|Glenn P. Gravlee, MD
Taking Care of Business
Several months ago I was asked by an ASA officer to write an article for ASA Newsletter (April 2004 issue) about anesthesiology presence during cardiopulmonary bypass (CPB). I'll spare you the agony of reiteration, since you can easily access this on the ASA web site (www.asahq.org/Newsletters/04_04/gravlee04_04) if you are desperate for something to do. The principal message was that some member of the anesthesia care team should be present during bypass. A number of reasons were given, but the two most important ones were that failure to do so violates the American Society of Anethesiologists Standards for Basic Anesthetic Monitoring (www.asahq.org/publicationsAndServices/standards/02.pdf, Standard I) and that billing for anesthesia time when no anesthesia provider is physically present legally constitutes fraud. The SCA supported this ASA monitoring standard several years ago. Other than that SCA has not taken a position on this issue, therefore the opinions offered herein should not be misinterpreted as SCA policies or standards.
The feedback I received from that ASA Newsletter article was mostly positive, but some anesthesiologists whom I know to be well intended and conscientious argued against a need for anesthesia presence. One indicated that he could be back in the room within 20 seconds. Understood, but it's still against the rules. Another indicated that leaving the room during bypass was common practice in other countries. I have asked anesthesiologists from England, Canada, Ireland, Germany, Australia, the Netherlands, and France about this, but as yet I have failed to confirm that impression. Clearly I may not have asked enough anesthesiologists in enough countries, so I welcome input from our international members about this issue (firstname.lastname@example.org). Still others have said that they just have no feasible way to provide breaks during CPB, and that this may be the only reasonable time to get a break during a six-hour case or a 10-12 hour workday. I understand and sympathize with this problem, and suggest a possible solution below.
Recently it came to my attention that the Federal Bureau of Investigation and a U.S Attorney's office are investigating an anesthesiology group for failure to provide anesthesiology presence during CPB. I have not determined what the specific situation or allegations might be, nor do I know how this situation came to the attention of those federal agencies. I do know that this investigation was in progress BEFORE this ASA Newsletter article was published, so (thankfully) it did not result from that article's strong support of anesthesia presence during CPB. Maybe this represents the work of a whistleblower. Presumably the primary violation under consideration is billing fraud, which in other circumstances has generated multimillion-dollar mandatory refunds plus multiplier penalties. I am unaware of previous settlements, mandatory refunds, or penalty charges assessed for the lack of anesthesiology presence during CPB. I gathered that the U.S Attorney's office might be considering charges such as reckless endangerment as a result of patient abandonment, although this charge seems much less likely to be substantiable. If you or your partners leave the operating room during CPB, I hope that these developments frighten you.
But I digress, as I promised a possible solution. In a previous President's Message (SCA Newsletter, August, 2004, www.scahq.org/sca3/newsletters/2004aug), I described some unreasonable expectations that hospitals and cardiac surgeons have been imposing upon American anesthesiology practices. The principal theme was that there is a reasonable limit to what hospitals and surgeons can expect from anesthesiology groups in view of personnel shortages and the unfavorable economics of cardiac anesthesia practices heavily populated with Medicare or Medicaid patients, i.e., nearly all cardiac anesthesiology practices. Simply stated, cardiac anesthesia services can be unprofitable in the face of current market pricing for anesthesia providers.
I recently learned that some anesthesiology groups are receiving hospital subsidies for cardiac anesthesia services, just as many groups have been receiving subsidies for providing often-unprofitable trauma and obstetric anesthesia coverage. Philosophically the concept of anesthesiology practices depending upon hospital subsidies leaves me cold, but if market forces and unreasonable service expectations mandate such a need, it may be quite reasonable. Bear in mind that hospitals typically turn a tidy profit on cardiac surgical services even when Medicare is paying for them. If your group should elect to pursue a hospital subsidy for cardiac anesthesia services, you should be willing and able to share the numbers that support this need. If you can make a credible case that the revenue stream from cardiac anesthesia services falls short of covering costs, they may agree with your assessment and respond favorably. If you want to play hardball, you should be prepared to walk away from cardiac anesthesia services if your service agreement permits that action. Obviously, having the cardiac surgeons' support will facilitate this process enormously. Wouldn't it be interesting if market-driven cost-shifting like this should induce hospital administrators and The American Hospital Association to lobby for increased Medicaid and Medicare Part B reimbursement for anesthesiology services?
So how does this information relate to anesthesia presence during CPB? One possibility is that a subsidy for cardiac anesthesia coverage would allow you to hire another anesthesiologist who can "cover the floor" and provide breaks. Another is that you can use this line of reasoning to hire (or to have the hospital hire) one or more nurse anesthetists to provide break coverage. Operating room scrub technicians and circulating nurses expect the hospital to provide personnel for breaks. Why shouldn't you?
This is a controversial subject, so I welcome observations and commentary from our members. If it appears that your wisdom and experiences might help SCA colleagues elsewhere, we will consider publishing them in the SCA Newsletter with or without attribution (with your permission, of course). Please share your thoughts via E-mail at email@example.com.