A non-traditional CRNA

Those of you familiar with the various CRNA listservers have been exposed to the opinions of Barry Cranfill, CRNA,MBA. His opinions, though not always popular, certainly invoke many responses, which makes Barry the perfect candidate for a CRNAbiz profile...

Barry, I know from reading your posts that you are a CRNA, a business owner, a pilot with a military background and that you have an MBA. Would you take a few moments and elaborate on your background and education ?

 Well, my family has decided that I just have never really decided what I wanted to be when I grew up. My route, to this point, has certainly been less than direct. I started off my early collegiate career as a music major with a concentration in piano performance. I worked as a piano instructor at the local music store, played piano at church and a few other less moral establishments and spent my summers working as a lifeguard. I used all my money to learn to fly at the local airport. The lifeguard work led to a course as an Emergency Medical Technician and a night job at Grady Memorial Hospital in Atlanta, driving the ambulance while finishing my paramedic program in the early 80’s...

I reported to Fort Rucker Alabama for Primary flight training, graduated and spent the next several years flying a variety of aircraft all over the world in less than optimal flight conditions while providing target practice for some of our unfriendly global neighbors. At least I got to shoot back! I returned from Desert Storm and was unfortunately diagnosed with Hepatitis C (exposed from my Grady Hospital ambulance days) and grounded. Thankfully, I have since been declared a “cure” as a result of my treatments and I was eventually placed back on full flying status with no restrictions. But, at the time, with no idea how I would respond to the treatment, I left the cockpit and the military and applied to the Medical University of South Carolina anesthesia program.

The director accepted me despite her worries about my non traditional nursing education and I hope I made her proud. In school, I begged for extra assignments to the Navy Hospital, the VA and the local community hospital where CRNAs worked independently. I knew what type of practitioner I wanted to be! Additionally, at the time, MUSC graduated folks with an Master in Health Sciences (not nursing) and the core MHS graduate program included health care administration type courses.

I graduated from MUSC and held a variety of positions…and I learned from all of them. I read voraciously to understand the anesthesia industry and I asked questions all the time about reimbursement and business models. I still had some VA education money left over so I enrolled in a local Executive MBA program. It was a “case based” program that required immediate application of the learned principles in case studies and projects. After graduation, I left the comfort of the employed world and started my own consulting and staffing company. This led to various contacts and I eventually joined an existing CRNA only group as a principal.

Our group is unique. We have three separate companies. A billing and management company Sentry Anesthesia Management, LLC (owned by CRNAs) that holds the facility contracts and contractually handles the daily “business management” of our two clinical entities: Southern Crescent Anesthesiology (owned by the Anesthesiologists) and Southern Crescent Nurse Anesthesia (owned by the CRNAs). Currently, we provide anesthesia for over a dozen surgical facilities to include Community Hospitals and Ambulatory Surgery Centers. And we are growing. We currently get approximately one Request for Proposal (RFP) each month. But we have decided to adopt a strategy of “controlled” growth so that we can ensure our level of quality. Thus we add two or three facilities each year.

Why Nurse Anesthesia ? You don't necessarily fit the profile of a typical CRNA.

Had I not been grounded temporarily, I would probably still be in the Army wearing a flight suit and spitting sand out of my teeth. But my dad (a lifelong Lockheed employee) told me to always have a plan B because the aviation industry was so volatile. Nursing WAS my plan B…but it became plan A when I left the military. Had I not been accepted into an anesthesia program I would have returned to the aviation industry as a pilot, educator or engineer. When I was again cleared for full flying duties, I did consider returning full time to the cockpit professionally. But I saw all of my colleagues flying in the airlines, getting furloughed and struggling to get the all important seniority punches, and I decided I would prefer a career where I could control my own destiny.

And I like anesthesia. It is one on one care, you devote 100% of your attention to that one patient, it is hands on, highly technical, and there is an art to doing it properly. Many folks compare anesthesia to flying and I guess it does have some parallels….with one huge difference: If you screw up an anesthetic you kill your patient. If you screw up a flight, you kill yourself, your passengers and untold numbers of folks on the ground.

Additionally, in our practice, we work independently. If I have a good day or a bad day, I have only one person I can blame…me. As an owner of the practice, I get the opportunity to grow the business and determine my own destiny.

Traditionally Nurse Anesthetists, perhaps because of our nursing background, have left the "business of anesthesia" to others - usually hospital administrators or anesthesiologists. Contrary to this tradition, you have ventured off into the business end of our profession. What sent you along this path ?

Independence. My psyche won’t allow me to participate in something that I don’t understand from all angles. I cannot imagine working in an industry of any type without knowing ALL that I can know about every aspect of the business to include how that business makes money and how that industry’s products could be adapted to better meet the needs of the stake-holders. Maybe it is the aviation and engineering background. Maybe it is the military leadership and combat experience that forces me to look at things strategically. In any case, I tend to be a bit obsessive compulsive about my interests.

Plus, if you intend to be independent…and I cannot imagine any other scenario for myself… you MUST understand the business aspects of our profession.

How does your business background make you a better or more valuable CRNA ?

A better question is “How does an understanding of business, economics, strategic management, marketing, organizational behavior, finance, accounting and human resources make ANY person (owner, or employee) more valuable in ANY industry?” Whether you are flipping burgers at Wendy’s, leading troops into hostile situations, building aircraft, running a church, playing in a band or teaching school…knowledge, expertise and experience in these areas will make you better at what you are doing. CRNA practice is no different. Nothing happens in a vacuum, yet many CRNAs want to just “do anesthesia” and not be bothered by the hassles of “business.” They are content to just understand the clinical job and leave all else to other folks.

What advice do you have for Nurse Anesthesia students and other CRNAs, regarding developing an understanding or appreciation for the business side of healthcare ?

First, do what you love. That way you will be inclined to research and fully actualize your potential because you are motivated. Second, know that if you fail to know all that you can know about your industry, you are destined to mediocrity within that industry. Third, read, read, read. No one is going to hand you this stuff. In fact, the anesthesiologists want you in the dark. How can you really negotiate your salary if you have no idea of the value of your services? But most CRNAs have no idea how their services are billed for, much less how much revenue they generate. And even less fully understand the FULL cost of employing an individual. Without this data, you are negotiating from a position of weakness.

Finally, understand that there is no single course or book out there that will tell you all you need to know. There are books that will give you the “rote” knowledge that is needed about billing, reimbursement, employment, finance, accounting, etc. but that information only scratches the surface. Once you have this very basic “data” you have to know how to apply and adapt the information to your needs. That is where many fall short and quit. You have to explore how others have used the basic information in their industries (read, read, read) and apply those principles to your specific situation.

Most CRNAs are employed by a hospital or anesthesiology group in an anesthesia care team setting, what can they personally do to enhance the value they bring to the anesthesia care team ?

This would take a whole book to answer.

If you are an employed CRNA, it is your duty to maximize your employer’s revenue, minimize your employer’s expenses, maximize efficiencies, ensure the highest possible quality, provide exceptional customer service and exceed the expectations of all of your employer’s stake-holders. But without basic business knowledge and acumen, you are ill prepared to provide this level of service to your employer. You will just be a “clinician.”

Patient care is always the first priority, but many clinicians stop there. Remember, the patients’ families, the facilities, the surgeons, the insurers and your employer (facility or group) all have needs and expectations. Don’t ignore these stake-holders. Take the time to explore what each of these players want and WHY they want it. The key is in the “why.” Remember that many will have opposing drivers and motivations, and understanding “why” will help you find solutions that are “win, win” for all concerned.

If an administrator or anesthesiologist sought your advice on developing the optimum anesthesia service in our current reimbursement environment, what would be your suggestions ?

Well this happens on a regular basis with our consulting service and the answer is never the really the same. No one size fits all, and every site has its own financial, operational and political issues. The key to finding the “optimum anesthesia service” lies in the initial needs analysis of the site and balancing all of these issues for the specific site.

Let me begin by saying that the expected response from me is to push the CRNA only or non medically directed CRNA model to all clients. Although this does provide the greatest number of anesthesia providers for the lowest cost, other factors play into the equation. Existing reimbursement contracts may cut the expected revenue in these models below the margin gained by the decreased cost of the providers. Thus, it is vital to look at each site individually.

Here are the steps that I take when analyzing a practice:

First, the “current reimbursement environment” varies wildly across the nation and from site to site within the same community. Some facilities and/or groups have good payer contracts, some not so good. Some have good payer mix ratios, some do not. Therefore, a proper economic analysis of expected revenue at the site is the best place to start, because the client (facility or group) cannot determine what it can afford to offer as a service without this information. So the first step is an analysis of the current professional anesthesia reimbursement that can be expected from the site. Once you know how much money you have, you know what you can afford to buy.

Next, the operational constraints have to be closely examined to determine the number of daily anesthetizing locations that a facility needs all day, every day. Notice, I did not say what the facility wants…I said what the facility needs. Assuming proper OR utilization and scheduling, how many ORs should be run for how many hours to cover the current case load? Also consider the same for special services such as OB, ER, code coverage etc. Then ask the facility how many anesthetizing locations they “want.” Facilities always want more than they need. But remember, they may “want” more because they know that their other stake-holders (surgeons and patients) may demand access to anesthesia at times that do not make economic sense, but the facility recognizes that strategically, they should offer the access in order to keep their customers.

Third, the political environment must be examined. Health care facilities and the players that work in them are creatures of habit. That does not mean they cannot be changed, but it doesn’t typically happen overnight. Organizational behavior (a business subject) is a science of its own so one has to respect the current organizational environment and culture when examining the best “practice solution” for a given site. Know which players wield the power and which players do not. Know who makes the decisions and who “thinks” they make the decision. Additionally, know that you cannot pound a square peg into a round hole. If the political environment demands a specific anesthesia staffing pattern, then understand that you may have difficulty changing the practice initially.

Once all this data is obtained, the work begins. I devise a financial pro forma of several different practice and staffing options and let the customer pick what they want. The revenue data for the various options is calculated by our exceptionally talented billing personnel and the expense data is benchmarked and compared to the Medical Group Management Association Compensation and Cost Surveys for the specific region.

I typically offer four different staffing options: MD only, CRNA only, 1:4 staffing of a Medically Directed Anesthesia Care Team, and a “Collaborative” Anesthesia Care Team that bills the CRNA services as non medically directed in ratios greater than 1:4. The pro forma data are provided for the “needed” facility staffing and the “wanted” facility staffing. The data is all there to determine the cheapest and the most expensive way to provide the service…including whether or not the site needs facility subsidization for certain staffing options.

Then the client(s) have all they need to make their own decision within their own financial, operational and political environment.

Finally, after deciding the staffing pattern, the next step is determining how to structure the contract between the facility and the providers to ensure that all the economic drivers are properly aligned. This is the toughest part of the whole process!

This answer is probably more than you really wanted to know, but the key is, that no one size fits all.

Thank you Barry, I appreciate the dynamics you bring to discussions, whether or not I agree with them all.

Thank you for allowing me to participate in your fine forum. I am certain that your work with CRNABIZ has helped countless CRNAs to be better, full service practitioners and I am grateful for your hard work and dedication.