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Insurance in the United States can be divided into two funding categories: private and government. Government insurance is paid for or subsidized by the government, while private insurance is either employer-sponsored or paid for by the individual. In the United States, both types of insurance function similarly, with insurance paying a certain amount for a service and sometimes requiring a copay, deductible, or monthly/annual premium from individuals. The benefits of insurance policies have become increasingly important in recent years as healthcare costs have increased. In 2018, healthcare spending increased by 4.6% to a total of $3.6 trillion, according to a study by Hartman et al [1]. 

Government insurance in the United States is offered to certain vulnerable groups. Medicare and CHIP are government insurance programs that offer coverage to individuals over 65 years of age, under 18 years old, and, in certain states, those significantly below the poverty line. Medicaid, however, is not an insurance product but a program that helps cover medical bills for low-income Americans and those with disabilities. In 2018, the U.S. government paid out a total of $731 billion for these government insurance programs, which accounted for 15% of federal spending [2].  

Despite its high price tag, government insurance tends to be more affordable and offers lower administrative costs than private insurance. In a study by Ku and Broaddus, the researchers simulated moving from private coverage to government insurance and found that, on average, costs dropped by 26% per person [3]. While government insurance tends to be the lower-cost option, it also tends to be less flexible. Government insurance has fewer, if any, options for plans, and little-to-no coverage for procedures it deems unnecessary. 

Overall, private health insurance tends to cost significantly more than government insurance. The tradeoff, however, is that plans tend to be more flexible and individuals can usually select from a variety of plans or customize their own according to their needs. Private insurance, which accounted for 34% of spending on healthcare in 2017, almost always requires a monthly or annual premium [4]. These premiums tend to be significantly higher than government plans but are sometimes covered or split with employers. For those who are covered under government insurance, private plans can also provide supplemental coverage for items or procedures not covered under the government plan [5]. 

In the United States, public healthcare marketplaces can blur the line between public and private insurance. Under the Affordable Care Act, which was put into law in 2010, every state was required to launch a public healthcare marketplace. Those who qualify for the Affordable Care Act can choose plans from an array of options on the marketplace [6]. While the federal government mandated that plans on these marketplaces follow certain regulations regarding coverage and cost, the plans themselves are offered by private companies. 

Recently, the role of private companies and the government in providing insurance has come to the forefront with the rise of “Medicare for All.” This proposal would eliminate private insurance, expanding Medicare to cover everyone in the United States [7]. Another option is the so-called “public option,” which would expand government insurance to cover everyone, while allowing individuals to keep private coverage. According to an article by Herzlinger and Boxer in the Harvard Business Review, this option has proven successful in Germany and the Netherlands, two countries with strong universal healthcare programs [8].  

While private insurance tends to be more flexible and can be split with employers, government insurance is usually more affordable and has lower administrative costs. Indeed, it is the difference between these two models that is at the core of recent proposals to expand government insurance programs. 

References 

[1] Hartman, Micah, et al. “National Health Care Spending In 2018: Growth Driven By Accelerations In Medicare And Private Insurance Spending.” Health Affairs, vol. 39, no. 1, 2020, pp. 8–17., doi:10.1377/hlthaff.2019.01451. 

[2] Cubanski, Juliette, et al. “The Facts on Medicare Spending and Financing.” Medicare, Kaiser Family Foundation, 20 Aug. 2019, www.kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing/. 

[3] Ku, Leighton, and Matthew Broaddus. “Public And Private Health Insurance: Stacking Up The Costs.” Health Affairs, vol. 27, no. 1, 2008, doi:10.1377/hlthaff.27.4.w318. 

[4] “Health Care Almanac.” CHCF, May 2019, www.chcf.org/wp-content/uploads/2019/05/HealthCareCostsAlmanac2019.pdf. 

[5] Shafrin, Jason. “What Should Be Covered by Government vs. Private Insurance?” Healthcare Economist, 20 Aug. 2018, www.healthcare-economist.com/2018/08/20/what-should-be-covered-by-government-vs-private-insurance/. 

[6] Carrns, Ann. “It’s Enrollment Time for Obamacare.” The New York Times, The New York Times, 22 Nov. 2019, www.nytimes.com/2019/11/22/business/obamacare-enrollment.html. 

[7] Qiu, Linda. “Examining Conflicting Claims About ‘Medicare for All’.” The New York Times, The New York Times, 9 Nov. 2019, www.nytimes.com/2019/11/09/us/politics/medicare-for-all-fact-check.html. 

[8] Herzlinger, Regina, and Richard Boxer. “The Case for the Public Option Over Medicare for All.” Harvard Business Review, Harvard Business School Publishing, 10 Oct. 2019, hbr.org/2019/10/the-case-for-the-public-option-over-medicare-for-all.  

One of the anesthesia provider’s main roles is to administer anesthetic and analgesic drugs before, during and after a procedure.¹ This delivery can occur via a variety of routes, including—but not limited to—orally; through intravenous, epidural or intramuscular injection; or through inhalation.^2,3 For continuous medication infusion, an anesthesiology professional may use large-volume, patient-controlled analgesia (PCA), elastomeric, syringe, enteral and insulin pumps.⁴ Some newer infusion pumps, known as “smart pumps,” alert the provider when there is a risk of adverse drug interaction or when the pump is set to deliver doses outside of safety limits.⁴ In order to provide the best care to their patients, anesthesia providers should be familiar with the technology behind smart infusion pumps and recent data on their efficacy. 

In general, infusion pumps offer advantages over manual fluid administration, as they can provide medicines in very small volumes and at precisely programmed or automated rates.⁴ Smart infusion pumps in particular include technologies that allow the provider to choose the desired medication from an approved list and input the patient’s information, after which the smart pump calculates the infusion rate.⁵ These pumps have drug libraries, which contain the most commonly used intravenous medications, and dose error reduction systems (DERSs), which alert the clinician if the calculated infusion rate exceeds normally acceptable dosing limits.⁵ Hard dose limits prevent the clinician from starting the programmed infusion, while soft dose limits provide a warning that the dose may be out of range but allow the clinician to start the infusion after the warning is acknowledged.⁵ Drug libraries can be tailored and may vary among certain contexts, such as the intensive care unit or operating room.⁶ Because of their perceived benefits, the use of smart infusion pumps has become widespread in recent years.⁷ A survey study by the American Society of Health-System Pharmacists (ASHP) found that the percentage of United States hospitals using smart infusion pumps grew from 44 to 72.9 percent from 2007 to 2013.⁷ Evidently, smart infusion pumps allow for efficient and precise delivery of anesthetic drugs. 

Recent studies on smart infusion pumps and their use show the advantages and disadvantages of integrating them into anesthesia care. For example, Keohane et al.’s paper emphasizes the potential for smart infusion pumps to avert high-risk dosing errors and provide data for continuous quality improvement efforts.⁸ A survey study by Schroeder et al. found a relatively high level of acceptance of a smart intravenous infusion pump by anesthesia providers, which was related to frequency of pump use.⁹ Another study by Eskew et al. found that in a three-month period of 135 smart pumps, providers received 693 alert messages, 22.8 percent of which led the providers to make a programming change.¹⁰ In Wilson and Sullivan’s study, a smart infusion pump prevented errors involving heparin, an anticoagulant drug, and the technology was easy to implement.¹¹ Furthermore, Maddox et al. found that use of a smart infusion pump for PCA prevented respiratory depression.¹² Nonetheless, many researchers state that smart infusion pumps have failed to live up to their potential.¹³ According to the United States Food and Drug Administration (FDA), infusion pumps in general are accompanied by problems related to software defects, user interface issues and mechanical or electrical failures.⁴ Evidence on the smart infusion pump’s role in harm reduction remains limited, perhaps due to poor design, programming errors, lack of end-user acceptance and unpredictable nature.¹³ Common sources of error when using the smart infusion pump include manually bypassing drug libraries and DERSs or overriding dose error alerts.⁵ Indeed, several studies have found that soft limits are relatively ineffective because they are easily overridden.^6,14 Also, clinicians may inadvertently program an incorrect dose, resulting in potentially catastrophic consequences.⁶ Though smart infusion pumps may help anesthesia providers with medication administration and dosing, they are unpredictable and may be used improperly. 

Anesthesia providers commonly use infusion pumps to provide a patient with medication or other fluids. Smart infusion pumps include technologies such as drug libraries and DERSs, which allow clinicians to efficiently select medications and make changes when dosing may be incorrect. Although smart infusion pumps are highly useful in allowing precise medication delivery and preventing mistakes, they are subject to technical issues and misuse by clinicians. Research suggests that future smart infusion pumps would benefit from iterative user-centered design, network and real-time monitoring of alerts, upgraded and standardized drug libraries, decreased number of unnecessary warnings and minimized workaround opportunities.^13,14 

1. American Society of Anesthesiologists. Role of Physician Anesthesiologist. When Seconds Count… Physician Anesthesiologists Save Lives 2020; https://www.asahq.org/whensecondscount/anesthesia-101/role-of-physician-anesthesiologist/. 

2. American Society of Anesthesiologists. Types of Anesthesia. When Seconds Count… Physician Anesthesiologists Save Lives 2020; https://www.asahq.org/whensecondscount/anesthesia-101/types-of-anesthesia/. 

3. Garimella V, Cellini C. Postoperative pain control. Clinics in Colon and Rectal Surgery. 2013;26(3):191–196. 

4. United States Food and Drug Administration. Infusion Pumps. General Hospital Devices and Supplies August 22, 2018; https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/infusion-pumps. 

5. Giuliano KK. IV Smart Pumps: The Impact of a Simplified User Interface on Clinical Use. Biomedical Instrumentation & Technology. 2015;Suppl:13–21. 

6. Cummings K, McGowan R. “Smart” infusion pumps are selectively intelligent. Nursing2020. 2011;41(3):58–59. 

7. Fox BI, Pedersen CA, Gumpper KF. ASHP national survey on informatics: assessment of the adoption and use of pharmacy informatics in U.S. hospitals-2013. American Journal of Health-System Pharmacy. 2015;72(8):636–655. 

8. Keohane CA, Hayes J, Saniuk C, Rothschild JM, Bates DW. Intravenous medication safety and smart infusion systems: Lessons learned and future opportunities. Journal of Infusion Nursing. 2005;28(5):321–328. 

9. Schroeder ME, Carayon P, Li Q. Anesthesia Providers’ Perceptions of Smart IV Infusion Pumps. Anesthesiology. 2005;103:A887. 

10. Eskew JA, Jacobi J, Buss WF, Warhurst HM, Debord CL. Using Innovative Technologies to Set New Safety Standards for the Infusion of Intravenous Medications. Hospital Pharmacy. 2002;37(11):1179–1189. 

11. Wilson K, Sullivan M. Preventing medication errors with smart infusion technology. American Journal of Health-System Pharmacy. 2004;61(2):177–183. 

12. Maddox RR, Oglesby H, Williams CK, Fields M, Danello S. Continuous Respiratory Monitoring and a “Smart” Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 4: Technology and Medication Safety). Rockville, MD: Agency for Healthcare Research and Quality (US); August 2008. 

13. Scanlon M. The Role of “Smart” Infusion Pumps in Patient Safety. Pediatric Clinics. 2012;59(6):1257–1267. 

14. Ohashi K, Dalleur O, Dykes PC, Bates DW. Benefits and risks of using smart pumps to reduce medication error rates: A systematic review. Drug Safety. 2014;37(12):1011–1020.