Anesthesiology, Monitoring Hardware and the ICU.

Opinion by David Crippen.

Anesthesiology and anesthesiologists have been a recent litmus for a lot of dealings with so-called "managed care"; medicine regulated by insurance companies rather than physicians. It is a very involuted and evolutionary progression. In the beginning, there was only fee-for-service, and since there was no expensive technology to speak of, medical care was cheap enough so most patients could pay out of pocket and indemnification was cheap enough for all to afford. Then came government funded insurance for the poor and elderly. Two important things happened quickly: consumers no longer bore personal liability for using medical services, and physicians developed an incentive to create demand for these services since they profited directly from them. Stir the development of expensive technology into this brew and you now have a picture of consumers with an incentive to consume and providers with an incentive to provide, and only a relatively inefficient Government bureaucracy riding herd over it.

As might be expected, the only limit was whatever strain the traffic could bear. All was well for a while because the affluent society could handle it. Then the Vietnam War ended, the Arabs declared war on oil imports, spending on foreign and domestic aid went through the ceiling and the boom was over. Sometime in the late 80s, John Q. Public took a hard look at tax based expenditures and they all became political issues. The formerly honorable Harris Wofford of Pennsylvania made health care a religious experience and our current Prez was wafted into office on only a few promises, one that health care be delivered fairly to all Americans. The rest is...shall we say...history. During this time, health care was insidiously delivered into the hands of businessmen entrepreneurs who promised to make it affordable, not to basic consumer units, but to EMPLOYERS. That is where the money came from, and that is who gets served. So when Health America proudly boasts on their ads that they have maintain X number of contracts from Fortune 500 companies, that does not mean that all those consumers are fairly treated, it simply means that they gave the employers the cheapest deal. These concepts are not synonymous.

Now in order to understand my next train of thought, it is necessary to understand how large regulatory bureaucracies function. If you read "A Bright and Shining Lie" by Neil Sheehan, he tells the tale of the Viet Cong learning curve. As they progressed from a rudimentary agrarian society into effective guerrillas, they had a slow but effective learning curve. At some point in the scheme, isolated VC riflemen could be seen standing in fields aiming at stationary helicopters then precipitously swinging their rifle barrel and firing ahead of the target. The airmen thought this funny and many jokes were made of it. They should have been chilled to their bones. These guys were learning how to "lead" their moving targets so that their rounds would not fall behind. Once they figured out you only need to lead moving helicopters, they started shooting them down pretty consistently.

Similarly, the United States Government health care funding bureaucracy has a very slow but effective learning curve. It takes them a long time to figure things out, but once they do, they become very effective in dealing with it. Among the first groups of organized physicians government administrators dealt with were Ophthalmologists, who had for years suckered Medicare into the proposition that "delicate eye surgery" mandated multi thousand dollar fees per patient. It took them a long time to figure this boondoggle out, but once they did, the eye surgeons found the rug pulled out from under them quickly, and further flim flams fell on deaf ears. The Government had been sensitized and their responsiveness to further snookering decreased accordingly. The same fate awaits other looters of the managed care till such as radiologists and pathologists.

Enter anesthesiologists. For years, anesthesiologists convinced government bureaucrats that decreasing their exorbitant fees would directly translate into fewer patients seen, more inefficiency and congestion in the system and thusly, more money spent in the aggregate. Anesthesiologists fees for relatively brief and simple procedures regularly induced heart failure in those who had any financial responsibility for them, especially since the majority of the case was probably done by a salaried Nurse Anesthetist. Well, this threat can be very effective if two prerequisites are met: 1) ALL the anesthesiologists in the pool must be willing to play the game, and 2) there must be no reservoir of manpower willing to do the same job for less.

Eric Hoffer tells us that the instigators of change are not those who benefit from it. Anesthesiologists had evolved into homeowners with kids in expensive private schools chauffeured by well dressed wives in expensive automobiles. Their threat was viable only as long as they did not have the potential to suffer financial losses that would threaten this established standard of living. Government administrators figured out that their threat went only as far as the point of suffering. Administrative Man called the bluff. The wailing began. The facade folded. One by one they folded when pain threatened. Nurse Anesthetists waved their hands from the back of the room..."We'll do it cheaper!". Then the cuts began. Instead of seeing fewer patients, they followed the realities of the supply/demand curve. They saw MORE patients for LESS reimbursement. Then the drop out began. Anesthesiologists are bailing out in droves and may go the way of the duck-bill and the Dodo by the end of the century. The anesthesiology residencies at the biggest trauma center in Pittsburgh did not have a single warm breathing body in September 1995. The ones currently in training have a job market picture resembling that of the Aerospace industry in 1976. Residency directors cannot look their residents in the eye without bursting into tears.

It is a fact of life that the best and the brightest will never work for peanuts. You want the best...you pay accordingly. The inverse is also true....if you are willing to pay big bucks, the B and B will crawl over the broken bodies of their competitors to service you. Want to pay a pittance? You get the unwashed. So, instead of maintaining a quality service for fewer patients, it actually works in reverse; you get less quality spread over a bigger population of patients. Not that this is of any interest to "managed care" because their priorities are different; simply the most employer clients kept as happy as possible at the cheapest price. That does NOT translate to the maximum number of actual potential consumers kept happy, but that's another story. The only time quality enters the picture is as an advertising gimmick. It gets worse.

One of the most currently fashionable ways to cut expenses is by "bundling" fees and charges. That means when a patient comes into the hospital for a procedure, they insurance company pays a flat fee to someone and those involved in the care divide it up. Surgeon gets some portion of it, Anesthesiologist, OR team, hospital and so on. Included in that bundling is (will be) durable hardware needed to perform surgery and recovery. That means that every piece of hardware will have to compete with humans for it's piece of the pie. What that further means is mute pieces of hardware will be competing with articulate humans who have an incentive to aggressively negotiate for the biggest piece they can get. As a practical matter, what is needed to put a patient to sleep? An anesthesia machine capable of delivering gas. An arterial line or cuff hooked to a blood pressure monitor. An IV bag. Some medications. A pulse-ox, A capnograph. A stethoscope attached to a human who can make decisions based on intuition, experience and training. Did I neglect to mention something? Oh yes....a $20,000 cerebral function monitor? Do you have any prediction which one of these items will make the cut when the bundled money for OR time gets tight (tighter)?

Now look at the ICU. Your first argument should be that the ICU is the biggest source of expenditure in the hospital and a great deal of the things that go on there are expensive way out of proportion to their utility. It is a place ripe for cuts. Therefore, the same argument should apply regarding supercilious and expensive hardware that applies to the OR. Wrong. There are fundamental differences. A large number of surgical operations are elective and a large number of the hardware on hand is not necessary for the MAJORITY of cases. Therefore, unless their promoters can prove that these instruments REALLY make a difference in mortality/morbidity, they can be scrapped by cost cutting bean counters because their argument is as good as yours. HOWEVER..the ICU is a completely different reality.

Consider the following scenarios. When John Q. Public walks into his local grocery and demands a free basket of food because he has no resources, he is unceremoniously escorted out. When John Q. Public calls the Internal Revenue Service and says he has no money to pay his taxes....he does three to five the hard way in Soledad. When JQP goes to his local surgeon and demands a hernia repair gratis because he puts on his pants one leg at a time just like paying customers, he is greeted with a round of guffaws and shown the door. HOWEVER, when JQP demands ICU care irrespective of his ability to pay, he is welcomed with open arms. Why? People desire access to intensive care on demand regardless of ability to pay as a humanitarian issue. When that happens in large enough populations, failure to provide it is called DISCRIMINATION. Any attempt to limit expensive technology for these resource depletors is met with cries of human rights violation and realistic threats of legal action.

In dealing with stunningly wasteful entities like ICUs and especially (shudder) emergency departments, insurers are no longer dealing with small, relatively ineffective groups of physicians. They are now dealing with large, committed groups of social activists like the AARP (American Association of Retired Persons) and legions of politically savvy poor people who know how to play the system like a cello. In such a system, there is little possibility of cost constraint because any meaningful conservation is perceived as discrimination. If you go to an administrative wonk in the OR and say you need a cerebral function monitor because it helps you know what's going on with brain function during a case, you are met with questions like: Has mortality/morbidity changed because of this instrument? What did you do before this instrument? Specifically what does it do that cannot be inferred by other instruments or clinical judgment already in place? As a practical matter, how many procedures a year might this instrument benefit and why? Who can you "charge" for this instrument to recoup it's investment?" Then the big one: Which human's portion of the pie are you willing to allot to the price of the instrument?

If you go to the administrative wonk of the ICU and say you need a cerebral function monitor, the same questions apply, but the answers are radically different.

1. Has mortality/morbidity changed because of this instrument? It doesn't matter. M & M is a moot issue in the ICU. People are not admitted to ICUs with either of these concepts in mind. People are admitted to ICUs because it is a service they desire and demand. Once they are ensconced, they own the bed as long as they or their relatives want it.

2. What did you do before this instrument? It doesn't matter. Effective ICU care is defined by the quantity and quality of monitoring devices that can be brought to bear. This monitoring device measures something that allows us to make clinical decisions on, therefore it is fair game.

3. Specifically what does it do that cannot be inferred by other instruments or clinical judgment already in place? It doesn't matter. The indication for an ICU monitor is simply that it monitors something that I can make a clinical intervention on the basis of. I can make a case for any clinical intervention empirically. Can outcome statistics be used to argue with this premise? Naaaaa. There aren't any, and there isn't any way to get any. Its being is its karma.

4. As a practical matter, how many procedures a year might this instrument benefit and why? How many patients have brain function that might be amenable to monitoring during highly stressful ICU admissions? How many angels can carve graffiti on the head of a pin with jackhammers?

5. Who can you "charge" for this instrument to recoup its investment?" It doesn't matter. Payers reimburse ICU care not because they want to, but because of threat of large lawsuit if they can't prove they monitored patients properly a la Libby Zion and Andy Warhol. "Charges" are meaningless concepts. The indication for any equipment has little to do with efficacy, it has simply to do with averting a potential bad outcome.

6. Then the big one: Which humans portion of the pie are you willing to allot to the price of the instrument? It doesn't matter for reasons reciprocal to question #5. The pie is split up with no deference to personalities or machines. It all gets swallowed into the big ICU black hole as unrecognizable mulch. The only driving force is desire and demand and the only control is fear of liability and discrimination.

So therefore, I seem to be creating a premise that funding ICU medicine follows completely different lines of logic than funding it's near-neighbor the Operating Room and it's denizens. How all this factors into "managed care" remains to be seen.