VALUE-BASED ANESTHESIA CARE

A feast-and-famine health care marketplace had developed by the early 1990s in the United States. Several decades of runaway escalation of health care costs at two to three times the general economy's inflation rate, coupled with a large uninsured segment of the population and health indices (e.g., life span, infant mortality) below those of countries with lower per capita health care spending, indicated misallocation of resources in the U.S. health care system. When federal reform failed in 1994, the marketplace accelerated the ongoing fundamental restructuring of health care financing and delivery. What has resulted is a payer-dominated, constrained, increasingly competitive health care marketplace that seeks greater value, which may be represented as

Value = Quality/Cost

Value-based anesthesia care is a neologism advanced to encourage anesthesiologists to look beyond widely misunderstood concepts, such as cost-effectiveness, to focus on enhancing the value of care by providing the best patient outcome achievable at reasonable cost.^[40] A large literature documents that perhaps 25% of care is inappropriate,^[41] that large variations in resource use for similar care exist across small geographic areas, ^[42] and that higher utilization of services is not associated with improved health status or quality of care^{[43] [44]} ; thus it is clear that quality and cost are not tightly linked: Better

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Insights into the relationship between patient outcome (or benefit) and cost may be gleaned by noting the relationship between overall health benefit and incremental inputs to health care ( Fig. 2-5A ).^[45] As in other productive endeavors, the anesthesiologist should continue to add resources (e.g., newer and more costly drugs, special patient monitoring, adjunctive pain management protocols) as long as the result is positive benefits. Beyond "the top of the curve," the point of maximal benefit and thus optimal investment, further investment merely results in negative benefit (e.g., complications,

Figure 2-5 A, The hypothetical relationship between inputs to a productive process and the benefits derived describes a production function. As investment continues, the net benefit, segment ΔBⁿ , progressively decreases and then becomes negative, illustrating the law of diminishing returns. B, Rationalizing rather than rationing health-care technology achieves maximal benefit at "the top of the curve," a level of investment associated with the optimal investment. (A is reproduced from Orkin^[45] ; B is modified from Orkin^[45] and Reinhardt.^[46] )

Seemingly arcane, this economic construct applies well to most decisions anesthesiologists face, including drug choice, equipment acquisition, and administrative policies. Common to each decision is choosing the appropriate technology or using technology appropriately. (We must acknowledge that medical technology is not limited to devices such as patient monitors; according to the former congressional Office of Technology Assessment, it also includes drugs, medical and surgical procedures, protocols, support systems, and organizational systems through which health-care professionals deliver care.^[47] ) The challenge of knowing when we are doing what is "appropriate" (and no more or less) is especially difficult because our knowledge of the effectiveness of our clinical practices, among other complex issues, is incomplete.^[41] The quandary is further complicated because of our rudimentary understanding of outcomes and economics, which extend well beyond the purely clinical and financial, to include quality of life, patient preferences, and patient-based assessment of care, among other seemingly subjective topics.^[48] Although general^{[49] [50]} and anesthesia-specific^{[48] [51] [52]} guidance is available, few anesthesiologists have sufficient time or expertise to undertake this outcomes-related research. Yet anesthesiologists must develop an appreciation of the considerations when evaluating or planning value-based comparisons of care ( Table 2-1 ).

Once a potential, value-enhancing practice change is identified from the work of others (e.g., an article in a professional journal) or through research in one's own institution, the next challenge is implementation. In truth, there is no shortage of good ideas, but putting

TABLE 2-1 -- Considerations in value-based comparisons of care

Include economic considerations in clinical decision-making: it is neither unethical nor immoral.

Be explicit in a comparison; assume nothing, if possible: nothing is "obvious."

Identify all possible benefits and risks associated with alternative clinical approaches.

Focus on costs, not charges (e.g., patient bills).

Capture indirect costs (e.g., patient's out-of-pocket losses) as well as direct costs.

Focus on marginal differences related to alternative approaches rather than on overall cost of care.

Emphasize real outcomes (e.g., myocardial infarction) rather than intermediate or surrogate end points (e.g., myocardial ischemia), unless they are highly associated.

Do not lose sight of implications of early "savings" on events "downstream" in the care process.

Opt for lower-cost approach unless value is demonstrated in higher-cost alternative.

Modified from Orkin.[40]

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Substantial cost savings without apparent adverse outcomes are possible through adoption of department-defined pharmaceutical practice guidelines for limiting use of several high-cost drugs.^[54] Acceptance ("buy-in") of the guidelines is achieved, in part, through soliciting comments from all anesthesia care providers and including among the guideline committees ardent proponents of particular drugs. Compliance is maintained by several mechanisms, including widely publicizing the department's successes, periodic feedback to each provider on his or her practice patterns, making compliance with the guidelines more convenient than noncompliance, and permitting departures from the guidelines in appropriate circumstances.

Ideally, we want to concentrate our improvement efforts where they will have the greatest effect; however, in many situations we have only vague impressions, in part because the processes of care are themselves so complicated and outcomes are typically not tracked. A variety of sources can guide the focus of improvement efforts: patient complaints, staff suggestions, critical incident reports, accreditation survey results, benchmarking (i.e., comparison with similar institutions), statewide databases, peer review organization results, and articles in professional journals. Figure 2-6 provides a framework for conceptualizing the improvement effort once a focus is chosen. Improving the care requires that we understand the underlying processes, particularly when there may be

Figure 2-6 General schema for improving the value of health care by applying the clinical value compass model. (Modified from Nelson et al. ^[55] ) Underlying this framework are several assumptions: health is composed of biologic, physical, mental, and social aspects; the aim of health care is to reduce or limit the burden of illness by restoring or improving health functioning; quality health care provides care processes most likely to achieve the health outcomes desired by the patient at a price representing value for that patient; and the value of health care is a function of quality, costs, and volume.