Surgical care remains one of the most significant drivers of overall hospital cost—yet the medical readiness of complex surgical patients is often overlooked in financial and operational planning. While the cost-effectiveness of any surgery requires consideration of both short- and long-term improvements in patient outcomes and quality of life, the episode-of-care cost varies depending on individual circumstances.
Consider a 54-year-old woman with a body mass index of 42 kg/m2, poorly controlled diabetes, anemia of iron deficiency, active tobacco use, and a high-deductible health insurance plan that has prevented her from getting regular health maintenance care, who presents for a Total Knee Arthroplasty. She undergoes an “uncomplicated procedure” and is discharged home. Yet her treatable chronic conditions have both increased her length of stay compared to the average and led to her readmission 28 days later with a fever. Her total cost of care ends up being three times higher than average. Moreover, her life expectancy is likely to be shortened by more than a decade.
Ideally, a surgical plan should begin when a patient is first identified as needing surgery and continue until fully recovered from surgery. Current models for surgical care commonly accept presenting medical conditions and lifestyle factors as concerns which must be adapted to, to permit surgery to take place as scheduled. In many instances these secondary and often modifiable medical conditions are not documented until the days before surgery or not at all. Foreclosing on the chance for adequate optimization, avoidable and costly complications ensue, driving up episode-of-care costs. Moreover, these unrecognized or underrecognized secondary diagnoses reduce operating room efficiency by leading to cause delays and cancellations.
Recognition and management of modifiable medical conditions and lifestyle factors before surgery has been shown to reduce complications, lengths of stay, readmissions, and the overall costs of care stemming from the surgical procedures. Moreover, under-documentation of comorbidities influences hospital DRG pricing based on patient risk adjustments and impacts episode-of-care cost. For example, allowances for complication readmissions, before CMS penalties start to accrue, are shifted based on the number and severity of medical conditions.
A general truth is that surgeons prefer operating, primary care clinicians prefer managing chronic medical conditions, and anesthesiologists prefer being in the operating room. Who is completing a highly detailed medical history and prioritizing those comorbidities for which improvement is most likely to influence outcomes, let alone developing and implementing a coordinated and timely optimization plan? Pre-op nurses sometimes help to fill this void, consequential to their performing mandated requisite preoperative visits. That said, they do not practice medicine, and their capability to inventory, stratify, prioritize, and optimize comorbidities and lifestyle factors are not uniform. The same can be said about development, implementation, and coordination of a prioritized and timely medical optimization plan, interpolated into preparation for the procedure itself.
Perioperative medicine (POM) is an evolving specialized area of practice that addresses an unmet need—the comprehensive, multidisciplinary, coordinated, and targeted capture of relevant comorbidities in surgical patients. It also includes their risk stratification and prioritized medical optimization prior to having their procedure, as well as coordinating and facilitating acute and post-acute recovery and related discharge matters, encompassing the entire period from the initial contemplation of surgery to highest level of recovery.
POM has some universally accepted delineated touchstones throughout the perioperative journey:
1) High-fidelity pre-operative assessment, risk stratification, optimization, and targeted care management to ensure patient readiness for surgery. This unlocks enhanced operational outcomes on the front end of the episode through improved throughput (e.g., fewer delays, reduced turnover time, and avoidable day-of-surgery cancellations, etc.) as well as on the back-end of the episode through decreased lengths of stay, prudential recovery & discharge disposition, and reduced readmissions. In the foreground of these admirable and expected results stands the weighty clinical outcomes—fewer and less severe complications both during and after surgery.
2) Proactive risk documentation by highly detailed capture of clinical comorbidities (CC) and major clinical comorbidities (MCC). This clinical documentation improvement facilitates accurate ICD-10 coding of surgical cases, risk adjustment and reset of penalty thresholds, and thus DRG performance.
3) More efficient resource management through enabling safe care team models and consequent cost reductions.
In addition to addressing preoperative readiness and acute & post-acute recovery coordination, POM ensures smooth transition back to each patient’s primary care physician.
Like so many other innovative approaches to health care, the widespread adaptation of this ideal model for surgical care in today’s market needs to confront restrictive payment methodologies, workforce shortages, and acceptance of long-term economic advantage over short-term investment.
Despite these barriers, there is currently both immediate and long-term clinical, financial, and operational upside for institutions to buy in to this new paradigm. The clinical enhancements can be shown by complication rates and patient-recorded outcome measures; operational results can be proven by throughput measures as noted above; and financial upside can be presented by comparing historical, proforma, and actual DRG performance.
What is the value:
• Better clinical and satisfaction outcomes for patients
• Better coordination of care and patient navigation
• Better standardization of care centered on evidence
• Enhanced revenue capture
• Reduction in episode-of-care cost
• Improved operating room efficiency
• Value-based framework of care, readiness for CMS programs
• Improved continuity of care
Perioperative medicine is not just a clinical enhancement—it’s a strategic imperative standing on the shoulders of a paradigm shift. Hospitals that embrace this model improve clinical, operational, and financial outcomes, streamline care delivery, and unlock financial value. In an era demanding smarter care and greater accountability, integrating perioperative medicine into your perioperative service line strategy is no longer optional—it’s essential.
To learn more, visit somniaanesthesiaservices.com
