesiologists really the best educated, best trained, and best suited to accomplish this effort in a cost-effective way? (3) Are all anesthesiologists expected to adapt to this model? (4) Will other providers and healthcare systems allow anesthesiologists to take on this role, or will there be competition from surgeons, hospitalists, nurse practitioners, and others, (5) In promoting the anesthesiologist as the physician in charge, are we developing antagonistic relationships with other stakeholders? (6) How will the PSH affect private practice, small group, and solo practices? (7) Will administrators be willing to pay for incremental improvements by the PSH after it has been established? (8) How will anesthesiologists be compensated for our role as creators, managers, and sustainers of the PSH?
Without the participation of other stakeholders, the PSH is unlikely to survive. The answer to some of these question may already be seen in the formation of regional or national multispecialty groups in which anesthesia is sometimes relegated as a commodity and hospitalists and nurse practitioners are responsible for the continuum of perioperative care. Thus, Prielipp believes the PSH is insufficiently disruptive. To achieve the value needed to assure the anesthesiologist’s future role, it takes more than reassignment of roles or development of a few specific clinical pathways (eg, colorectal, orthopedic, or urological), major elements of the PSH model.
One way to produce an even greater paradigm shift involves producing a fewer number of more skilled anesthesiologists, graduating from a pool of heavily resourced, 5-year training programs. This would produce a cadre of highly trained specialists in adult multi-specialty, pediatric, critical care, pain, and academic anesthesiologists. Such a change requires a hard reexamination of who we are, who we hope to become, and how we plan to get there (Anesth Analg 2015;120(5):1142-8).
2. Thomas Vetter of University of Alabama et al essentially concur with Prieliff in stating a fundamental change in residency should be considered, with the goal of training a cohort of super-specialists including practice management. Currently, only Stanford University and University of California, Irvine offer postgraduate fellowships in perioperative medicine. The current educational system can produce only a handful of dual-specialty trained perioperatists per year. A critical discussion of the PSH is in order (Anesth Analg 2015;120(5):968-73).
3. Peter Davis of Children’s Hospital of Pittsburgh et al asks questions similar to Prielipp: Why should health care systems pay high priced anesthesiologists when equally bright physicians could provide the same service? Why shouldn’t care coordination go to the role of a mid-level care provider (such as a nurse, nurse assistant, or social worker) or “bot-work” intelligent software systems? In the era of bundled care, why would surgeons hand over money to do what they perceive they are already doing? And the PSH will require a plan to train anesthesiologists to fulfill this new role (Anesth Analg 2015;120(5):978-9).
In his summary of the articles Steven Shafer, editor of Anesthesia and Analgesia, writes, “the Experts have spoken. Next year we will let the data speak.” (Anesth Analg 2015;120(5):966-7). My concern is that even when the data arrives, it will do so inconsistently, in piecemeal, with unexpected results, as is the usual case with data. And even if it were to favor the value PSH, there is no plan to solve the aforementioned problems of implementation, training, and acceptance of the anesthesiologist as the team leader.