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Clinical Case for Discussion: You are appointed Chairman of Anesthesia at an acute-care California community hospital. The hospital administrator offers you a stipend to support the anesthesia care for his medical center, but it will be up to you to determine how to staff your operating rooms in the most cost-effective, safe, and efficient manner. What do you do?
Discussion: What will the future of anesthesia manpower and staffing in California look like? Will you be supervising an infantry of nurse anesthetists? Will you become the employee of another anesthesiologist who is your Medical Director? Let’s stroke the crystal ball:
In the Rovenstine lecture published in the May 2006 issue of Anesthesiology, Mark Warner, M.D. (ASA President-elect for 2010) wrote, “Do we really need our best and brightest physicians to sedate and monitor patients undergoing cataract procedures when these patients have only an infinitesimal risk of developing a life-threatening problem intraoperatively? Do we need them to deliver one-on-one care to healthy 20-year-olds who need general anesthetics for simple surgical procedures such as herniorrhaphies and peripheral orthopedic procedures? . . . There will be too few anesthesiologists, as well as insufficient funds to pay for such physician-intensive care. Further, there are no studies to suggest the need for physicians to personally deliver care to healthy patients undergoing minimally invasive procedures. As proven in a number of diverse practice models and in our intensive care units daily, physician oversight or supervision of well-trained sedation and critical care nurses, nurse anesthetists, and anesthesiologist assistants is a remarkably safe, efficient, and cost effective model for delivering care to appropriately selected patients. . . . We have truly outstanding anesthesiologists who provide terrific care in intensive care units across this country. None of them—not a single one of them—are assigned to provide one-on-one care to even the most critically ill patients in these units.”
On Friday March 20, 2009, the California Society of Anesthesiologists sponsored the first-ever meeting of the California anesthesia residency program directors, where representatives from all 11 anesthesia training programs in the state (UCSF, Stanford, UCLA, UCSD, San Diego Naval Hospital, UC Irvine, Harbor, Cedars-Sinai, USC, Loma Linda, and UC Davis) met at UCLA. A portion of the meeting focused on likely changes in anesthetic practice over the next three decades, and how to best train the newest generation of anesthesiology residents to prepare for that future.
Michael Champeau, at that time the President of the California Society of Anesthesiologists and Adjunct Professor of Anesthesia at Stanford, attended the UCLA meeting. According to Dr. Champeau, “the meeting attendees overwhelmingly felt that in order to remain economically viable in the changing health care world, anesthesiologists needed to expand the scope of services they provide beyond traditional one-on-one physician administered OR anesthesia to encompass the entire scope of perioperative medicine.”
Per Dr. Champeau, the program directors believed that the future of anesthesia will include a tiered spectrum of models of anesthesia care staffing ranging from a one-anesthesiologist-per-one-patient model for complex surgeries or complex patients down to one anesthesiologist supervising multiple nurse anesthetists (or Anesthesiologist’s Assistants, should they become licensed in California) for straightforward surgeries on healthy patients. He emphasized that the CSA was certainly not promoting the expansion of the anesthesia care team model, but rather simply bringing the leaders of the anesthesia residency training programs in California together, listening to their thoughts about the future of the specialty, and drawing attention to the likely economic consequences of the anticipated changes in modes of practice. The program directors believed that expertise in preoperative evaluation and optimization, risk stratification, operating room and perioperative team leadership, postoperative pain management and intensive care would be skills required for the anesthesiologist of the future.
While one-anesthesiologist-per-case staffing is currently the predominant model in California, Dr. Champeau went on to say that many groups might be only one entrepreneurial physician and one forward-thinking administrator away from changing to a tiered care model utilizing anesthesia care teams. Per data presented at the 2009 American Society of Anesthesia Conference on Practice Management, between 60-70% of anesthesia groups in the country are supported by a hospital stipend subsidy. If utilizing the anesthesia care team model costs less than an all-physician model for anesthesia care, there may be increasing pressure in the upcoming years for utilizing anesthesia care teams.
In the U.S., solo M.D. practitioners deliver 35% of the anesthetics, anesthesia care teams with anesthesiologists medically directing Anesthesiologist Assistants or CRNAs deliver 55% of the anesthetics, and CRNAs in solo practice deliver 10% of the anesthetics. The anesthesia care team model is less common in California, partly because the supply of anesthesiologists in California is sufficient to staff most cases without CRNAs.
The Kaiser system in California utilizes the anesthesia care team model. David Newswanger, M.D., the Chairman of Anesthesia at Kaiser Santa Clara, told me the following key facts about his department: His anesthesia staff includes 21 anesthesiologists in the general O.R., 7 anesthesiologists in the cardiac O.R., and 29 CRNA’s. This staff covers 19 O.R.’s in three locations. In the Ambulatory Surgery Center and in the Eye Center, 90% of the cases are done by CRNA’s supervised in a 4:1 or 3:1 CRNA:anesthesiologist ratio. In the main O.R., anesthesiologists working alone cover 50% of the cases (more complex cases such as abdominal aortic aneurysms or thoracic cases), and supervised CRNA’s cover the other 50% of cases. Kaiser has a system for assessing which patients are appropriate for an anesthesia care team and which need a solo anesthesiologist. A Preoperative Clinic team of 7 Nurse Practitioners screens 35% of pre-surgery patients, an MD anesthesiologist examines 5%, and medical assistants interview the remaining 60% by telephone and fill out standardized, preoperative questionnaires.
Back to our clinical case from the beginning of the column: (1) Would you hire both MDs and CRNAs, utilizing the anesthesia care team model? (2) Would you hire anesthesiologist employees and pay them the lowest salary you possibly could? (3) Would you assemble a team of anesthesiologists as equal partners?
Regarding the Kaiser CRNA anesthesia care team model, for a small hospital the start-up costs for staffing a pre-operative clinic and hiring enough anesthesiologists to cover all the night call may not leave any cost savings. According to Dr. Newswanger, in the capitated Kaiser model a CRNA is equivalent to 2/3 of an anesthesiologist when it comes to the economics of O.R. staffing. That is, if he staffs his O.R.’s at a 3:1 ratio of CRNA:anesthesiologist, it’s a break-even point (1 + 3 X 2/3 = 3 M.D. equivalents for 3 O.R.s), whereas a 4:1 ratio is a money-saving staffing scenario (1 + 4 X 2/3 = 3 2/3 M.D. equivalents for 4 O.R.s). In a fee-for-service practice, these numbers may be different, depending on the payer-mix of the patients.
Regarding the second option, a Medical Director anesthesiologist employing a team of lower-paid anesthesiologist employees, a central issue is that most anesthesiologists shun lower paying positions, and these hospital departments may be doomed to understaffing and high turnover. The third option, assembling a team of equal-partner anesthesiologists, avoids these problems but may be less cost-effective.
There are specific concerns in staffing out-of-hospital surgery centers and office-based anesthetic locations. I currently work in a one-anesthesiologist-per-patient private practice in which 15% of our cases are done in locations where there is only one operating room in a surgery center or a plastic surgery center. In these settings, there is be no cost saving to having both an M.D. and a CRNA present to do the anesthetic, and a solo anesthesiologist-per-patient seems the likely staffing model. The question regarding the safety of replacing that solo anesthesiologist with a solo CRNA is a heated and separate issue that will not be discussed in this column.
The crystal ball is murky, and no one knows if the anesthesia care team model will turn out to be a dominant form of practice in California. While the specifics of future anesthesia care staffing in California are uncertain, I am optimistic that the future will involve vigilant, high quality perioperative medicine, led by physician anesthesiologists.
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