physician-only groups- dead?

[optimus_prime]

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If we do, as feared, go to some sort of national health care plan- is a physican-only anesthesia group sustainable? Is it inevitable that we will have to oversee 4 rooms to have any sort of profit margain?

would you fear signing on with a physician only group at this time?

just food for thought

 

[Consigliere]

Yes to both questions. Save this post and revisit in 2012 to see...

 

[maceo]

If we do, as feared, go to some sort of national health care plan- is a physican-only anesthesia group sustainable? Is it inevitable that we will have to oversee 4 rooms to have any sort of profit margain?

would you fear signing on with a physician only group at this time?

just food for thought

I wouldnt fear physician only anesthesia, I think some places will still have it simply because not enough nurse anesthetists out there. I like doing my own cases, and many people do. I think the answer is opening up more anesthesia assistant schools and allowing physician assistant to train to be in the operating room. this wil give competition to the nurse anesthetists.

 

[Southpaw]

If we do, as feared, go to some sort of national health care plan- is a physican-only anesthesia group sustainable? Is it inevitable that we will have to oversee 4 rooms to have any sort of profit margain?

would you fear signing on with a physician only group at this time?

just food for thought

Just started residency here...could someone explain how physician only anesthesia could become less economically desirable than it currently is? I understand how supervision works and the economics of that job, but if changes are made to health care, how exactly would this effect physician-only anesthesia groups?

 

[MDEntropy]

There is no effect unless differences in reimbursement are introduced.

CRNA supervision does not save money for payors at least not currently.

ACTs can be used to improve physician and CRNA income in an ideal situation.

At Kaiser CRNA's could save money because it is a closed system and in theory savings to the hospital could be passed on to the health plan, but they generally aren't even cost saving even at kaiser. This is mainly because they are only cost saving at most kaiser hospitals if one have a constant 4 to 1 ratio and this just doesn't work out much of the time.

The bottom line is there is an assumption that CRNA's are cost saving. I have asked for years...for whom do they save money? It's not the payor.

Now, if you changed reimbursement so as that MD only cases were paid differently from CRNA cases then things change...but you would have to reimburse less for CRNA directed cases or more for MD's (relatively speaking).

Now, physician only groups with large hospital stipends could theoretically have their stipends placed at risk if the hospital wanted to bill for the anesthesia services and employ "providers" thinking they could save money. But this savings could be the result of employing docs, ACT or crna's alone Usually using an ACT doesn't save the hospital in an area where there are plenty of anesthesiologists.

CRNA's are expensive, especially when you need coverage during times where no billing is taking place. Docs are very cheap on call. CRNA's generally cost a fortune.

In states that have opted out, CRNA only groups can certainly compete with anesthesiologists as hospital employees. They bill for less when not directed so if they wanted to get paid 70% of a physician salary with the same call responsibilities etc, they could possibly be considered a threat.

All of this has nothing to with health care reform. Again, directed CRNA's don't save payors (e.g. insurance companies, medicare, medicaid etc.) If anyone can prove otherwise, I would love to hear about it.

 

[dragerdude]

Most insurance companies pay lees per unit for crna anesthesia, where I am an anesthesiolgist recieves at 37$ a unit and a CRNA 27$ per unit, many insurance companies operate this way, medicare does not pay any differently except for pain procedures then depending on the many factors can be 60-90% of the MD rate. Is there a savings? There can be but the groups and hospitals bill the same for both and take a write off in both up 60% in some areas.

 

[sevo85288]

Most insurance companies pay lees per unit for crna anesthesia, where I am an anesthesiolgist recieves at 37$ a unit and a CRNA 27$ per unit, many insurance companies operate this way, medicare does not pay any differently except for pain procedures then depending on the many factors can be 60-90% of the MD rate. Is there a savings? There can be but the groups and hospitals bill the same for both and take a write off in both up 60% in some areas.

Wrong. Anesthesia services are reimbursed the same no matter who provides it. The OB can give the spinal and charge for the anesthesia at the same rate. It is NOT provider dependent. Only payer/region dependent.

 

[dragerdude]

I am sorry that is not the case, I wish it were I assure you. CRNA's can bill at the same rate but the insurance companies (god rot thier souls) reimburse less for CRNA's.

 

[jwk]

I am sorry that is not the case, I wish it were I assure you. CRNA's can bill at the same rate but the insurance companies (god rot thier souls) reimburse less for CRNA's.

You probably need to qualify that for SOME insurance companies - it's not an across the board deal.

 

[jwk]

In states that have opted out, CRNA only groups can certainly compete with anesthesiologists as hospital employees. They bill for less when not directed so if they wanted to get paid 70% of a physician salary with the same call responsibilities etc, they could possibly be considered a threat.

Although it's quite common for CRNA's to be hospital employees, I don't believe that it is a frequent occurrence with anesthesiologists. Unless a stipend is involved, anesthesiologists usually cost a hospital nothing.

This is another reason the rural pass-through reimbursement for CRNA's and not MD's is a very big deal.

 

[dragerdude]

True, it may not be all companies the one I am most familiar with is Anthem. As for employess it is becoming more common, most groups do cost the hospital in stipends I belive the ASA pointed out that 70% of the groups in the country were supported by hospital subsidies, this situation will only worsen as medicare rates squeeze and more and more people utilize medicare, and if Obamas plan comes through well I think we all know what that will cause. It sure as hell will not be higher reimbursments.

 

[dfk]

I wouldnt fear physician only anesthesia, I think some places will still have it simply because not enough nurse anesthetists out there. I like doing my own cases, and many people do. I think the answer is opening up more anesthesia assistant schools and allowing physician assistant to train to be in the operating room. this wil give competition to the nurse anesthetists.

funny you say this. many don't understand that the numbers will never really "win" or be the reasoning answer.
on a similar thought process - when i see attendings doing their own rooms at my ACT, usually, i'm thinking... 'i bet they're pissed' ('cause some you just know), or that we all as providers should still be current no matter who you are. it's a little bit warming (simply b/c of the stupid stigma) to see those humbled in some fashion.

 

[Consigliere]

it's a little bit warming (simply b/c of the stupid stigma) to see those humbled in some fashion.

Since when is sitting in a room doing an anesthetic "humbling" clown fart? I would do ALL my own cases were it not for the HUGE pay cut I'd have to take.....

 

[michael3469]

I think it all depends which state you are in and how much you get paid per unit. Some states you can supervise 4 rooms at a time billing 50% for each room. If the reimbursment per unit will decline many more groups will not be able to sustain the physician only model and keep the current income level. It also depends who employs CRNA's and how much do they cost the group.

 

[thegasman]

in many cases, crnas are employed by the hospital. Anesthesiologist revenue increases with the number of cases you are able to supervise. I can get a lot more revenue (cases) supervising 4 crnas at once than if I was running one room solo. MD - only anesthesia cannot compete financially without a large hospital subsidy. And it is only going to get worse.

 

[michael3469]

Yep, exactly what the Gasman said. Md only groups only work in states with high per unit reinbursment, in hospital with a large percentage of good insured patients or with hospitals that give large subsidies to the group. I suspect that all of those will begin to decline. Regardless how much one wants to do their own cases the economic reality might make it harder and harder to do. In a good group with well trained CRNa's , MD/CRNa's model might be the safest thing for the patient in many cases. (don't mean to open a can of worms with that comment however"

 

[MDEntropy]

Yep, exactly what the Gasman said. Md only groups only work in states with high per unit reinbursment, in hospital with a large percentage of good insured patients or with hospitals that give large subsidies to the group. I suspect that all of those will begin to decline. Regardless how much one wants to do their own cases the economic reality might make it harder and harder to do. In a good group with well trained CRNa's , MD/CRNa's model might be the safest thing for the patient in many cases. (don't mean to open a can of worms with that comment however"

It is certainly true that using CRNA's can increase physician income. But the economic reality is that when you model out CRNA usage the increase in income is often not from the payor.

When CRNA's are hospital employees, those with any amount of experience usually earn more more than half of a what a physician would bill for in they did the same cases on their own and provided the same coverage in terms of call etc. The latter half of this concept is critical. Most CRNA's would not work in eat what you kill type of environment...they wouldn't be paid enough especially when you consider benefits, paid time off, the employer portion of medicare and social security taxes etc. But as pointed out by many, CRNA's are usually hospital employees. What essentially happens is the hospital subsidizes anesthesia care but by paying the CRNA's more than they could effectively earn by keeping their portion of payor's reimbursements. The subsidy for anesthesia care is just as real as in many doc only groups, it simply shifts who receives the funds. In situations where the payor mix is such that the above is untrue, it may actually makes sense for a physician group to employ the CRNA's provide the schedule is amenable to the directing 3-4 room a significant amount of the time.

If average reimbursement drops across the board, none of the above changes, everyone is simply paid less.

 

[kmurp]

It depends what the average $/unit collected ends up at. If ALL reimbursement was at the $20/unit level of medicare, the care team model would be too expensive. There isn't enough money to pay both the MD and the CRNA plus admin. overhead. Either an all MD or all CRNA model (or greatly reduced MD and CRNA salaries) would be required. In the more likely scenario of a mixed reimbursement level above that number (like we have now but with a higher % of formerly private patients at the $20 level), the care team would make sense using maximal leverage.