You seem to have a grasp of some of the theoretical pitfalls of the AA field. A point that I think is important to focus on is the fact that if they do become the anesthesia “midlevel” provider of choice, that opens up a new set of pitfalls for them. If they muscle out CRNAs, then they are screwed, because then they will get paid what the market allows, and that becomes problematic if they don’t have CRNAs out there driving wages higher by competition with physicians. If they latch themselves too tightly to the physician bandwagon, then they have to leave the party WITH the physicians if the physicians lose out to CRNAs. Here’s a case study.... Anesthesioligists take on only AAs to work under them in a group, and they bid for a contract at a surgical center. Each Anesthesiologist can supervise 4 AAs. The bid provides $400,000 salary for the MD, and $150,000 salary for the AAs. That’s a total of $1,000,000. They compete against a group with 5 CRNAs that make $150,000 each, for a total of $750,000. Who gets their pay cut in the Anestesiologist led group to make the bid more competitive? The AAs start making $90,000 and the physician makes $390,000 per year, and that puts them at the same rate as 5 CRNAs. Or the hospital decides that it’s better for the money to have 5 CRNAs tat can work unsupervised for call, and go with them.
The point of the above exercise is that there could be unintended consequences of AAs becoming the choice provider of MDs. And it might even make Md groups even more uncompetitive if they latch on to that idea and try to work against CRNAs because they are “competing for jobs”.
As for why AAs make around what CRNAs do, the answer is because nobody has gotten around to screwing them over yet, and folks still believe in the adage that you get what you pay for, and they know that CRNAs work out well for the relatively high price, so nothing has been tinkered with yet.
Another thing about AAs is liability. When one messes up (or is accused of messing up), a lawyer is more excited about it because they can go after the big money physician for not “supervising” as well as they think they should have. CRNAs, not so much. If you think that won’t be an issue over time, you aren’t paying attention to the fact that PA malpractice insurance is around $7,000 per year vs $1000 to $1500 for NPs. That’s that way for the same reason.... PA mistakes can easily lead to a physician being roped into the lawsuit, and physicians are insured well, and tend to make much more money.
I always get a kick out of folks that live together and don’t get married because a marriage license is “just a piece of paper”. Well if it is just a piece of paper, then why not get one so you can reap the rewards and enjoy the protection that one provides. Likewise, if AAs were interchangable with CRNAs, then why would independence be valuable? Because it just is. When you need it, then nothing else will do. Every place where a CRNA or an NP lobby wants to expand independence for their patrons, they can point to almost half of all states and say “look at how well it’s working in those places.” AAs and PAs aren’t independent anywhere, and can’t say the same. And in states where they aren’t present, they won’t make up ground because the nurse lobby will halt them in their tracks by pointing to CRNA oversaturation.
I don’t disdain AAs or PAs, and personally considered both of those fields for myself. I would have gotten into those field a lot easier than the roundabout way I’ve taken to become an NP. But the reason I took that route to NP is because I looked carefully at the fundamentals of the industry and where it was headed, as well as the freedom I wanted to have professionally. I probably would have loved to be an AA, and appreciated the fact that I could have accomplished that goal in 2 years, but I don’t want to be at the mercy of trends that I can’t control. If the market pushes AAs into $90,000 per year territory, then they just have to oblige because they are dependent providers. Everything they have going for them is a gift that is contingent on someone else allowing them to practice. They have no real safe haven. To practice in my state would require them begging for a foothold, and that just isn’t going to be provided to them.
There is the possibility that he market won’t sway towards cost savings, and AAs will go ahead and become the midlevel of choice for anesthesiologists who feel disaffected. And maybe AAs will continue to make good wages under the authority of their physicians....but you have yourself why. If the world is bending to the will of greater cost savings and efficiency, why wouldn’t AAs be the canary in the coal mine? Do you think that CRNA groups won’t be better positioned to adapt to lower bids by anesthesiologist led groups? How will AAs stand up to MDs when MDs start paying AAs less? They aren’t as mobile as CRNAs, and they form a much smaller community. They will have to take the lower wages that are offered. But the groups that employ them will still have to deal with being underbid by CRNAs. And with an oversupply of CRNAs coming over the next decade, CRNAs will have the upper hand. The more CRNAs out there, the lower the wage offers that CRNAs will take. That will mean they will become the more appealing providers due to cost savings. So in my case study, CRNA groups could make themselves even more appealing by taking $140,000 salaries to underbid physician led groups. That’s a minor adjustment for a group of 5 CRNAs to make in order to beat out the 4 AAs and 1 MD group. But there is a point where an MD just won’t go lower, and it’s well beyond where they are willing to squeeze every penny from an AAs salary. And where would the AAs go if all the anesthesia groups are pulling the same trick on them?