In a July 1, 2010 article on Becker’s ASC Review, American Society of Anesthesiologist President Alexander A. Hannenberg MD, responded to a recently published study by the Lewin Group in the Journal of Nursing Economics regarding the Cost Effectiveness of Anesthesia Providers. Juan Quintana, a Certified Registered Nurse Anesthetist offers this analysis of Dr. Hannenberg’s perspective.
As I read Dr. Hannenberg’s responses I wasn’t particularly surprised. I don’t actually feel we need to refute each and every response. The data from the survey speaks for itself. However; given the information presented here are some thoughts.
The Lewin Group’s study focused on a comparison in cost effectiveness and efficiency between two anesthesia providers in the provision of anesthesia services in the USA. The characteristics listed underwent literature review and study using claims data which included: Education: Costs – Direct and Indirect and Timeframe, Quality: In Anesthesia services today, Practice Models: Derived from Simulations and Claims Data and Access to healthcare services.
1. Dr. Hannenberg doesn’t argue that we are more cost effective in his first statement he simply infers that anesthesiologists bring a value added component to the table. The real question in each and every one who reads this should be, ”Is the value added component worth twice the cost of anesthesia services and can the anesthesiologists show reimbursement to offset his cost?”
After hours fees and call services are eliminated if CRNAs are treated like professionals instead of clock punchers. He falsely represent this as solely an anesthesiologists service. Given the opportunity to earn in terms of productivity many CRNAs would alter their payment methodology.
2. Hannenberg goes on to say that the outcomes are invalid because the available literature related to “solo” CRNAs is limited and they types of cases are less difficult in areas done by CRNAs. However, the Lewin group did not approach the issue of which provider did what and where. Instead the Lewin group focused on ALL claims in which complications or mortality were indicated by modifiers in hospital claims records. The literature clearly shows no difference and the claims supported very little complication /mortality rate. The incidence of complication and mortality were so low that the only inference was that very good quality anesthesia is provided by both providers. Any other attempt to justify one providers services as better than another are without merit.
3. The surgeon is responsible for the surgical procedure. The anesthesia provider is responsible for the anesthetic. The surgeon in non-Opt Out states must “supervise” the CRNA to meet the Conditions of Participation, Part A Medicare regs. However, the definition of supervision has never been provided. In some states the surgeon meets his/her responsibility by simply writing an order, “Anesthesia per CRNA.” The CRNA equipped with his/her educational frame of reference then provides anesthesia. How this translates into the surgeon doing anything associated with the anesthetic remains to be proven. We discuss anesthetic needs with the surgeon, just like the anesthesiologist then we provide the best, safest anesthetic we can for the patient. Anesthesiologists should quit hiding behind the idea that a physician must be integrally involved in anesthesia and instead prove it!!
4. Anesthesiologists consult with specialists frequently. I am currently unaware of any studies indicating CRNAs utilize more consultations with specialists than Anesthesiologists, though I would like to see if them if they are available.
Hannenberg fails to see the forest for the trees. Yes the cost to the patient would be the same if a CRNA or Anesthesiologists provided the anesthesia but the cost to the healthcare system is at least twice the cost when retaining an Anesthesiologist, due to their salary. The facility bears the burden of paying stipends since the anesthesiologists alone cannot cover their salary administering anesthesia for Medicare patients. The study shows that in variable volume the only practice model that consistently successfully meets it’s cost is the CRNA only model.
5. Studies have shown that Anesthesiologists work more hours than CRNAs. Once again Dr. Hannenberg ignores the obvious. If broken down to an hourly rate, the cost to retain a CRNA would still be less than to retain an anesthesiologist. In an anesthesia department the reduction in Anesthesiologists hours of service and direct reduction in salary would never balance the increase in cost to have a CRNA provide the services. The CRNA would be the better more cost effective choice.
Hannenberg goes on to say that Anesthesiologists have more education and responsibility. I agree that Anesthesiologists spend more time gaining their education but to what end. The cost from start to finish of an anesthesiologists is approximately $1,000,000.00 (1million) dollars while an average cost to educate a CRNA is $160,000.00 (160k). Under these circumstances one would expect a HUGE difference in outcomes and quality, NOT a slight or even non-existent difference in outcomes. These numbers suggest an overqualified provider – the anesthesiologist practicing in a field (nursing) where his/her skill set is not required.
6. Hannenberg lost his train of thought. :O) The Lewin group simply noted minimum time frames for CRNA education and Anesthesiologist education, it’s not rocket science. The Ingenix data base was scrutinized for various reasons however any variations in numbers would have affected both anesthesia providers equally.
7. On this point I will agree with Hannenberg, patients do request anesthesiologists more frequently.. but I disagree that they prefer anesthesiologists. I have functioned in rural NE Texas for 12 years. The patients will request me and know me YET, they often refer to me as their anesthesiologist. It is a matter of semantics.
I realize most of you already know this information, sometimes it just helps to really spell out.
This reflects my opinion on the statements made by Dr. Hannenberg and my interpretation of the information I reviewed in the Lewin Groups study.
Juan F. Quintana CRNA, DNP
SLEEPY ANESTHESIA ASSOCIATES PLLC
Office: 903-725-3595 Fx: 903-725-3599
