Anesth Analg 2000;91:1311-1312
© 2000 International Anesthesia Research Society
LETTERS TO THE EDITOR
Are Medicare Patients Sicker, More Complex, and at a Higher Risk for Perioperative Complications?
Amr E. Abouleish, MD, MBA, and
Donald S. Prough, MD
Department of Anesthesiology The University of Texas Medical Branch Galveston, TX 77555-0591
To the Editor:
We are concerned about the recent decision of the Health Care Finance Administration (HCFA) to remove the physician involvement rule for anesthesia care for Medicare patients (1). Recently, Silber et al. (2) showed that the involvement of an anesthesiologist in medical direction was associated with a decreased incidence of complications and death in elderly (over 65 yr) Medicare recipients. This is consistent with our clinical impression that Medicare beneficiaries present more medically complex situations, thus making the task of providing safe perioperative management more difficult.
Because medical complexity, as assessed by the ASA physical status classification system, correlates highly with perioperative morbidity and mortality (3,4), we tested our clinical impression by performing a one-year retrospective review of patients who were scheduled for ambulatory surgery or for admission on the morning of surgery and who were evaluated preoperatively by an anesthesiologist in the Department of Anesthesiology at the University of Texas Medical Branch between September 1, 1995, and August 31, 1996. Both payer class and ASA physical status were noted. We grouped together ASA physical status I and II patients (representing relatively healthy patients or patients with mild systemic disease) and ASA physical status III and IV patients (representing medically complex patients with severe or incapacitating systemic disease). We then compared Medicare patients with non-Medicare patients (those who had other or no insurance coverage) and their ASA physical status using 
2 analysis (P < 0.05 significant).
We reviewed records of 6412 patients, 917 of whom were insured by Medicare and 5495 of whom were not. The percentage of each group in each ASA physical status is displayed in Table 1. Of the total number of Medicare patients represented, 50% had severe or incapacitating systemic disease compared with only 21% of non-Medicare patients. This difference was statistically significant (P < 0.001).
Because ASA physical status is defined by the extent of systemic disease and correlates with anesthetic morbidity and mortality, our results confirm the clinical impression that Medicare patients are more medically complex and have a higher risk of perioperative morbidity than non-Medicare patients. Thus, the decision of HCFA to remove physician supervision as a minimum benefit to Medicare patients undergoing anesthesia is highly questionable, primarily because it removes the requirement for supervision for exactly those patients who are most likely to present complex medical management challenges. HCFA’s zeal to give hospitals greater flexibility in delivering care is not without consequences—their decision must be viewed with the understanding that the patients affected by this change in the minimum standard of care are sicker, medically more complex, and at higher risk for perioperative complications.
References
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MacKenzie R. President’s update, March 31, 2000. American Society of Anesthesiologists website. http://www.asahq.org/hcfa/presupd.html. Accessed May 25, 2000.
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Silber JH, Kennedy SK, Even-Shoshan O, et al. Anesthesiologist direction and patient outcomes. Anesthesiology 2000; 94: 152–63.
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Hosking MP, Warner MA, Lobdell CM et al. Outcomes of surgery in patients 90 years of age and older. JAMA 1989; 261: 1909–15.[Abstract/Free Full Text]
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Arvidsson S, Ouchterlony J, Sjostedt L, Svardsudd K. Predicting postoperative adverse events: clinical efficiency of four general classification systems. Acta Anaesthesiol Scand 1996; 40: 783–91.[Web of Science][Medline]
