|Glenn P. Gravlee, MD
This will be my final President's message, so I first wish to express my appreciation for the opportunity to serve in this position, which I have greatly enjoyed. Based on what I have been hearing and reading over the past two years, I have chosen to use this final message as an opportunity to address challenges or threats to the practice of cardiovascular anesthesiology, with emphasis on anesthesia for adult cardiac surgery in the United States. Apologies go to our international members and to those who emphasize vascular, thoracic, or pediatric cardiovascular anesthesia in their practices, although some of these issues may apply to those practitioners as well. I will attempt to briefly present each challenge and then respond to it at greater length. Please recognize that these are my thoughts only, and that they do not represent official positions or policies of the SCA.
Challenge Number 1. Case volumes in cardiac anesthesiology are decreasing.
Response: National Medicare statistics indicate that coronary artery bypass (CABG) volumes decreased 5-10% between 1999 and 2001, and then stabilized in 2002 and 2003. The perception that the numbers have dropped more than this probably derives from continuing growth in the number of centers performing cardiac surgery, so shrinking the pie contributes less to this observation than cutting it into smaller pieces. Combining assumptions about the impact of drug-eluting stents and the aging of Baby Boomers, the Centers for Disease Control projects a further 7% drop in CABG volume between 2003 and 2008. This estimate includes off-pump CABG, which is projected to grow slowly but not to supersede CABG performed on bypass. This will be accompanied by growth in cardiac surgery for valve repair or replacement (up 14%), in combined operations such as CABG/valve or CABG/ventricular remodeling, in various operations for failing hearts including permanent ventricular assist devices or artificial hearts, and possibly in modified Maze procedures, thoracic aneurysm repairs, and open transmyocardial laser revascularization procedures. This projects to a 2008 net estimated cardiac surgical volume that is approximately the same as that for 2003. It comes as no surprise that our 2008 patients will be older and sicker on average than they are now. The distinct possibility exists that cardiac anesthesia expertise will be desirable or essential for the growing numbers and complexity of percutaneous valve, revascularization or electrophysiologic procedures performed either in cardiac catheterization or electrophysiologic laboratories. Similarly, we will likely see growth in the use of general anesthesia and transesophageal echocardiography (TEE) in multifunction procedure rooms accommodating angiography and open or robotically-assisted cardiac surgery.
Challenge Number 2. Pressures to exceed standardized minimum procedural numbers at each cardiac surgery center will increase.
Response: The Leapfrog Initiative, a consortium of Fortune 500 companies that has been quite willing to express dissatisfaction with our current healthcare delivery system, has suggested a minimum CABG volume of 400 cases per center per year. This number seems high, and the evidence supporting it remains unclear to me. Nevertheless, there is some evidence supporting the concept that minimum volume standards for surgeons and/or medical centers for CABG may improve outcomes (Is comparable data for anesthesiologists next?). The inexorable ongoing increase in the number of centers performing cardiac surgery exacerbates this problem, as does the high likelihood that variety and complexity of cases will continue to increase. At least one study suggests that the abandonment of the Certificate of Need process in many states has facilitated growth in the numbers of centers performing cardiac surgery, and that increased overall mortality for CABG has accompanied this growth. I believe that these factors will combine to fuel a move toward fewer numbers of busier cardiac surgical centers over the next decade. I see this as appropriate and past due, because politics, money, and civic pride have been driving the proliferation of cardiac surgical centers at the likely expense of quality of care.
Challenge Number 3. Reimbursement for cardiac anesthesia services is inadequate.
Response: Right you are! Even with 20-25 base units, modifiers, and fee-for-service billing for transesophageal echocardiography (TEE), cardiac anesthesia services in the USA are under-compensated. To a large degree, this under-compensation derives from the fact that a large proportion of our patients fall into the Medicare basket. Medicare compensation for anesthesia services, while lower than customary managed care fees for all specialties, is proportionately lowest (arguably) for anesthesiology services. Clever anesthesiologists who do not share our lust for a professional challenge have learned that a six-hour day of rapid-turnover eye cases (even Medicare ones) can yield more revenue than back-to-back arduous five-hour heart cases. It is important to the future of anesthesiology and particularly to cardiovascular anesthesiology that this imbalance be repaired. To have a fighting chance of improving this situation, we should financially support political action committees at the local, state, and national levels. These groups can at least get our message across to legislators, because inadequate revenue probably limits needed growth in the number of subspecialized cardiac anesthesia providers. It is encouraging that hospitals have begun to recognize a need to specifically subsidize cardiac anesthesia services, but it would be much better to fix the underpayment problem so that we need not grow dependent upon such institutional "welfare."
Challenge Number 4. A variety of forces are converging to threaten our ability to provide and bill for TEE services.
Response: The threat is real, but its perceived magnitude and imminence by some practitioners far exceeds reality. Many of the concerns SCA members have expressed have been based on the availability of certification in perioperative transesophageal echocardiography from the National Board of Echocardiography. This issue has been addressed by others and by me in the SCA Newsletter within the past year. I believe that testamur status from NBE (i.e., passing the examination without fulfilling the full set of requirements for certification in perioperative TEE) will be sufficient for the vast majority of cardiovascular anesthesiologists to conduct their practices for at least the next decade, and perhaps indefinitely. One may have to defend this privilege locally to credentials committees or medical staff executive committees, but the defense should succeed if we are willing to do our homework and a bit of "politicking" (read: surgeon support) before stating our case before these groups. I believe that it will become increasingly difficult to practice cardiac anesthesia without achieving NBE testamur status, but this projection will be greatly impacted by the numbers of cardiac surgical centers (Challenge 2) and by reimbursement for cardiac anesthesia services (Challenge 3).
As always, I welcome comments and responses addressed to firstname.lastname@example.org.
Thanks again for giving me the opportunity to serve as SCA President. The Society will be in excellent hands with Jamie Ramsay as President, Christina Mora Mangano as President-elect, Steve Konstadt as Secretary-Treasurer, and an excellent Board of Directors and management organization (Ruggles Service Corporation) supporting them. I offer special thanks to Past President Roger Moore for his mentoring and to Heather Spiess for her energetic and effective advice, organizational skills, and pragmatism.
Glenn P. Gravlee, MD