Anesthesia Service: CRNAs and the Elephant in the Room
Some anesthesiologists suspect there is a conspiracy by duplicitous certified registered nurse anesthetists (CRNAs) to displace them and or disrupt the anesthesia care team model. There are culprits all right, but they are called capitalism, competition, and technology.
You can't blame anesthesia management companies ("AMCs") and physician practice management companies ("PPMCs") for acting like private equity companies because some are backed by bigger private equity companies. The process used by private equity firms large and small is something like this:
- Evaluation the process
- Improve the processes
- Cut costs (in anesthesia cases this almost always staff costs)
- Continue to improve process and reduce costs
- Provide a return to investors
In this process some workers, in this instance anesthesia professionals, have lost their jobs and some companies, in this instance anesthesia groups, have closed, but that my friends is what we call capitalism.
Good old All-American competition is a culprit too. If you haven't been paying attention, there has been a focus replacing physicians services with advanced practice nurses ("APNs") and physicians' assistants ("PAs"). In the anesthesia APNs are called CRNAs and PAs are called AAs. We can debate the studies done to compare the equivalency of the care provided by the physician centric vs extender centric models, but they must look pretty good to someone because the acceptance of the concept continues to grow. The role of the AMCs and PPMCs for anesthesia professionals seems to follow this slippery slope:
- anesthesiologist only practices (no CRNAs/AAs); become
- anesthesia care team model practices (fewer anesthesiologists, more CRNAs/AAs); become
- collaborative anesthesia practices (fewer and fewer anesthesiologists, more and more CRNAs/AAs); become
- CRNA only practices (no anesthesiologists); become
- anesthesia professional light practices (fewer anesthesiologists, CRNAs, AAs, and more technology)
If done properly, each rung down this later comes with lower staff costs. The effect on overall costs is unclear.
There is also the competition between larger groups and medical service organizations ("MSOs") to lower "back office costs" like billing, administration, human resources, and performance improvement. AMCs and PPMCs can have higher non-staff costs because of the need to provide a return to investor over and above administrative costs. Again, the overall effect on costs are unclear.
The another culprit is technology. Anesthesiologists have felt immune to replacement by other anesthesia professionals (CRNAs and AAs) because the presence of preoperative catastrophes required advanced airway and/or anesthesia skills possessed by anesthesiologists were needed for the best possible results. With the introduction of the
videolaryngoscopy,
ultrasound guidance, and improvements in monitoring as well as telecommunications, there is an assumption by some that CRNAs and/or AAs could replace anesthesiologists.
There is an
elephant in the room. Are CRNAs and AAs the winners? Not by a long shot. Who or what is being replaced in the “New World Order” should confuse no one. There will be continuing efforts to replace higher cost anesthesia professionals with lower cost staff or technology.
Take Home Points:
- The effect of private equity, competition, and technology is causing changes in the anesthesia.
- There will be continuing efforts to replace higher cost anesthesia professionals with lower cost staff or technology