That is the title of this month's Editorial in Anesthesia and Analgesia (September 2009 Volume 109, No. 3 page 695).
You must read this Editorial. It is only 4 pages long.
You must read this Editorial. It is only 4 pages long.
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"Their notable findings are a continuing desire to hire more anesthesiologists into academic practice and another increase in the subsidy from hospitals to anesthesia groups (now $109,000/year per faculty full-time equivalent [FTE]) simply to maintain the status quo in terms of filled faculty positions. The figure represents the difference between revenue per faculty FTE generated by the department and the cost per faculty FTE borne by these same academic departments. "
"The current commodity users of anesthesia services are ready for a solution that better meets their needs, and the products, technologies, and services that could provide this solution are already visible, albeit faintly."
"Anesthesiologists are expensive. The total annual cost of an academic anesthesiologist reported by Kheterpal et al. is $605,000. Academic programs are unable to generate enough revenue to cover this compensation, in part because academic surgical cases are long and ORs are not optimally utilized.10,11 An increase in the number of anesthetizing locations over the past decade means that the relative number of available providers decreases, and compensation must increase to ensure service. Of course, this scenario also motivates a search for less expensive alternatives."
" One does not need to look very far to see potential replacements"
"However, with sufficient incentive to alter the status quo plus a little luck, anesthesiologists' protected status can be altered by the stroke of a pen, as evidenced by the gubernatorial opt-out provision from physician supervision of nurse anesthetists, published in 2001. Cost, protectionism, and unmet needs provide the incentive for change"
"The current commodity users of anesthesia services are ready for a solution that better meets their needs, and the products, technologies, and services that could provide this solution are already visible, albeit faintly."
"Anesthesiologists are expensive. The total annual cost of an academic anesthesiologist reported by Kheterpal et al. is $605,000. Academic programs are unable to generate enough revenue to cover this compensation, in part because academic surgical cases are long and ORs are not optimally utilized.10,11 An increase in the number of anesthetizing locations over the past decade means that the relative number of available providers decreases, and compensation must increase to ensure service. Of course, this scenario also motivates a search for less expensive alternatives."
" One does not need to look very far to see potential replacements"
"However, with sufficient incentive to alter the status quo plus a little luck, anesthesiologists' protected status can be altered by the stroke of a pen, as evidenced by the gubernatorial opt-out provision from physician supervision of nurse anesthetists, published in 2001. Cost, protectionism, and unmet needs provide the incentive for change"
"This is an opportunity to leverage technology to become more efficient in our use of personnel and their intellect. Seizing this opportunity implies that we should regard technologies, such as anesthesia information management systems, decision support tools, closed-loop control for drug administration, as well as new care team models as the topics of enthusiastic research and development. Choosing this course moves OR and procedure room anesthesiology closer to the model used in intensive care units, where anesthesiologists assure that care is provided, but only personally provide care when their unique skills cannot be replaced."
Editorial- A&A Sept. 2009
Editorial- A&A Sept. 2009
Do you think anyone in academia is reading SDN?👍
I am glad to have them on board even if we don't always see eye to eye on all the issues.
I am glad to have them on board even if we don't always see eye to eye on all the issues.
I must give credit to military MD. He coined the term "stool sitter" and is 100% correct that in the end, we are too expensive and too well-trained to be the primary stool sitter. That role will be filled by someone else.
We must bring a "unique skill set" to the table or we will end up being the meal.
Blade
We must bring a "unique skill set" to the table or we will end up being the meal.
Blade
Thanks for the article suggestion, Blade. I've seen the author, Warren Sandberg, talk before on the "the future of anesthesiology" at a Grand Rounds and essentially painted a picture of surgery and surgical anesthesia in 20-30 years that is entire automated and performed by robots, monitored by surgeons and anesthesiologists in central cores overseeing many operating rooms.
I think his argument that the reimbursement profile, especially for academic departments, is not sustainable...but also that we ALREADY have situations in which nurses and midlevels do virtually all the direct supervision and care of critically ill and intraoperative patients. What's the difference between an intubated, ventilated, paralyzed patient on norepi gtt in an ICU versus the one that's having TIVA for a procedure with minimal blood loss in the OR? (Other than the fact that the ICU pt is probably being intermittently checked in on by, most likely, a pulmonologist?)
I think he makes a good argument that the physician-only model of anesthesia, especially for academic departments, is not sustainable, and yet, there are only so many "high-end" operations requiring "high-end" anesthesiologists. It's worrying to say the least.
I think his argument that the reimbursement profile, especially for academic departments, is not sustainable...but also that we ALREADY have situations in which nurses and midlevels do virtually all the direct supervision and care of critically ill and intraoperative patients. What's the difference between an intubated, ventilated, paralyzed patient on norepi gtt in an ICU versus the one that's having TIVA for a procedure with minimal blood loss in the OR? (Other than the fact that the ICU pt is probably being intermittently checked in on by, most likely, a pulmonologist?)
I think he makes a good argument that the physician-only model of anesthesia, especially for academic departments, is not sustainable, and yet, there are only so many "high-end" operations requiring "high-end" anesthesiologists. It's worrying to say the least.
It's the early 1990s revisited folks. Those who don't know history are doomed to repeat it.
So coming from more experienced minds, what exactly does this portend for the future? Sounds to me like less anesthesiologists needed vs midlevels? Or is this nothing to worry about?
Sorry for the questions I just spent thousands of dollars applying today on ERAS and would like to know. Thanks in advance
Sorry for the questions I just spent thousands of dollars applying today on ERAS and would like to know. Thanks in advance
Blade, as always telling it like it is. You my man are the one who is opening our eyes and bringing us down to reality and helping us face the inevitable. I have now realized that midlevels will be the stool sitters of the future. Eventually they will also fall victims to technology (Macsleepy). Thank you for all the great advice and I will be a better physician and man for it.
How long will your career be in this field? 5 years? 10? 20? 30? Do you really want to be without a fellowship and formal certification in a highly skilled subspecialty 20 years from now? IMHO, that is a HUGE mistake especially when we need LESS supervisors and not more down the road.
Why work for 200K as a slave for some PP Group when you could do a fellowship and land a better paying job in a better location? The odds favor the fellowship trained MD going forward. As for going back and working for 70K after tasting real money that simply doesn't happen very often.
CCM. Long and hard debate but I could not endure seeing a SRNA place lines including a swan while being directed by a cardiac attending while I practiced with the TEE on the same patient. I thought to myself, besides the TEE skill, what else will this fellowship do for me that a cheap hospital CEO won't be willing to pay a CRNA for. Before I finish residency, I will have done 4 months of cardiac plus one month of TEE.
In the end, I will be functional in and out of the OR. I have arranged to get TEE experience during my CCM fellowship to get a pretty good level of proficiency and sit for the exam. One of our TEE gurus agreed to help me in this regard. I am exposed to a large volume of cardiac cases so getting the numbers will be easy.
I will still do gas after I graduate but in case all goes to hell, I will have another skill set that will keep me employed.
http://viewer.zmags.com/publication/9960917c# (coincidence?)
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When I was a resident, I bought into the whole idea of CRNA's taking our jobs and anesthesiologists being out of work because of it. Guess what? CRNA's don't want our jobs. Ask the typical CRNA working in a care team model if they would rather be independent and the vast majority will say NO. Smart CRNA's realize that independent practice sucks to a certain degree: no back-up, no breaks and usually an undesirable location. The very vocal minority of militant CRNA's would make you believe that every CRNA is just waiting, watching over our shoulders, wanting our jobs. Nothing could be further from the truth.
The free market has set the price of an anesthesiologist and that is why we get paid what we get paid. Some are concerned about the ever rising subsidy by hospitals. Lets look at it another way. If anesthesiologists truly ran the OR schedules at a typical hospital and optimized for efficiency (and not surgical convenience), the stipend paid would be a lot less. If anesthesiologists refused to do cases that reimbursed them poorly (but reimbursed the hospital greatly), then the stipend would be even more less. The true "customer" for the private hospital is the surgeon and hospitals need to make them happy. Hospitals aren't stupid. They would not pay a subsidy if they didn't think it was good business sense all the way around.
Do you think pilots are worried about the computer takeover of aviation? The new airplanes basically fly themselves. Has American or United Airlines cut all their pilots loose because of this? No. Because no one in their right mind would get into a plane that wasn't flown by a human. The same is true with anesthesia. No one will place their care in the hands of a robot without immediate human oversight (CRNA or MD, and I'm not talking about someone sitting remotely in a "central core").
Those who have pursued fellowships will definitely have a niche, but those of us who didn't do fellowships will be okay too. A thoughtful board certified anesthesiologist proves their value every single day in medical decision making perioperatively. Although a fellowship helps, you don't need it in order to bring a specialized skill set to the table.
Lets be real here. The economy is in a tight spot which means the job market is in a tight spot. Older partners who wish they could retire are working longer. Private groups have put the brakes on partnership tracks because they don't know what the future holds and also because the market has made people willing to take a strictly employee position. Academic centers are seeing their budgets slashed by state and federal entities and are unable to staff as they would like. Those graduating in 2010 will have a tough time finding a job. This was obviously impossible to predict back in February 2006 when they were making their rank lists. In time, this health care "crisis" will stabilize, the economy will stabilize, people will start to retire again and the job spigots will open up once more.
The free market has set the price of an anesthesiologist and that is why we get paid what we get paid. Some are concerned about the ever rising subsidy by hospitals. Lets look at it another way. If anesthesiologists truly ran the OR schedules at a typical hospital and optimized for efficiency (and not surgical convenience), the stipend paid would be a lot less. If anesthesiologists refused to do cases that reimbursed them poorly (but reimbursed the hospital greatly), then the stipend would be even more less. The true "customer" for the private hospital is the surgeon and hospitals need to make them happy. Hospitals aren't stupid. They would not pay a subsidy if they didn't think it was good business sense all the way around.
Do you think pilots are worried about the computer takeover of aviation? The new airplanes basically fly themselves. Has American or United Airlines cut all their pilots loose because of this? No. Because no one in their right mind would get into a plane that wasn't flown by a human. The same is true with anesthesia. No one will place their care in the hands of a robot without immediate human oversight (CRNA or MD, and I'm not talking about someone sitting remotely in a "central core").
Those who have pursued fellowships will definitely have a niche, but those of us who didn't do fellowships will be okay too. A thoughtful board certified anesthesiologist proves their value every single day in medical decision making perioperatively. Although a fellowship helps, you don't need it in order to bring a specialized skill set to the table.
Lets be real here. The economy is in a tight spot which means the job market is in a tight spot. Older partners who wish they could retire are working longer. Private groups have put the brakes on partnership tracks because they don't know what the future holds and also because the market has made people willing to take a strictly employee position. Academic centers are seeing their budgets slashed by state and federal entities and are unable to staff as they would like. Those graduating in 2010 will have a tough time finding a job. This was obviously impossible to predict back in February 2006 when they were making their rank lists. In time, this health care "crisis" will stabilize, the economy will stabilize, people will start to retire again and the job spigots will open up once more.
Good post. Overall I agree. We must just agree to disagree on the value of 12 more months of training to your CV. I think those 12 months are added icing on very tasty cake.
You spent your entire life to get here. I understand there is some money lost by doing that 12 month fellowship. But, IMHO, I think you will recoup that lost money over your career OR by landing a job that would otherwise have gone to someone else.
Peace,
Blade
CRNAs taking over our jobs is not the issue. It's the increasing pressure we will face to supervise more and more thereby creating less of a need for supervisors that is the problem. What do we do then?
Blade, I think you are one of the most thoughtful posters on this forum and I greatly respect and value your opinions. For the fellowship issue, I think that if someone has an interest in doing a fellowship that provides a certificate (pain, ICU, TEE cert) or one that provides true clinical expertise (pediatrics), then by all means, that person should do that fellowship. The other fellowships (OB, neuro, regional, ambulatory) in my opinion don't give you much back for your sacrifice. Just like pain and critical care, in the future there may be a subspecialty certificate that can be attained by those who already have interest and expertise in these areas by taking an exam and meeting certain qualifications. So, we'll have to agree to disagree, but I do think you are at least half right.
Those who have PM'd me know I pretty much agree with your post above.
1) If you decide on Neuro you must get an elevtive in EEG from Neurology.
The money is in Neuromonitoring.
2) If you decide on Regional 6 months is enough. Try to get a job as an "attending" on the side as Regional is not an official Fellowship.
3) OB- 6 months is more than enough. This fellowship is best combined with something else for the other 6 months like Regional.
4) Ambulatory- Is this a CRNA Fellowsip?
Numbers 3 and 4 have LITTLE value in private practice; they are best used to get a job in Academia as most hospitals offer their own fellowship in these areas: it is called a job
For all those who think Pediatric Anesthesia is a safe fellowship:
http://cphs.wayne.edu/anesth/doc/ped-cert-post-masters-plan.pdf
USC offers CRNA "Fellowships"
http://www.usc.edu/schools/medicine/departments/anesthesiology/education/crna/program.html
I think an ICU fellowship is a long term insurance plan which pays poor upfront and in the long run. A CV/Pain/Peds fellowship pays same, with one year lost, however buys 5-10 years on top of CRNA victory.
No fellowship brings immediate cash with glorified CRNA status upon expiration date.
Don't forget that ICU competition will be fierce from surgeons/medicine guys, and the bevy of midlevels who are currently nearly attending many an ICU across the land.
Thoughts?
http://cphs.wayne.edu/anesth/doc/ped-cert-post-masters-plan.pdf
USC offers CRNA "Fellowships"
http://www.usc.edu/schools/medicine/departments/anesthesiology/education/crna/program.html
I think an ICU fellowship is a long term insurance plan which pays poor upfront and in the long run. A CV/Pain/Peds fellowship pays same, with one year lost, however buys 5-10 years on top of CRNA victory.
No fellowship brings immediate cash with glorified CRNA status upon expiration date.
Don't forget that ICU competition will be fierce from surgeons/medicine guys, and the bevy of midlevels who are currently nearly attending many an ICU across the land.
Thoughts?
The goal, as others have stated, is to have credentials that are not easily attained by non-physicians. Yes, they have midlevels in the ICU. They permeate every aspect of healthcare but evidence strongly favors the presence/use of an intensivist. The same cannot be said for OR anesthesia. In the end, it is about differentiating yourself.
The problem with that theory is that the department and hospital can't advertise to surgeons and patients about your advanced training if you don't do a fellowship. The certificate on the wall adds marketability even though you could learn everything while making a better living in private practice vs fellowship.
I know that patients don't know the difference between the janitor in scrubs and the anesthesia chairman, but they may pay more attention to who we are if there is an information campaign if we have to stand up for our position in the OR. Some informed patients already ask about anesthesia.
"as well as new care team models as the topics of enthusiastic research and development"
So, does anyone care to opine on the above comment? Does the author mean midlevel ratios should increase to 6-7:1? Does he mean CRNAS should be allowed to function with minimal supervision on ASA 1 and 2 patients?
Should the Physician Anesthesiologist preop the patients and "screen" CRNA only cases for them to do solo?
I think he is hinting at all the above as new paradigms to control costs and show hospitals we are doing everything possible to save money.
Again, Military MD was correct when he stated we need less Anesthesia Residents and more midlevels going forward.
So, does anyone care to opine on the above comment? Does the author mean midlevel ratios should increase to 6-7:1? Does he mean CRNAS should be allowed to function with minimal supervision on ASA 1 and 2 patients?
Should the Physician Anesthesiologist preop the patients and "screen" CRNA only cases for them to do solo?
I think he is hinting at all the above as new paradigms to control costs and show hospitals we are doing everything possible to save money.
Again, Military MD was correct when he stated we need less Anesthesia Residents and more midlevels going forward.
"One does not need to look very far to see potential replacements."
I have been singing this tune since I first posted on SDN more than 2 years ago. We have a major problem in this field and soon it will come to a boiling point. Please be prepared to deal with this issue head on over the next 5-10 years as it will be unavoidable.
I have been singing this tune since I first posted on SDN more than 2 years ago. We have a major problem in this field and soon it will come to a boiling point. Please be prepared to deal with this issue head on over the next 5-10 years as it will be unavoidable.
Yes. You are correct. The Editorial is only 4 pages long. 4 pages. Read it 3 times and then see what you think. I agree with the author 100% on this:
"things can't continue for much longer the way they are going. "
This means MORE midlevels working in the field and less one on one MD anesthesia. Hence, unlike the author I believe we will have a surplus of supervisors in te O.R. Thus, the need more than ever before to distinguish yourself as a "premium" grade provider.
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"The current commodity users of anesthesia services are ready for a solution that better meets their needs, and the products, technologies, and services that could provide this solution are already visible, albeit faintly."
The facts remains that the AANA sees the solution very, very clearly. While McSleepy may be an answer for us in 10-20 years the AANA has no plans on waiting that long to present an already "proven" solution to basic anesthesia services.
What is our plan? The author provides no answers. Once the front gate to the city falls then it is just a matter of time before it all falls.
The facts remains that the AANA sees the solution very, very clearly. While McSleepy may be an answer for us in 10-20 years the AANA has no plans on waiting that long to present an already "proven" solution to basic anesthesia services.
What is our plan? The author provides no answers. Once the front gate to the city falls then it is just a matter of time before it all falls.
"However, with sufficient incentive to alter the status quo plus a little luck, anesthesiologists protected status can be altered by the stroke of a pen, as evidenced by the gubernatorial opt-out provision from physician supervision of nurse anesthetists, published in 2001. Cost, protectionism, and unmet needs provide the incentive for change"
The AANA and the Governor of this State both speak the same line: "I will be back." California won't be the last to fall.
Blade
The AANA and the Governor of this State both speak the same line: "I will be back." California won't be the last to fall.
Blade
Not that I'm disagreeing with Blade in total, but the author did state he didn't believe the alternative to be CRNAs stating they're "comparable with anesthesiologists in many ways, including cost".
I believe the author's point, which is a good one, is that many of the areas in which anesthesia is delivered (GI suites, MRI, angio, short quick procedures on ASA 1 patients, etc.) don't require the skill or knowledge of an anesthesiologist. The alternative for simple cases might be McSleepy, or sedation nurses, or respiratory therapists, or someone totally different. Dr. Sandberg simply stated that many of our customers are constantly seeking ways to find an alternative to us, and rather than constantly remain resistant to change perhaps we should simply find a way to make our consumers believe we provide a valuable service to them.
In pediatric, cardiac, and many difficult cases (ASA 4 and 5 patients among many other patients where it hits the fan quickly) it becomes very obvious very quickly to everyone in the OR that the knowledge and skill of an anesthesiologist is invaluable and not replaceable. Dr. Sandberg's point seems to be we need to find a way for all of our consumers to believe this. It's essentially what MMD said time and time again during his time here.
CRNAs and the AANA can claim they're the alternative all they want, but I don't believe this to be the case and neither does Dr. Sandberg. They're expensive as hell and the very, very large majority don't want the hours or liability of an anesthesiologist. The very large majority of CRNAs don't want a single thing to change b/c they're perfectly happy working 40 hours a week, no nights, no call, no weekends, bringing in 130k-200k/year. I'm sorry, but that's not the alternative Dr. Sandberg was writing about. But, this won't stop them from legislating anesthesia into the ground.
I believe the author's point, which is a good one, is that many of the areas in which anesthesia is delivered (GI suites, MRI, angio, short quick procedures on ASA 1 patients, etc.) don't require the skill or knowledge of an anesthesiologist. The alternative for simple cases might be McSleepy, or sedation nurses, or respiratory therapists, or someone totally different. Dr. Sandberg simply stated that many of our customers are constantly seeking ways to find an alternative to us, and rather than constantly remain resistant to change perhaps we should simply find a way to make our consumers believe we provide a valuable service to them.
In pediatric, cardiac, and many difficult cases (ASA 4 and 5 patients among many other patients where it hits the fan quickly) it becomes very obvious very quickly to everyone in the OR that the knowledge and skill of an anesthesiologist is invaluable and not replaceable. Dr. Sandberg's point seems to be we need to find a way for all of our consumers to believe this. It's essentially what MMD said time and time again during his time here.
CRNAs and the AANA can claim they're the alternative all they want, but I don't believe this to be the case and neither does Dr. Sandberg. They're expensive as hell and the very, very large majority don't want the hours or liability of an anesthesiologist. The very large majority of CRNAs don't want a single thing to change b/c they're perfectly happy working 40 hours a week, no nights, no call, no weekends, bringing in 130k-200k/year. I'm sorry, but that's not the alternative Dr. Sandberg was writing about. But, this won't stop them from legislating anesthesia into the ground.
The AANA will market its membership as that Alternative just as they did in California 2 months ago.
Now, read the FACTS below and tell me that Anesthesiologists cost the same as a CRNA:
"Anesthesiologists are expensive. The total annual cost of an academic anesthesiologist reported by Kheterpal et al. is $605,000."
The Author's "opinion" that CRNAs are similar in expense to an MD Anesthesiologist will be refuted by the AANA propaganda machine. California bought the argument and so will other states over the next 10 years.
Now, read the FACTS below and tell me that Anesthesiologists cost the same as a CRNA:
"Anesthesiologists are expensive. The total annual cost of an academic anesthesiologist reported by Kheterpal et al. is $605,000."
The Author's "opinion" that CRNAs are similar in expense to an MD Anesthesiologist will be refuted by the AANA propaganda machine. California bought the argument and so will other states over the next 10 years.
Not that I'm disagreeing with Blade in total, but the author did state he didn't believe the alternative to be CRNAs stating they're "comparable with anesthesiologists in many ways, including cost".
The author is wrong here; it is wishful thinking to believe that a hospital based/employed MD Anesthesiologist costs the same as a hospital based CRNA. That simply isn't true.
Now, whether the extra cost of the MD provider is worth the additional expense is something to debate (see midlevel forum).
If the Solo CRNA is allowed to "bill" as an independent provider then costs may be comparable. But, that is not the method some hospitals and many surgicenters use to pay CRNAs.
The author is wrong here; it is wishful thinking to believe that a hospital based/employed MD Anesthesiologist costs the same as a hospital based CRNA. That simply isn't true.
Now, whether the extra cost of the MD provider is worth the additional expense is something to debate (see midlevel forum).
If the Solo CRNA is allowed to "bill" as an independent provider then costs may be comparable. But, that is not the method some hospitals and many surgicenters use to pay CRNAs.
"Choosing this course moves OR and procedure room anesthesiology closer to the model used in intensive care units, where anesthesiologists assure that care is provided, but only personally provide care when their unique skills cannot be replaced."
In this statement the author recognizes that midlevels are CHEAPER and hence, must be utilized whenever and wherever possible to minimize hospital expenses. Thus, MD Anesthesiologists must be utilized to fill a role that midlevels can not perform adequately.
The AANA will claim there is no such role. However, the facts of hospital practice prove that to be untrue on a daily basis. Increasingly the ASA is realizing that "unique skill" set is our last defense against a very powerful adversary.
In this statement the author recognizes that midlevels are CHEAPER and hence, must be utilized whenever and wherever possible to minimize hospital expenses. Thus, MD Anesthesiologists must be utilized to fill a role that midlevels can not perform adequately.
The AANA will claim there is no such role. However, the facts of hospital practice prove that to be untrue on a daily basis. Increasingly the ASA is realizing that "unique skill" set is our last defense against a very powerful adversary.
I'm just pointing out what the author stated in his own words. And I believe him. CRNAs make more than many physicians with better hours and less liability. They're not the anesthesia alternative that many of our consumers are looking for. I firmly believe Dr. Sandberg on that point. Do I believe our legislators can be convinced of this point in the face of aggressive legislative efforts by the AANA? No, I don't. Because I think many legislators are too lazy to see the truth for themselves. I do plan to read that Kheterpal study though to see where those numbers come from.
"In pediatric, cardiac, and many difficult cases (ASA 4 and 5 patients among many other patients where it hits the fan quickly) it becomes very obvious very quickly to everyone in the OR that the knowledge and skill of an anesthesiologist is invaluable and not replaceable. Dr. Sandberg's point seems to be we need to find a way for all of our consumers to believe this. It's essentially what MMD said time and time again during his time here."
True. But, the problem is the midlevel can handle the basic GI case safely and easily; in addition, anesthesia safety has increased to the point the vast majority of CRNAs don't need anesthesiologists any longer for ASA 1 or 2 cases. Hence, we have become a commodity provider.
Thus, it will become increasingly difficult to convince the CONSUMER of this service to pay a premium price for a basic commodity level service.
True. But, the problem is the midlevel can handle the basic GI case safely and easily; in addition, anesthesia safety has increased to the point the vast majority of CRNAs don't need anesthesiologists any longer for ASA 1 or 2 cases. Hence, we have become a commodity provider.
Thus, it will become increasingly difficult to convince the CONSUMER of this service to pay a premium price for a basic commodity level service.
D
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Yes sir. You are indeed correct. That is why an all CRNA model at our major hospitals won't happen in the foreseeable future. But, can we change the anesthesia care team model and maintain safety? The data strongly suggests that we can and must do so if we wish to maintain our "premium" price tag.
D
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Yes sir. I agree with you again on your post. You will indeed end up as a stool sitter as this field will mature into perioperative medicine; thus, MD Anesthesiologists will end up as "helpers/screeners" for midlevels who provide one on one anesthesia to the patient.
For your sake I hope the ASA can hold off the adversary for another ten years; however, I doubt our current model will survive that long.
Blade
D
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No problem. The AANA is more than willing to allow you to administer an anesthetic to a patient one on one. At least for now anyway. However, in the future don't expect the CONSUMER to pay a premium price for a BASIC commodity service. A CRNA level service will be reimbursed at a CRNA level wage.
As more states go "opt-out" the one on one administration of an anesthetic will be viewed as a Advanced Nursing level function. Hence, compensation for this Nursing level service will be appropriate.
If you are providing a one on one anesthetic to an ASA 1 patient at an outpatient center which "product performance" best describes your job?
If the center can replace you with a BASIC COMMODITY LEVEL PROVIDER for half the cost at the same quality will they do so?
If the government isn't willing to pay any more money for the HIGH END product vs. the LOW END product who is willing to sell them the high end product? How long can the seller of the high end product stay in business once the PRIVATE BUYERS no longer pay a premium for the high end product?
"Anesthesiology is at a crossroads. In some settings compensation outstrips revenue, supported by stipends to anesthesia groups from hospitals"
"If a less expensive, albeit less capable but still sufficient, alternative becomes available, will commodity users of anesthesia care pay extra for the super-capable product? Experiences from other industries say no. Ongoing rising cost of the available high-end product will motivate the search for lower cost alternatives and whet the payers' appetites for implementation"
"If a less expensive, albeit less capable but still sufficient, alternative becomes available, will commodity users of anesthesia care pay extra for the super-capable product? Experiences from other industries say no. Ongoing rising cost of the available high-end product will motivate the search for lower cost alternatives and whet the payers' appetites for implementation"
I guess it has become time to bail out of med school and head down the CRNA path...
The Author and I agree completely on the problem. We agree on his analysis of the situation in this field. But, we disagree on the role of the AANA/CRNA as a basic provider of the service.
Unlike the author I know that in private practice the hospital can hire the CRNA at a HUGE COST savings upfront to that of an Anesthesiologist. Will the extra morbidity/mortality negate that savings? Will the extra consults eat up most of the salary differences? You know my opinion.
But, will the CONSUMER of these service who is paying a huge stipend for the PREMIUM level service decide to stop paying for it? If and when the stipend shoots through the roof will that Consumer look for cheaper alternatives if at all possible? Of course.
Hence, the current Anesthesia Care team model will be the first casualty of the Consumer's decision to no longer pay the extra cost for the premium level service.
Or, realize that Perioperative Medicine is much more than sitting on a stool and turning a dial.
"Low-end consumers of anesthesia services regard the ability to safely produce a deeply sedated or anesthetized patient who is happy at the end of the procedure as a commodity, where the key differentiators—compensation and fit with the procedure area workflow—boil down to cost. "
Time for you all to re-read Mark Lema on the future of this specialty.
Note he predicts 10:1 ratios as possible and MORE Solo CRNA practice.
http://www.asahq.org/Washington/PM2007-01-DRLEMAUPDATE.pdf
Time for you all to re-read Mark Lema on the future of this specialty.
Note he predicts 10:1 ratios as possible and MORE Solo CRNA practice.
http://www.asahq.org/Washington/PM2007-01-DRLEMAUPDATE.pdf
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So the question is, how can the ASA get AAs in every state? CRNAs can't supervise anyone. A smart anesthesiologist pays the AA less than these CRNAs are making, like $100-120k (pretty good for the training and liability involved) and supervises more like 4-5 instead of 3.
My attending today pointed at the stool and asked me (dumb med student) what it was. I said, "Um, looks like a stool to me."
His reply: "No, that is the devil's tool."
Well played sir.
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Truth. When I interviewed, the last part of the day was him sitting with all of us in the conference room and delivering this article in speech form.
