TEN REASONS NURSE ANESTHETISTS (CRNAs) WILL BE A MAJOR FACTOR IN ANESTHESIA CARE IN THE 21ST CENTURY

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

 

My debut novel, The Doctor and Mr. Dylan features a nurse anesthetist in the starring role of Mr. Dylan. Nurse anesthetists have provided anesthesia care in the United States for nearly 150 years, and CRNs will be a major factor in the future.

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In the beginning, anesthesia care for surgical patients was often provided by trained nurses under the supervision of surgeons, until the establishment of anesthesiology as a medical specialty in the U.S. in the 20th century.

Here are 10 reasons why certified registered nurse anesthetists (CRNAs) will be a major factor in anesthesia care in the 21st century:

1. Rural America is dependent on CRNAs to staff surgery in small towns underserved by MD anesthesiologists. CRNAs are involved in providing anesthesia services to about one-quarter of the American population that resides in rural and frontier areas of this country. Despite a significant rise in the number of anesthesiologists in recent years, there is no evidence that they are attracted to practice in rural areas.
2. Obamacare will increase the demand for mid-level healthcare providers, e.g. nurse practitioners, physician assistants, and nurse anesthetists. These mid-level providers are perceived as a cheaper alternative to MD health care.
3. Seventeen states have opted out of the requirement for physician supervision of CRNA anesthetics. These states are Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, Montana, South Dakota, Wisconsin, California, Colorado, and Kentucky. In these states, it’s legal for a CRNA to give an anesthetic without a supervising anesthesiologist or surgeon.
4. For cost-saving reasons, hospital administrators will consider the lower hourly rate charged by CRNAs to be a saving over MD anesthesia care rendered by anesthesiologists alone.
5. Future trends such as the American Society of Anesthesiologists’ Perioperative Surgical Home or bundled payments to Accountable Care Organizations will seek out the cheapest way to manage anesthetic populations. A likely economic model for a healthy patient population is the anesthesia care team, e.g. a 4:1 ratio of four CRNAs supervised by one MD anesthesiologist. This model can be used to staff four simultaneous surgeries on four healthy patients having simple surgical procedures. More complex procedures such as open-heart surgery, brain surgery, major vascular surgery, or emergency surgery will be best served by MD anesthesia care. Extremes of age (e.g. neonates or very old patients) and patients with significant medical comorbidities will be best served by MD anesthesia care.
6. Certain regions of the United States, particularly the South and the Midwest, are already entrenched with anesthesia care team models of 3:1 or 4:1 CRNA:MD staffing because of anesthesiologist preference. An MD anesthesiologist’s income can be augmented by supervising three or four operating rooms with multiple CRNAs simultaneously. These physicians will have little desire to rid themselves of nurse anesthetists and to personally do only one case at a time by themselves.
7. The American Association of Nurse Anesthetists (AANA) presents a strong, well-funded lobby which promotes the continuing and increasing role of CRNAs in medical care in the United States.
8. The educational cost for a registered nurse to become a CRNA is significantly less than the cost of training a board-certified MD anesthesiologist. The median cost of a public CRNA program is $40,195 and the median cost of a private program is $60,941, with an overall median of $51,720.
9. A registered nurse can significantly increase their income by becoming a CRNA. A registered nurse with one year of intensive care unit or post-anesthesia care unit experience can become a CRNA with 2-3 years of CRNA schooling. The average yearly salary of a CRNA in America in 2011 was $156,642.
10. The increasing starring role of CRNAs in American fiction ☺. (See The Doctor and Mr. Dylan, below)

After perusing this list one might ask, are CRNAs and anesthesiologists equals?
No, they are not. Anesthesiologists are doctors, and their training of four years of medical school followed by a minimum of four years of anesthesia residency makes them specialists in all aspects of surgical medicine.

The American Society of Anesthesiologists’ STATEMENT ON THE ANESTHESIA CARE TEAM states “Anesthesiology is the practice of medicine including, but not limited to, preoperative patient evaluation, anesthetic planning, intraoperative and postoperative care and the management of systems and personnel that support these activities. In addition, anesthesiology includes perioperative consultation, the management of coexisting disease, the prevention and management of untoward perioperative patient conditions, the treatment of acute and chronic pain, and the practice of critical care medicine. This care is personally provided by or directed by the anesthesiologist.” (Approved by the ASA House of Delegates on October 26, 1982, and last amended on October 16, 2013)

Doctor J H Silber’s landmark study from the University of Pennsylvania documented that both 30-day mortality and failure-to-rescue rates were lower when anesthesia care was supervised by anesthesiologists, as opposed to anesthesia care by unsupervised nurse anesthetists. This study has been widely discussed. The CRNA community dismissed the conclusions, citing that the Silber study was a retrospective study. In a Letter to the Editor published in Anesthesiology, Dr. Bruce Kleinman wrote regarding the Silber data, “this study could not and does not address the key issue: can CRNAs practice independently?”

I’m not a fan of CRNAs working alone without physician supervision. In both my expert witness practice and in the expert witness practice of my anesthesia colleagues, we find multiple adverse outcomes related to acute anesthetic care carried out by non-anesthesiologists.

CRNAs will play a significant role in American healthcare in the future. That significant role will be best played with an MD anesthesiologist at their right hand.

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

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OBAMACARE AND ANESTHESIA

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Key questions in our specialty in 2014 related to Obamacare and anesthesia. This article was originally published in 2014, when Barack Obama was the President of the United States. A key question in our specialty at that time was “How will ObamaCare affect anesthesiology?” The following essay represents my thoughts as of 2014, prior to the Trump presidency.

I don’t have a crystal ball, but based on what I’ve read, what I’ve observed, and what I’m hearing from other physicians, these are my predictions on how ObamaCare will change anesthesia practice in the United States:

  1. There will be more patients waiting for surgery. Millions of new patients will have ObamaCare cards and coverage. A flawed premise of ObamaCare is that a system can cover more patients and yet spend less money.
  2. Reimbursement rates will be lower. How many anesthesiologists will sign up for Medicaid or Medicare-equivalent rates to care for patients? Large organizations such as university hospitals, Kaiser, Sutter, and other HMO-types will likely sign up for the best rate they can negotiate. As a result, their physicians will have increased patient numbers and lower reimbursement for their time. The insurance plans that patients purchase will have higher deductibles, and most patients will have to pay more out of pocket for their surgery and anesthesia. This will lead to patients delaying surgery, and shopping around to find the best value for their healthcare dollar.
  3. Less old anesthesiologists. Older anesthesiologists will retire early rather than work for markedly reduced pay.
  4. Less young anesthesiologists. The pipeline of new, young anesthesiologists will slow. Young men and women are unlikely to sign up for 4 years of medical school,  4 – 6 years of residency and fellowship, and an average of $150,000 of student debt if their income incentives are severely cut by ObamaCare.
  5. More certified nurse anesthetists (CRNAs). It seems apparent that ObamaCare is interested in employing cheaper providers of medical services. CRNAs will command lower salaries than anesthesiologists. The premise to be tested is whether CRNAs can provide the same care for less money. Expect to see wider use of anesthesia care teams and of independent CRNA practice. Expect the overall quality of anesthesia care to change as more CRNAs and less M.D.’s are employed.
  6. A two-tiered system. Anesthesiologists who have a choice will not sign up for reduced ObamaCare rates of reimbursement. Surgeons who have a choice will not sign up for reduced ObamaCare reimbursement. Expect a second tier of private pay medical care to exist, where patients will choose non-ObamaCare M.D.’s of their choice, and will pay these physicians whatever the physicians charge. This tier will provide higher service and shorter waiting times before surgery is performed. This tier will likely be populated by some of the finest surgeons–surgeons are unwilling to work for decreased wages. A subset of anesthesiologists will work in this upper tier of medical care, and these anesthesiologists will earn higher wages as a result.
  7. Will the Accountable Care Organization (ACO) model stumble as the Health Maintenance Organization (HMO) model did in the 1990’s? ObamaCare provides for the existence of ACO’s, which are hospital-physician entities designed to provide comprehensive health care to patients in return for bundled payments. In this model the surgeon, the anesthesiologist, and the hospital (i.e. nurses, pharmacy, and the medical device industry) will divide up the bundled surgical payment. In this model it’s essential that an anesthesiologist leader has a strong presence at the negotiating table. A worrisome issue with the ACO model, as it was with the HMO model, is the flow of money. Physicians will no longer be working for their patients, but will be working for the ACO. The  primary incentive will be to be paid by the ACO, rather than to provide the best care possible.
  8. Anesthesia leadership skills will change. The physician leader of each anesthesia group must be a powerful and effective politician and economic strategist. These traits are not taught during anesthesia residency, and these traits have nothing to do with being an outstanding clinician.
  9. What about the Perioperative Surgical Home (PSH)? The American Society of Anesthesiologists is proposing the model of the PSH, in which anesthesiologists will assume leadership roles managing patient care in the preoperative, intraoperative, and postoperative arenas. This is a desirable goal for our specialty. No physician is better equipped than an anesthesiologist to supervise patients safely through the perioperative period with the highest standards of quality and cost-control. The Perioperative Surgical Home is designed to work with the model of the Accountable Care Organization. How these systems of the Perioperative Surgical Home and the Accountable Care Organization will evolve remains to be seen. It will be the role for individual anesthesia physician leaders in each hospital to seize the new opportunities.  Rank and file anesthesiologists will likely follow their leadership.

10. Consolidation of anesthesia groups. Small anesthesia groups will likely merge into bigger groups in an effort dominate a clinical census, and therefore to negotiate higher reimbursement rates. In November, 2013, the 100-physician Medical Anesthesia Consultants Medical Group, Inc, of San Ramon, California was acquired by Sheridan Healthcare Inc, a 2,500-physician services company based in Florida. Per Sheridan’s CEO, John Carlyle, the acquisition “provides a platform that will accelerate our expansion in the California marketplace.” This was the largest merger in Northern California anesthesia history.

11. Requirement of more anesthesia clinical metrics. Government and insurance payors will require more metrics to document that the provided clinical care was excellence. A typical required metric may be a high percentage of patients who received preoperative antibiotics prior to incision, or a low percentage of patients free from postoperative nausea and vomiting. Each anesthesia groups will need to establish computerized data-capturing systems to present this information to payors. The effort to tabulate these metrics will be another incentive for anesthesia groups to merge into larger clinical entities.

In summary:  More patients, more cases, less money, more bureaucracy, less money, more CRNA providers, and less money. These are the challenges ObamaCare presents to anesthesiologists. Stay tuned. Legions of patients with ObamaCare cards will be knocking on hospital doors. The government is expecting enough anesthesiologists to sign up for ObamaCare contracts to make the new system successful. It’s impossible to tell what behaviors ObamaCare will incentivize. Each anesthesiologist has the benefit of 25+ years of education, and each anesthesiologist will make intelligent choices regarding their career and their time.

Bob Dylan once sang, “I ain’t gonna work on Maggie’s Farm no more.”

Time will tell if ObamaCare is Maggie’s Farm for physicians.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

*
*
*
*

Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited