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*	

With a new administration soon to take office,
President Biden has already stated his support
for lowering the Medicare eligibility age, and for
a " public option " that would likely be pegged to
Medicare payment rates.3

*	

The Medicare Trust Fund is expected to become
insolvent as soon as 2024.4 The chair of the
Medicare Payment Advisory Commission, Michael
Chernew, PhD, recently commented, " We are very
dedicated to finding payment models to promote
efficient delivery of care. " 5 No one could possibly
think this will mean anything other than lower
payments to physicians.

*	

Scope-of-practice expansion is gaining ground.
On March 30, the Centers for Medicare &
Medicaid Services issued an array of " temporary "
waivers and new rules, waiving the requirement
that a nurse anesthetist must work under
the supervision of a physician.6 How likely
are these new rules to be reversed under a
new administration, whether Republican or
Democratic? Whether or not you live in an " optout " state may not matter in the near future.

*	

Hospitals were in trouble even before the
COVID-19 pandemic. Many have gone bankrupt7;
others are merging with larger health systems.
At present, around 80% of hospitals subsidize
their anesthesiology departments to the tune
of millions of dollars each year. Realistically,
can these subsidies continue? Probably not.
Will hospital administrators seriously consider
cheaper staffing models for delivering anesthesia
care?8 Probably.

Make Yourself Indispensable
First, it would be wise to assume that a downward
market adjustment to anesthesiologist compensation
is coming. Plan for it now. Stop yourself from

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spending to the full extent of your income, and put
away all you can in a tax-deferred retirement account.
Anesthesiology residents today are well advised
to specialize. Do a fellowship year or two. Pursue
advanced training in clinical research, if that's what
you enjoy. Consider working toward a PhD. There are
other alternatives as well: advanced degrees such as
a master's in public health, business administration
or hospital administration. The days are over
when it was enough to learn to deliver anesthesia
competently in order to get a decent job. We need to
do more to establish our value beyond simply putting
patients to sleep and waking them up. Set yourself
apart from advanced practice and nonphysician
practitioners, or you'll find yourself classified as a
" provider " -an equivalent pawn on the OR chessboard.
Make your skill set unique and your services
indispensable to your hospital or group.

Don't Be Afraid to Act Like
a Physician
In a remarkable JAMA column written in 2012,
Ezekiel Emanuel, MD, PhD, one of the architects of
the Affordable Care Act, recommended shortening
medical school to three years.9 His argument: Less
medical education would " enable physicians to
use evidence more effectively to improve care; and
enable physicians to become comfortable with group
decision making, standardization of practices, task
shifting to nonphysician providers, and outcomes
measurement. "
Obviously, Dr. Emanuel's advice is a trap. As a
champion of protocols and cookie-cutter medicine, he
wants physicians to be afraid to defy a care protocol,
even if they are convinced it would be in the individual
patient's best interest. Standardization of practice
works best for a single procedure such as central
line insertion, or a patient who has only one medical
problem. What if your patient has more than one
medical condition with conflicting protocols?



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