|Glenn P. Gravlee, MD
An anesthesiologist from a small city (population approximately 50,000) recently called to seek advice about a problem his group is facing. His group covers both hospitals in this city, each of which has a cardiac surgery program. The same cardiac surgery group covers both hospitals. Each hospital has two cardiac surgical operating rooms available exclusively to these cardiac surgeons, and each hospital does about 250 cardiac cases per year, hence averaging about 1 cardiac case per hospital per scheduled workday, and 0.5 cardiac cases per operating room per workday. His group is expected to staff as many as two rooms at each hospital each day, whether or not all four rooms are used that day. The cardiac surgeons perform very few noncardiac procedures in these rooms, and the hospitals dare not place noncardiac cases in the heart rooms for fear of invoking the surgeons' wrath. Since the two hospitals are competitors, neither one wishes to run the risk of a "use it or lose it" insistence that the surgeons use their allocated OR time more efficiently. To add insult to injury, the cardiac surgeons now are pressing the hospital administrations and the anesthesia group to provide anesthesiologists who have expertise in transesophageal echocardio-graphy (TEE) for each of those four ORs on each cardiac case.
Driven substantially by interventional cardiologists' needs for cardiac surgical back up and by variability in state-by-state Certificate of Need processes, the past two decades have seen considerable growth in the number of hospitals offering cardiac surgery. Over the past decade, the American cardiac surgical caseload held fairly steady at approximately 600,000 cases per year (through 2002 at least). One source indicates that 62% of cardiac surgical programs in Pennsylvania have an annual cardiac surgical volume of less than 100 cases (Cardiovascular Roundtable, The Advisory Board Co., Washington, DC, 2004). The highly influential Leapfrog Group suggests an annual minimum hospital volume of 450 cases for CABG alone, although that number has provoked much controversy. Medium-sized communities take great pride in being able to provide a full range of cardiac services locally, to the point that towns in Ohio with populations of 20-30,000 persons now sport cardiac surgical programs. If pressed about the need, a typical response is, " We serve a referral base of over 100,000 people." My guess is that, if one added up the referral bases of all the hospitals making such claims, the inferred population of the US would exceed that of China and India combined.
When new cardiac surgical programs open, I have often been amazed at how little thought goes into planning anesthesia coverage for this service. The expansion of cardiovascular surgery programs has therefore strained anesthesia groups, which now must cover many cardiac surgical programs that have relatively small caseloads. The surgeons typically receive carte blanche cooperation from the hospitals, and the anesthesia groups are expected to provide the coverage. Since the daily caseload is unpredictable and the coverage is expected 24/7, many groups have understandably decided that the most efficient way to cover cardiac cases is to ask most of their practitioners to perform anesthesia for cardiac cases. Groups recognize that there simply are not enough fellowship-trained, TEE-qualified cardiovascular anesthesiologists to cover the hearts. Even if there were, the economics wouldn't compute. If a hospital averages 1 cardiac case per operating room (OR) per day, and if this generates average gross revenue of $1,200 per case (central Ohio reality), this yields $300,000 in gross revenue per year, assuming 250 working weekdays per year. Assuming conservative 8% overhead and 15% benefits costs, net annual revenue available for physician compensation becomes $231,000 for this OR. Further assuming that it takes 1.15 full-time-equivalents (FTEs) to staff this OR every day (e.g., vacation, meetings, post-call days), this yields a net annual revenue available for physician compensation of $201,000 per FTE. I don't know about your situation, but we can't recruit cardiac (or any) anesthesiologists for that amount in the Midwest. Consequently, our colleagues in small-city USA are being asked to take one for the "team." Further, they are being asked to provide hot-and-cold running CV anesthesiologist/echocardiographers for ORs that likely generate less than $100,000 in physician salary per FTE per year. The numbers don't work, regardless of whether a group supervises CRNAs/AAs or provides all-physician anesthesia for its heart cases.
The coverage situation becomes even more complex when anesthesiologists are expected to provide expert TEE coverage either on demand or routinely on all cardiac cases, which seems to be increasingly desired. TEE is a skill that requires extensive dedicated training and experience beyond what can be reasonably expected of the "occasional" cardiac anesthesiologist. Medicolegal considerations come into play if the anesthesiologist is expected to make calls about the suitability of a mitral valve for repair (vs. replacement) or of the adequacy of a valve repair after it is performed. Cardiologists increasingly resist coming to the ORs to provide this service because - Guess what? - it is not cost-effective for them to do so.
What should our small-city colleagues do? Cardiac surgeons and hospitals need to understand that a competitive anesthesiologist marketplace does not permit anesthesia groups to accommodate gross inefficiency. The USA has a shortage of anesthesiologists, yet anesthesiologists have too often failed to avail themselves of the leverage afforded by the short supply. If we can't drive the OR engine now, surely we'll never be able to do so. If we fail to insist on a reasoned approach, then when a hospital opens its doors to premiere its state-of-the-art small-volume cardiac surgical program, we may as well accept the role of the red carpet. Yes, we CAN insist upon efficiency in the use of OR resources, because the hospital and surgeons most often can't replace us with sufficiently qualified anesthesiologists at an affordable price. If the volume justifies one room, tell the administrator that you'll staff one room. If he or she wants more, show him the economics using your own reimbursement figures. If he persists, ask him to show you the money. Inefficiency hurts him as much as it hurts you, and most hospitals can ill afford to sustain a cardiac surgical program on one case per OR per day. Hospital administrators may assume that this "loss leader" is justifiable because it will increase the overall volume of their cardiac services product line. They might be correct about that, in which case compensating you for the inefficiency should become an accepted line-item on the hospital's "cost of doing business" budget.
If the one fellowship-trained, TEE-certified anesthesiologist our small-city group has can't cover two hospitals and four ORs at once (Slacker!), then the anesthesia group must explain to the cardiac surgical group that they cannot provide TEE routinely for CABGs - at least not yet - and that they may need to stagger their elective valve procedures on alternate days at the two hospitals. Heaven forbid that the need for subspecialized cardiac anesthesia care should impact surgeons' scheduling practices! Another viable possibility is to work together with cardiology on joint TEE coverage or on a transition plan while further anesthesiology TEE expertise is being recruited or obtained internally through additional training.
This group's experience underscores an increasingly clear reality: Anesthesiology TEE competency is becoming the expected standard for anesthesiologists who practice in the heart rooms. Obtaining and maintaining this competency will require more than occasional appearances in a cardiac room. We should embrace this emerging standard, and we should also use it as a means to gain respect and concessions as needed.
Glenn P. Gravlee, MD