Anesthesia and the Surgical Experience

ANESTHESIA AND THE SURGICAL EXPERIENCE E. M. PAPPER" And soothed them into slumbers full and deep. —Keats Introduction A major revolution is now taking place in the practice of medicine in the United States and to a considerable degree in Western Europe as well. There is already great concern among the people who are actual or potential patients—now called consumers in the vernacular of this revolution of health care delivery—about the quality of their care and its availability. In the United States, costs have escalated to the point where our society either can not or does not choose to expend the funds required from both public and private sectors to ensure the level of care which preserves the high standard of the recent past. This mode of care is often associated, in the minds of many erroneously, with the traditional fee for service method of payment. The present environment, which was the consequence of a decision driven by the economic force of cost containment, is truly threatening in its impact on patients or consumers, as well as on physicians—or providers as they are called in the new language of managed care. These changes are variously described, but always in economically oriented terms. It is the worry of many physicians and patients that the quality of medical care will decline as a casualty of economic concerns. Early after the election of President Clinton, there was an ill-timed and ill-fated effort on the part ofthe new President, with Mrs. Clinton in charge, to determine national health policy. It was designed to preserve the traditional American quality of excellent care while restraining or reducing the expenses deemed to be excessive. This entire process failed because of faulty political management—whether fortunately or unfortunately, is, at present, irrelevant. There was no government control put into place as a result of the activities of the White House which would have succeeded in *Department ofAnesthesia, University of Miami School of Medicine, P.O. Box 16370, Miami , FL 33101.© 1997 by The University of Chicago. All rights reserved. 0031-5982/97/4003-1014$01.00 Perspectives in Biology and Medicine, 40, 4 ¦ Summer 1997 | 597 preserving the quality of care and simultaneously managing to restrain total expenditures at an "affordable" level, whatever that might be. It is probably an over-simplification, but it is an accurate one, to state that other options of controlling costs appeared very quickly. They took the form of private sector and entrepreneurial activity to set up Health Maintenance and Managed Care Organizations that were designed to control excessive expenses and also to preserve the quality of care. These economically driven events soon produced significant private enterprise profits, reduced income for many physicians (including anesthesiologists and other specialists), and posed a threat both to hospital survival in the not-for-profit sector and to academic medical centers. In the view of many physicians, a focus on the bottom line soon replaced the focus on compassionate and clinically effective care. The bottom line is more descriptive of the quality of care at present than of the economic successes. Those who attributed the excessive cost to the consequences of malpractice lawsuits were very active in lobbying activities to control "pain and suffering"jury awards, thus far to little avail. Those who believed that insurance carriers were to blame for the excessive costs in terms of the way they managed their businesses also had little or no impact upon that particular industry. Finally, a modest number of clear-cut activities took place which not only redefined the nature of the practice of medicine but were predicting that its future would be driven by economic factors, possibly at the expense of professional skills. The managed care organizations were charged with the interesting problem of containing or reducing costs as well as preserving or enhancing the quality of care. All this had to take place while supporting a business establishment with comfortable, and often , generous salaries for executives as well as suitable returns for investing stockholders. All this is perfectly legal and is part of the established tradition of the American business free enterprise system. These effects had to be ensured in order...