Moving toward value-based anesthesia care

As a broad consensus develops for fundamental restructuring of health care financing and delivery in the United States to treat runaway cost escalation coexisting with limited access, health care services and equipment that seem “expensive” will receive special scrutiny.’ Anesthesiologists are likely to wonder what lies ahead for our specialty. Thus, it is timely that Drs. Tuman and Ivankovich consider in this issue of the Journal of Clinical Anesthesia the implications of cost-containment for high-cost technology use and development in anesthesiology. * Their presentation is as far-ranging as it is incisive, including many salient examples, such as the uncertain cost-effectiveness of monitoring with a pulmonary artery catheter and the influence of anesthetic technique in cardiac surgery on length of stay in the intensive care unit (ICU). They urge us to consider the economic implications of and patient outcomes relating to our practice decisions so that we “provide only the necessary amount of testing and monitoring for effective patient care and eliminate the excessive, extraneous use of high-cost technology.” In short, Tuman and Ivankovich call for what is termed technology assessment to guide us in delivering cost-effective care. s Their arguments are persuasive, but anesthesia practitioners are likely to feel bewildered and require some guidance, especially as they view the enormity of the task. Although Tuman and Ivankovich do not define technology explicitly, what they describe is considerably broader than the term’s colloquial usage. Their description is consistent with the usage of the congressional Office of Technology Assessment, which views medical technology as the drugs, devices, medical and surgical procedures, support systems, and organizational systems through which health care professionals deliver health care to individuals.* The clinician also may conclude, mistakenly, that the threat of decreased access to and development of anesthesia technology described here is a looming, a distant, or perhaps only a potential threat. Actually, the threat has been impinging on us for some time, albeit in subtle ways, and will have progressively greater influence. In fact, a convergence of evolving economics and a growing concern about patient outcome have already led purchasers of health care to seek what might be called value-based care-essentially the best patient outcome achievable at a reasonable cost-which will have a growing influence on decision making in anesthesia care as well as throughout the health care industry. Before considering how we can meet the challenges ahead, we should pause to reflect on how value-based care has evolved, for an appreciation of changes in the health care marketplace will aid our understanding of what we must do.