PACIFIC ANESTHESIA (Everett: 2005 – 2009)
Pacific Anesthesia in Everett uses a “physician-driven” anesthesia delivery model developed to meet the needs and challenges of evolving tertiary care requirements of the community and in the new Providence Regional Medical Center Everett Tower that will open in 2011.
Surgical treatment in Everett before the 1950’s was not too different than that found in many other communities around Washington State – or other parts of the country for that matter. Anesthesia was provided primarily by unsupervised nurse anesthetists (where an anesthesiology doctor may not even be present in the facility) or a minimally supervised nurse anesthetist model where physician anesthesiologists work in parallel with the nurse anesthetists but do not supervise their work. These early nurse anesthetist practioners were nurses with several months of specialty training – as well as on-the-job education and self improvement through continuing medical education.
In 1950, the medical staff at General Hospital and Providence Hospital of Everett encouraged graduates of anesthesia residency training programs (which currently require completion of medical school and four years of specialty anesthesia training) to join the medical staff in order to complement the work being done by the nurse anesthetists. Gene Mason and Don White arrived in town and joined forces with the local nurse anesthetists. This partnership evolved into an informal unsupervised or minimally supervised model of anesthesia care that served Everett well until major changes in healthcare evolved in recent years.
General surgery and orthopedic surgery gradually became more complex. Neurosurgery was pioneered in Everett by Wally Nelson M.D. on a part-time basis (1959) until later a full time neurosurgeon, Johnston M.D. arrived on the scene (1962) (see “homepage”). Doctor Bagleman and Doctor Richard Phillips subsequently brought cardiac surgery to Everett and Mike Jenkins, John Ford and physicians in the Everett Clinic developed Vascular Surgery programs. These and multiple other developments resulted in increased complexity of care for these specialty surgical cases and our anesthesiologists responded with more sophisticated and technical anesthesia capabilities.
As the years have passed, other changes in healthcare have arisen that have further impacted the structure of anesthesia service in our community. Patients have become sicker, older and more obese with more frequently challenging problems including severe cardiac and respiratory disease, diabetes and increasingly severe chronic illnesses. Further compounding these matters, patients more frequently have no insurance or limited insurance despite the fact that they are admitted to the hospital in need of more complex and higher risk surgical procedures.
The medical community in Everett- like elsewhere- has risen to this challenge. Patients have become segregated into “outpatients” and “inpatients” to help direct the healthier patients with more “minor” problems to outpatient surgical centers leaving the sicker patients with more complicated problems to be treated as inpatients.
The relatively healthy outpatients, who present with lower anesthesia risk can be cost effectively and safely treated in outpatient setting such as the surgical centers found in the Everett Clinic, the Everett Bone and Joint’s surgical center or the Gateway outpatient surgical center to name a few. Our Everett community is somewhat different in this regard, however, since even the outpatient surgeries that are done in the hospital represent a sicker patient population than would usually be found as outpatients. This is because many outpatient procedures done in the hospital are procedures for patients that have too many medical issues to be done in free-standing outpatient surgery centers. Ready access to inpatient hospital services are required for these patients and they are most often sent to the hospital for their outpatient surgery.
Healthcare planners recognize that some areas, such as Everett and Snohomish County, have a greater percentage of poorly insured or uninsured individuals and a higher percentage of obesity and the added healthcare morbidity that goes with it than other neighboring cities and counties.
Also, rising healthcare costs are a major public issue throughout our country. Whereas healthcare has focused on quality and cost effective medical and surgical care, healthcare planners have also had to take into account the public’s concern about less than optimal medical and surgical outcomes that are reflected in the significant medical malpractice claims and corresponding increases in medical malpractice insurance premiums. The increase in medical malpractice premiums are just one of many areas of healthcare cost escalations that make it difficult to offer competitive salaries to young physicians, including young, highly trained anesthesiologists, when they are searching for the best practice opportunities.
Recognizing these trends, the Providence Regional Medical Center Everett hospital Board of Directors and administration have always tried to find ways of improving quality, while making local healthcare more efficient and cost effective. Furthermore, the mission of Providence from the early days has always been that of making quality healthcare available locally to decrease the inconvenience of seeking care at tertiary centers in Seattle like Swedish Medical Center or the University of Washington.
By 2005 it became evident to the hospital and to the two anesthesia groups serving our community- the anesthesia group serving the Everett Clinic and the other major physician group, the Western Washington Medical Group- that a combined group could provide better overall efficiency, while maintaining the same quality of anesthesia service.
As these issues were discussed between the hospital and anesthesia groups, the hospital responded to an appeal from the anesthesiology groups to make possible certain pay incentives that would bring the reimbursement level of local anesthesiologists up closer to the reimbursement of anesthesiologists in other parts of Washington, especially tertiary care hospitals in Seattle and the surrounding region. This would ensure that recruitment of new anesthesiologists would remain or become more competitive. Our Everett community had long been challenged by an exodus of excellent anesthesiologists from Everett to surrounding hospitals, particularly in Seattle and the Bellevue/ Kirkland areas (the two Everett groups in the past jokingly referred to themselves as a “farm club” for Seattle and Eastside anesthesia groups).
The two anesthesiology groups felt that transitioning from the unsupervised or minimally supervised nurse anesthetist model of years ago to a physician driven anesthesia group would better serve the increasing needs of the evolving subspecialties and challenges of sicker, older and more obese patients treated in the hospital. Every patient in the operative environment would be cared for by a specialty trained physician on a one to one basis. Our homogenous all-physician anesthesiologist model would also allow for more seamless coverage of the Colby and Pacific Campuses, including Obstetrical services at the Pavilion, increasing access for patients and surgeons. This model was agreed upon and our two Everett anesthesiology groups joined with the Pacific Anesthesia group in Tacoma, Washington to form an all-physician model. This all-physician anesthesiology model employed by Pacific Anesthesia worked extremely well and achieved multiple milestone goals over the past four years. With the addition of the anesthesia group from Stevens Hospital in Edmonds to Pacific Anesthesia, we have been able to achieve even more favorable contracting strategies and economies of scale significantly improving the economic conditions for the group and helping us to provide continually extended and expanding care for patients at a low cost to the hospital. Recruitment and retention of the highest quality anesthesiologists had finally become a reality in the Everett area, providing the most stable anesthesia conditions in the last 20 years.
Pacific Anesthesia is proud of our cardiac specialty subgroup that has maintained the highest of standards (including recruitment of specially trained cardiac anesthesiologists and the requirement of certification in specialty safety measures such as transesophageal echocardiology). This subgroup has assisted the cardiac program in developing a nationally recognized level of excellence. We have also assisted the vascular and general surgery practices in Everett in development of nationally recognized quality care. In addition, Pacific Anesthesia has assisted the neurosurgical surgeons and facilitated developments in neurosurgical care in this community including anesthetic techniques suitable for complex intracranial neurosurgical cases including stealth technology. We have assisted in the expansion of both neurosurgical and orthopedic spinal surgery service lines volume and complexity with anesthetic techniques developed to aid in spinal cord monitoring during surgery. We have developed protocols and procedures to assist our obstetrical and urologic surgeons with DaVinci robotic surgery. Pacific Anesthesia has one of only five anesthesia quality programs that have been recognized by the State of Washington. We have instituted an anesthesia coordinator to facilitate case transitions, assist in scheduling cases and to help out throughout the facilities in emergencies. In addition, we have assisted Providence in attaining increased surgical throughput and efficiency through the Utilization Subcommittee, which we chair. We have helped the hospital, nursing staff and surgeons to exceed continually rising expectations and standards. To this day, our group enjoys tremendous support from the surgical and nursing community in Everett.
However, in the past few years the hospital has become challenged by changes in the economy and the need to reduce expenses in order to pay for the much needed Providence Regional Medical Center Everett Tower that will be completed in 2011. Therefore, the hospital has understandably re-examined the quality and cost effectiveness of the current physician driven model as opposed to the older mixed anesthesia model employing nurse anesthetists that had served our community for decades earlier.
Pacific Anesthesia recognizes that there are many nurse anesthetists of excellent quality, who can give very excellent anesthesia, particularly to the lower risk short stay or outpatient procedures done outside of the Providence facilities. However, Pacific Anesthesia also sees that- unlike in the past- the highest level of quality anesthesiology is going to require a change from the older unsupervised and minimally supervised nurse anesthetist models to a physician-driven model.
The Pacific Anesthesiologists always enjoyed very satisfactory working relationships with many nurse anesthetists over the years and therefore in response to the hospital’s inquiry, did a quality/cost analysis of the present physician driven model versus the possibility transitioning to a supervised nurse anesthetist/anesthesiology model. We employed three nationally prominent anesthesia consultants to assist us in addressing these competing models. Unsupervised or minimally supervised nurse anesthetist models were rejected as typical of older models of care or anesthesia models more usually found in outlying community hospitals, certainly not a model found in tertiary referral centers or modern and progressive obstetrical suites.
When Pacific Anesthesiology and our consultants did an in-depth analysis of the two physician driven models- the homogenous all-physician anesthesiologist model currently used by the group versus the physician supervised nurse anesthetist/anesthesiologist model- we could see that such factors as “on-call” schedules, staffing and coverage flexibility and economic incentives would need to be considered to maintain the Everett based anesthesia group’s ability to attract the best young anesthesiologists to our community.
The analysis showed that the expense of the two viable options- physician supervised nurse anesthetist/ anesthesiologist model versus homogenous physician-only model- differed little in cost. Pacific Anesthesia did feel that the more homogenous physician-only model had the edge in terms of quality of service to the community. Each patient would have an individual physician anesthesiologist dedicated to their care during surgery. The Pacific Anesthesia group, with it roots in the medical community for the past 60 years, felt that physician-driven models would best meet the overall quality/cost effectiveness for patient anesthesia care at Providence. In particular, the expansion of services and complexity of cases characteristically present in referral centers and embodied in the new Providence Regional Medical Center Everett Tower warranted such high quality care. According to the Pacific Anesthesia estimates there would be only minor difference in cost and greater quality potential if the current model would be continued.
We have over 260 combined years of service to the Everett community and seven of our members have more than 20 years of individual service here. We understand the community and how it has grown in size and in surgical complexity. We understand the desire to become a regional referral center as the new PRMCE tower project moves toward a projected 2011 start date. We feel that our current physician-driven model is the best option for continued and improving quality and safety. We further believe that our model provides the best value to the community compared with miniscule savings from a supervised nurse anesthetist/ physician anesthesiologist blended model and to an older unsupervised nurse anesthetist model more suited to less risky surgical environments. Since every member of our group sincerely felt that careful analysis of the matter favored the physician-driven model, we felt uncomfortable making a change that might be considered “regressive”. Furthermore, we believe that any significant service expansion would be more efficient, less expensive to the community and better provided with our current model, expanded as needed to fill community needs.
The hospital indicated that they no longer wish to have a physician-driven model like the one used successfully here by Pacific Anesthesia encompassing the Colby and Pacific operative suites and Pavilion obstetrical service. They have contracted with an outside agent to import a different model to our community at the termination of our contract here. Therefore, we have chosen to pursue our vision of quality and cost effective anesthesiology service elsewhere.
We leave behind our surgical, nursing and support staff colleagues and friends of many years- friends that we have worked with so closely throughout the hospital. The intense environment of the operating suite and elsewhere in the hospital has created a tremendous wealth of deep and trusting relationships of immense importance to us, and countless memories that we will always treasure.
Of course we recognize that the Providence Regional Medical Center Everett policy-makers and administration has carefully considered all of these options and has done what they feel is best. We wish all of our surgical colleagues, the community and all of our friends and our families in the Providence Regional Medical Center Everett all the best with the new model of anesthesiology service that has been selected.