What Obamacare Doesn't Do

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BLADEMDA

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http://www.cbsnews.com/videos/what-obamacare-doesnt-do/

JANUARY 11, 2015, 8:22 PM|With the passage of the Affordable Care Act, everyone with a stake in the $3-trillion-a-year health industry came out ahead -- except the taxpayers, says author Steven Brill. Lesley Stahl reports.

Conclusion: The Taxpayer is footing the bill for all these subsidies and massive expansion of Medicaid. These costs are unsustainable and eventually will lead to a major fiscal crisis.

My opinion:

The Fiscal crisis created by the ACA leads to the Medicare Option on the exchanges or a single payer system exactly as planned by Obama. The result is that Anesthesiology becomes the lowest paid medical specialty and/or a complete takeover by CRNAs.

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New research just out in the journal Psychology and Aging says pessimists live longer and healthier lives. If this is true, then contemplating the future of anesthesiology ought to make us immortal, because our professional prospects don’t look bright. As we teach residents to do what we’ve always done, shouldn’t we ask ourselves honestly if we’re training them for a future that doesn’t exist?

Especially here in California, it seems likely that our predominantly MD-provided, fee-for-service practice of anesthesiology will not survive indefinitely, and perhaps not for long. We can blame the reelection of President Obama and the passage of the Affordable Care Act if we like, but the reality is that market forces were eventually going to catch up with us whether or not Mitt Romney went to the White House.


In a way, we’re the victims of our own success; we’ve made anesthesia so safe that everyone thinks there’s nothing to it. But that’s exactly the point. Technology has indeed made anesthesia much safer. When I started learning anesthesia, pulse oximetry and end-tidal CO2 monitoring were new to the market, unproven, and scarce. Now they’re everywhere. We fear the difficult airway less now that we have video laryngoscopes readily at hand.

Since technology is so much better, why do so many of us still believe that every case requires the costly expertise of a board-certified anesthesiologist? We can make the argument that physician-provided anesthesia care is simply better, in the way that a $75,000 BMW is a superior product to a $15,000 economy car. But in a world of increasing pressure to control healthcare costs, people are willing to consider cheaper solutions, and therein lies our risk.

Medicine isn’t the first business to be threatened by cost pressure and new technology. Look at what happened to vinyl records when CDs came on the market, and what happened to the demand for CDs when iPods and digital downloads appeared. Who could have imagined that the giant Eastman Kodak Company would crumble when digital photography killed the demand for camera film? People complained at first that the new technologies lacked the same sound quality or rich color, but as time passed the market no longer cared.

Clayton Christensen, a Harvard Business School professor, uses the term “disruptive innovation” to describe how “complicated, expensive products and services are eventually converted into simpler, affordable ones.” In a recent Wall Street Journal column, Christensen and his co-authors argue that accountable care organizations, or ACOs, can’t make a dent in costs because they won’t fundamentally disrupt and transform the delivery of American healthcare. While many anesthesiologists agreed with that assessment, they were appalled by the authors’ recommendation that policy makers “consider changing many anticompetitive regulations and licensure statutes that practitioners have used to protect their guilds.” The authors praised California for enabling “highly trained nurses to substitute for anesthesiologists”–the last thing anesthesiologists wanted to hear.

Has California’s “opt-out” changed the marketplace?

In the years since 2009, when Governor Schwarzenegger signed the “opt-out” letter that freed California nurse anesthetists from the CMS requirement for physician supervision, many of us haven’t seen huge changes yet in the delivery of anesthesia care. Most California anesthesiologists still provide personal care, one patient at a time, and believe their hospitals, surgeons, and patients are satisfied with the status quo.

But if you think everything is fine with your hospital because you take good care of your patients, you’ll hear a counterargument from Dr. Michael R. Hicks, an anesthesiologist and executive who heads anesthesia services for EmCare, a national physician practice management firm. In an online article, “Disruption and the Theory of the Anesthesia Business,” Dr. Hicks wrote, “Nearly every anesthesia practice that I have seen replaced has had satisfied patients.” But the incumbent group fell out of favor and lost its contract because it became “out of touch with its environment, and secure in the knowledge, erroneously so, that the group and group members are irreplaceable.”

One southern California anesthesiologist who coordinates anesthesia services for several hospitals recently hired his first nurse anesthetist to practice on her own, without any supervision. She works on a flexible schedule when he needs to staff an additional operating room with routine cases. He’s quite pleased with the quality of her practice and her work ethic, as opposed to some younger anesthesiologists he’s hired who arrive with a sense of entitlement and a list of demands. “She’s a lot less trouble,” the anesthesiologist says.

Anecdotal evidence suggests that anesthesiologist pay in California is on a downward trajectory, perhaps because employers are aware that they could hire nurse anesthetists instead, and are bolder about extending low offers. An academic anesthesiologist, posting recently on the physician-only website Sermo, bemoaned the fact that an excellent resident accepted a job offer for pay that was barely above that of a nurse anesthetist. Anesthesiologists who want to work in desirable locations like the Bay area, work part-time, or work in surgery centers with no call and no weekends, appear to be willing to accept pay that no one would have considered competitive just a few years ago.

Understanding “disruptive innovation”

Clearly, there are major fault lines beneath the anesthesia marketplace. Much as we may dislike Professor Christensen’s comment about nurse anesthesia, perhaps we should hear more about his theory of disruptive innovation before we call for his head on a pike. With co-author Jason Hwang, he wrote an elegant article for Health Affairs that examines the theory’s implications for health care.

The traditional business model of hospitals and physician practices has been the “solution shop”–an institution created to diagnose and solve complex, unstructured problems, staffed by experts. This business model still works well for consulting firms and law firms, for instance. In medicine, the “solution shop” model evolved in an era when medical care involved minimal technology and relied upon the diagnostic intuition and hands-on experience of highly skilled physicians.

But times have changed. Two other business models now apply as well to the delivery of health care:

1. Value-added businesses: Like traditional manufacturing firms and restaurants, these businesses transform resources into outputs of greater value. They focus on process excellence and efficiency in order to produce high-quality products consistently and at low cost.

2. Facilitated user networks: These businesses deliver value and make money by facilitating the operation of a network and its user transactions. Examples are mutual insurance companies, stock exchanges, and banks.

As Christensen and Hwang view American health care, the current crisis was inevitable once hospitals and physician practices that began as highly competent solution shops started to change haphazardly. They “subsumed under their organizational umbrellas many activities that are perhaps better suited to businesses based on value-adding processes or user-network models. The legacy institutions of health-care delivery are jumbled mixtures of multiple business models struggling to deliver value out of chaos, incorporating indecipherable systems of cost accounting, excessive overhead, pervasive cross-subsidization, and an unacceptable amount of variability and medical error.”

Instead, the authors suggest, we should separate the diagnostic and intellectual work of physicians (the solution shop) from the value-added processes of health care. In other words, it doesn’t make sense for me, as an expensive and highly trained anesthesiologist, to change the suction canister on the anesthesia machine, push the gurney down the hall, and watch the ventilator during a long, stable case. Those tasks could be done by someone else at far less cost, someone who wouldn’t be qualified to decide if the patient is in optimal condition for surgery or to formulate the anesthetic plan. Many of the predictable, routine processes of anesthesia care don’t require anesthesiologist-level training.

As the authors explain, “When the value-adding procedures are organizationally separated from the work of solution shops, the overhead costs of the value-adding process hospitals and clinics can deliver care at prices that are 60% lower than those at hospitals and physician practices in which the business models of value-adding businesses and solution shops are conflated.”

If anything, this approach values physician time and education more highly, pointing out that it is a mistake to focus on reducing physician pay. “Cutting reimbursement in an attempt to force the solution-shop business models of hospitals and physician practices to somehow figure out a way to become more efficient does little to improve health care delivery,” the authors conclude. “With lower reimbursement, hospitals and physicians struggle even more to fulfill their value propositions of providing complex, inherently expensive medical care, and they become even less inclined to hand off work to value-added process businesses.”

Starting over: Stop squeezing the bag

If we could start all over again and develop the optimal model for delivering anesthesia care, what would it look like? I bet that it would have little in common with anesthesia practices today. If we let go of the idea that squeezing the bag in person is the only anesthesia-related activity that deserves compensation, then a world of possibilities opens up.

Right now, there are three models of anesthesia care in the U.S.:

1. Personally provided care by an anesthesiologist;

2. The anesthesia care team model in which anesthesiologists supervise nurse anesthetists, anesthesiologist assistants, and/or residents;

3. Personally provided care by a nurse anesthetist.

When we look at delivery of care in different settings, it becomes clear how much irrationality there is to current practice patterns. Why is it routine for a cardiologist or a gastroenterologist to supervise a nurse who is administering sedation, but an anesthesiologist only supervises a much more expensive midlevel anesthesia practitioner or resident? Why is it routine for an ICU nurse to monitor a patient who is intubated and receiving medications like fentanyl, midazolam, and propofol, but the same nurse isn’t allowed to monitor the same patient the moment he crosses the OR threshold?

Perhaps we need to change the conversation, and draw a distinction between “giving anesthesia” and monitoring patients.

Consider the patients who need sedation in outpatient settings, cardiac catheterization labs, and gastroenterology suites, for instance. Envision a scenario where an anesthesiologist supervises several nurses who are trained to administer sedation. The anesthesiologist has evaluated the patients, and is capable of converting any case to deep sedation or general anesthesia if the need arises. We improve patient safety by eliminating the all too common crisis when the patient under sedation gets into trouble and an anesthesiologist must be paged stat from elsewhere in the hospital. We eliminate the chance of having a case canceled in midstream because the patient can’t be adequately sedated and “anesthesia” isn’t available. We provide better service to the hospital by taking responsibility for all these cases, and the problem of scheduling “anesthesia” for occasional cases disappears. Potential liability decreases for the hospital as well as the surgeon or proceduralist, and the cost is far less than it would be with an anesthesiologist or a midlevel anesthesia practitioner assigned to every case.

Now consider patients who are having procedures performed under regional block with sedation. Once the anesthesiologist has placed the block, the patient has been sedated, and vital signs are stable, is there really a compelling reason why a sedation nurse could not monitor the patient with the anesthesiologist immediately available?

Of course, under the current fee-for-service payment model, none of these options are feasible. Under an integrated care model, however, the facility could offer a reduced price for the entire procedure, which would include the anesthesiology and sedation services. We redefine the nurses’ role so that instead of “providing anesthesia” they are monitoring patients who are under the anesthesiologist’s care.

We can envision an intelligently designed operating suite where the appropriate level of care is determined for each patient after evaluation by an anesthesiologist. Nurse practitioners or physician assistants would facilitate patient evaluation and throughput in the preoperative area, and assist anesthesiologists in the placement of regional blocks. Aides or technicians would facilitate room turnover, setting up fresh circuits, suction, and airway equipment. Staggered case starts would ensure that an anesthesiologist is present at the onset of each case, and then would delegate to the appropriate level of care for monitoring: a sedation nurse or a critical care nurse, for instance. Today’s technology can enable an anesthesiologist to view operating rooms and vital sign monitors from a tablet computer, and respond to any change in patient status. Anesthesiologists would provide personal care for complex cases or very high-risk patients, or might supervise a resident or a midlevel anesthesia practitioner.

As radical as such a proposal sounds, it offers an alternative vision for redesigning the delivery of anesthesia care and reducing costs. It would free the healthcare system from being held hostage by expensive midlevel anesthesia practitioners who believe their training makes them equivalent to physicians. I would rather supervise a nurse who understands her boundaries, and summons the responsible physician appropriately for consultation and further orders.

Barriers to change

Our colleagues in emergency medicine, gastroenterology, and pediatrics sail into the dangerous waters of deep sedation with hardly a glance back, while anesthesiologists hesitate to make any change in practice to adapt to an increasingly competitive environment. Until anesthesiologists come to terms with the fact that the world around us is changing rapidly and our business theory is failing, there is little hope that our specialty will survive as we know it. Certainly any anesthesiologist is living in a dream world if he believes that he can infuse propofol to one patient at a time in a GI suite or outpatient center for the next 20 or 30 years, and continue to enjoy a handsome six-figure income.

California anesthesiologists are understandably reluctant to embrace the anesthesia care team model if the only option is to work with nurse anesthetists. The American Association of Nurse Anesthetists (AANA) has clearly established itself as our opponent, and believes that there is no need for supervision by or consultation with anesthesiologists.

The California Society of Anesthesiologists stands in support of state regulation that would enable anesthesiologist assistants (AAs) to practice in California. Hiring AAs would be an excellent option for any group seeking to move toward the anesthesia care model. As opposed to nurse anesthetists, AAs practice under the authority of the state medical board and must be supervised by anesthesiologists. However, there are not nearly enough AAs in practice or in training to fill the need for cost-effective anesthesia services.

So we need to break the mold and look at different ways of providing anesthesia care, taking advantage of the technology that has made anesthesia remarkably safe. Sadly, some of the major barriers to our progress come from within. Leaders of anesthesiology groups tend to be near retirement age, and are more interested in protecting the status quo than in leading into the future. As Dr. Hicks of EmCare puts it, “Many anesthesia practices, like other medical practices and physicians in general, equate leadership with longevity and wisdom with accommodation.” Their resistance to change is driven by a desire to maintain political power and maximize current income.

Even our professional societies are failing us, in Dr. Hicks’ view. “Unfortunately, from my perspective,” he writes, “many leaders in anesthesiology are poorly equipped for this broader discussion and continue to view the care we deliver, and how we deliver it, through the lens of history. These leaders are clinging to what has worked or what is desired by our profession over what is needed or affordable by those who receive care, benefit by its delivery, or are responsible for its funding.”

We have an opportunity now to accept the fact that the Affordable Care Act is reality, and to use its principles to create new models of anesthesia care. The ACA promotes increasing scope of practice, and we can capitalize on that to make better use of nurses and physician assistants to extend our reach. We can encourage them to expand their career horizons and to work with us in the operating rooms and procedural suites. Instead of using an earpiece to monitor the heart rate and respirations of one patient, we can use technology to supervise the monitoring of multiple patients. By reducing the number of anesthesiologists needed in any given surgical or procedural suite, we can enable the anesthesiologists of the future to practice as the specialists they truly will be.

If I have any advice to give to residents today, it would be this: Gain all the specialty expertise you can. Do a fellowship; seek out the tough cases; differentiate yourself from a midlevel anesthesia practitioner. Use your specialist education to its fullest extent, and learn to work with other clinicians to manage the cases that don’t require your continuous expertise. They don’t need to know advanced interventional pain techniques or transesophageal echo in order to monitor a patient who is having a knee arthroscopy or an inguinal hernia repair. You can survive the winds of change if you’re well prepared and flexible. Too many anesthesiologists are in denial, and are irrationally optimistic that their current practices will never be at risk. In anesthesia, as in the rest of life, pessimists may be more likely to learn to survive.

Karen S. Sibert is an associate professor of anesthesiology, Cedars-Sinai Medical Center. She blogs at A Penned Point.
 
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"America's Bitter Pill": Behind Obamacare, healthcare costs

JANUARY 5, 2015, 8:31 AM|The government says more than 6.5 million people signed up for 2015 medical coverage through the Affordable Care Act's website. Coverage is expanding and so are costs. Steven Brill, who has spent years investigating the health care industry and the creation of Obamacare, joins "CBS This Morning" to discuss his new book, "America's Bitter Pill."

http://www.cbsnews.com/videos/americas-bitter-pill-behind-obamacare-healthcare-costs/
 
The "fiscal Crisis" which the author says is coming to our government is probably a few years away as our elected leaders keep kicking the can down the road.
How much longer can we continue to borrow money and increase the debt? I have no idea but at some point the $18 Trillion then $20 trillion then $25 Trillion will likely come home to roost.


http://www.usdebtclock.org/current-rates.html
 
I once had a successful plastic surgeon say, not to me per se, but to the room in general, that "as long as you stay close to the patient you will always have a job". The further away you get from direct patient care, such as perhaps diagnostic radiology, the greater risk you will be.

This COULD apply to the chart signing anesthesiologist, but for those of us who maintain our direct patient care skills, we will always have a place in anesthesia delivery. Will it pay the premium over other providers as we have seen in the past? Maybe not.

Wanna hedge? Know how to take care of sick patients, and keep your hands on skills. Never lose the "flow" of direct delivery of an anesthetic. This is NOT that hard to do in ACT models, as I've stated many times.

To say that anesthesia by a human will be obsoleted is about as ludicrous as stating that, in OUR careers, robotic surgery will be performed by exclusively by the robot.

I know a mid-60's CRNA. Very nice guy. A little slower these days but still good at what he does. Sitting the stool day in and day out. He knows I love what I do and he'll often say how much fun he has doing what he does. Guys, there are WAY worse ways to earn a living.

Obsoleting an anesthesiologist? Too much education? Well, aren't the CRNA's mandating a "Doctorate" at some point in the near future for new grads? I don't know if that's settled down or not. But, the point IN GENERAL, in our society is emphasizing MORE education, not less. This is the absolute trend in our society and in the world.

Want that auto job that used to require a GED or H.S. Diploma? Better have a BA now. Wanna be a hot shot on Wall Street? 30 years ago, you could have done so with an HS Diploma, or more likely a BA. Now?? Better have the MBA. And not just ANY MBA. Same with law school. Wanna be a nurse with some future options? We like the BSN's, not the associates gals or the LPN's for sure.....

Suggesting that our training is going to OVERqualify us to be involved in anesthesia IMHO is fuc.king ridiculous. Guys, take a deep breath.

That being said, for the younger folks, realize that a lot of old-timer CRNAs that still sit stools, do so earning a very good wage, and having a pretty good lifestyle. This is our "bottom". If it comes to that, so be it. There are some things you can't control in life. We can try, but if we fail, you will still have a job.

If my future is making $80/hour for a 40 hour week, for around 150-160k and picking up some extra call or weekends for a max of 200K, then that sucks to be us, but it WILL NOT be a horrible life.

There will always be work if you stay CLOSE to the patient. I can think of many other specialties which are far more vulnerable to technology changes than is ours.

And with the complexity of patients I see almost daily, at a community hospital (NOT a tertiary care center), I'm just not that worried. Are changes coming which may effect us negatively? Looks like. But, lets be realistic about the future, not overly pessimistic.

Remember too, that these changes will be gradual over a period of years..... Deep breath people.....
 
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The "fiscal Crisis" which the author says is coming to our government is probably a few years away as our elected leaders keep kicking the can down the road.
How much longer can we continue to borrow money and increase the debt? I have no idea but at some point the $18 Trillion then $20 trillion then $25 Trillion will likely come home to roost.


http://www.usdebtclock.org/current-rates.html

There are a lot of things totally unsustainable in or US economy/society. I agree with you BLADE. But, as we've seen over and over, just because it "should" change, doesn't mean it WILL change. Being aware of our environment is very smart indeed. But, losing years on one's life (not suggesting YOU are) from obsessing about it isn't.

I've learned this mindset from some smart guys, and happy ones as well.
 
@BLADEMDA I thought the PSH model was the correct solution for ensuring Anesthesiology's viability in the modern, ObamaCare world?

http://forums.studentdoctor.net/threads/thank-you-asa.884348/

As the gatekeeper for reducing health care costs and optimizing care, doing ASA 3+ cases individually, as well as by owning the patient, wouldn't it follow that perioperative anesthesiologists would become indispensable in the eyes of the public and hospital administration?

(I keep going back and forth with doing Anesthesiology vs IM+sub-specialty. It's driving me nuts).
 
@BLADEMDA I thought the PSH model was the correct solution for ensuring Anesthesiology's viability in the modern, ObamaCare world?

http://forums.studentdoctor.net/threads/thank-you-asa.884348/

As the gatekeeper for reducing health care costs and optimizing care, doing ASA 3+ cases individually, as well as by owning the patient, wouldn't it follow that perioperative anesthesiologists would become indispensable in the eyes of the public and hospital administration?

(I keep going back and forth with doing Anesthesiology vs IM+sub-specialty. It's driving me nuts).

http://www.despair.com/worth.html
 
I worked my a** off to get into medical school and am busting my rear to learn as much as possible during it. To suggest that a nurse can replace physicians who have true medical expertise pisses me off to no end.

You can have all the righteous indignation you want, it's happening at an alarming pace.
 
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Are you pessimistic about PSH as well? Doesn't it increase the value of anesthesiologists in ACOs?

Very pessimistic. I'll retire from the practice of medicine before I work as an anesthesiologist in a PSH.
 
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Very pessimistic. I'll retire from the practice of medicine before I work as an anesthesiologist in a PSH.
Wow, seriously? Why is that? I really appreciate your perspective.

As naive as this may sound, to me PSH is like a promotion from actor to director/producer of a movie. More autonomy, more respect, more pay.
 
The average income of Crnas who is around $140k working 35 hours a week. Meaning they aren't cheap when compared to MDs who work 50 hours a week. It's the fat cats anesthesiologists who are really selling out (the ones who supervised and collect $500-600k).

There simply are not enough Crnas to "take over anesthesia". Plus many Crnas are not equipped to handle high acuity cases. Thousands or maybe 100k Crnas probably are in work situations where they haven't done a spinal or epidural in 10 years or more.

We be all dead by the time Crna supposely tAke over anesthesia.

And explain how Crnas are going to fill the gap with hospital calls when probably half aren't even going to want to work weekend (day shift).
 
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This was my favorite one from that website. And what Blade is poking at but not putting his finger on.

preservationdemotivator.jpg
 
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Wow, seriously? Why is that? I really appreciate your perspective.

As naive as this may sound, to me PSH is like a promotion from actor to director/producer of a movie. More autonomy, more respect, more pay.
The PSH is a theory that is based on creating a super anesthesiologist who is going to do the jobs of all the specialists who are currently involved in the care of the surgical patient for free.
That super anesthesiologist is going to do all the medical aspects of the surgeon's job , the job of the hospitalist, the job of the patient's primary physician, and the jobs of several consultants, all that for the same or less pay.
Does that really make sense to you?
Of course it appeals to hospital CEO's and to insurers since it provides free care, but it actually leaves the intra-operative domain completely to the midlevel providers.
Once anesthesiologists are no longer seen as the doctors who provide intra-operative anesthesia they will be seen as some sort of hospitalists or primary care physicians and that means they will be paid as such.
 
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Wow, seriously? Why is that? I really appreciate your perspective.

As naive as this may sound, to me PSH is like a promotion from actor to director/producer of a movie. More autonomy, more respect, more pay.

Oh my God, dude you are so wrong on this. The only thing it will be MORE of is work.
 
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The average income of Crnas who is around $140k working 35 hours a week. Meaning they aren't cheap when compared to MDs who work 50 hours a week. It's the fat cats anesthesiologists who are really selling out (the ones who supervised and collect $500-600k).

There simply are not enough Crnas to "take over anesthesia". Plus many Crnas are not equipped to handle high acuity cases. Thousands or maybe 100k Crnas probably are in work situations where they haven't done a spinal or epidural in 10 years or more.

We be all dead by the time Crna supposely tAke over anesthesia.

And explain how Crnas are going to fill the gap with hospital calls when probably half aren't even going to want to work weekend (day shift).

agreed on all points. not sure what the male to female ratio is for CRNA's but we have plenty of females that want daytime hours only......
 
New research just out in the journal Psychology and Aging says pessimists live longer and healthier lives. If this is true, then contemplating the future of anesthesiology ought to make us immortal, because our professional prospects don’t look bright. As we teach residents to do what we’ve always done, shouldn’t we ask ourselves honestly if we’re training them for a future that doesn’t exist?

Especially here in California, it seems likely that our predominantly MD-provided, fee-for-service practice of anesthesiology will not survive indefinitely, and perhaps not for long. We can blame the reelection of President Obama and the passage of the Affordable Care Act if we like, but the reality is that market forces were eventually going to catch up with us whether or not Mitt Romney went to the White House.


In a way, we’re the victims of our own success; we’ve made anesthesia so safe that everyone thinks there’s nothing to it. But that’s exactly the point. Technology has indeed made anesthesia much safer. When I started learning anesthesia, pulse oximetry and end-tidal CO2 monitoring were new to the market, unproven, and scarce. Now they’re everywhere. We fear the difficult airway less now that we have video laryngoscopes readily at hand.

Since technology is so much better, why do so many of us still believe that every case requires the costly expertise of a board-certified anesthesiologist? We can make the argument that physician-provided anesthesia care is simply better, in the way that a $75,000 BMW is a superior product to a $15,000 economy car. But in a world of increasing pressure to control healthcare costs, people are willing to consider cheaper solutions, and therein lies our risk.

Medicine isn’t the first business to be threatened by cost pressure and new technology. Look at what happened to vinyl records when CDs came on the market, and what happened to the demand for CDs when iPods and digital downloads appeared. Who could have imagined that the giant Eastman Kodak Company would crumble when digital photography killed the demand for camera film? People complained at first that the new technologies lacked the same sound quality or rich color, but as time passed the market no longer cared.

Clayton Christensen, a Harvard Business School professor, uses the term “disruptive innovation” to describe how “complicated, expensive products and services are eventually converted into simpler, affordable ones.” In a recent Wall Street Journal column, Christensen and his co-authors argue that accountable care organizations, or ACOs, can’t make a dent in costs because they won’t fundamentally disrupt and transform the delivery of American healthcare. While many anesthesiologists agreed with that assessment, they were appalled by the authors’ recommendation that policy makers “consider changing many anticompetitive regulations and licensure statutes that practitioners have used to protect their guilds.” The authors praised California for enabling “highly trained nurses to substitute for anesthesiologists”–the last thing anesthesiologists wanted to hear.

Has California’s “opt-out” changed the marketplace?

In the years since 2009, when Governor Schwarzenegger signed the “opt-out” letter that freed California nurse anesthetists from the CMS requirement for physician supervision, many of us haven’t seen huge changes yet in the delivery of anesthesia care. Most California anesthesiologists still provide personal care, one patient at a time, and believe their hospitals, surgeons, and patients are satisfied with the status quo.

But if you think everything is fine with your hospital because you take good care of your patients, you’ll hear a counterargument from Dr. Michael R. Hicks, an anesthesiologist and executive who heads anesthesia services for EmCare, a national physician practice management firm. In an online article, “Disruption and the Theory of the Anesthesia Business,” Dr. Hicks wrote, “Nearly every anesthesia practice that I have seen replaced has had satisfied patients.” But the incumbent group fell out of favor and lost its contract because it became “out of touch with its environment, and secure in the knowledge, erroneously so, that the group and group members are irreplaceable.”

One southern California anesthesiologist who coordinates anesthesia services for several hospitals recently hired his first nurse anesthetist to practice on her own, without any supervision. She works on a flexible schedule when he needs to staff an additional operating room with routine cases. He’s quite pleased with the quality of her practice and her work ethic, as opposed to some younger anesthesiologists he’s hired who arrive with a sense of entitlement and a list of demands. “She’s a lot less trouble,” the anesthesiologist says.

Anecdotal evidence suggests that anesthesiologist pay in California is on a downward trajectory, perhaps because employers are aware that they could hire nurse anesthetists instead, and are bolder about extending low offers. An academic anesthesiologist, posting recently on the physician-only website Sermo, bemoaned the fact that an excellent resident accepted a job offer for pay that was barely above that of a nurse anesthetist. Anesthesiologists who want to work in desirable locations like the Bay area, work part-time, or work in surgery centers with no call and no weekends, appear to be willing to accept pay that no one would have considered competitive just a few years ago.

Understanding “disruptive innovation”

Clearly, there are major fault lines beneath the anesthesia marketplace. Much as we may dislike Professor Christensen’s comment about nurse anesthesia, perhaps we should hear more about his theory of disruptive innovation before we call for his head on a pike. With co-author Jason Hwang, he wrote an elegant article for Health Affairs that examines the theory’s implications for health care.

The traditional business model of hospitals and physician practices has been the “solution shop”–an institution created to diagnose and solve complex, unstructured problems, staffed by experts. This business model still works well for consulting firms and law firms, for instance. In medicine, the “solution shop” model evolved in an era when medical care involved minimal technology and relied upon the diagnostic intuition and hands-on experience of highly skilled physicians.

But times have changed. Two other business models now apply as well to the delivery of health care:

1. Value-added businesses: Like traditional manufacturing firms and restaurants, these businesses transform resources into outputs of greater value. They focus on process excellence and efficiency in order to produce high-quality products consistently and at low cost.

2. Facilitated user networks: These businesses deliver value and make money by facilitating the operation of a network and its user transactions. Examples are mutual insurance companies, stock exchanges, and banks.

As Christensen and Hwang view American health care, the current crisis was inevitable once hospitals and physician practices that began as highly competent solution shops started to change haphazardly. They “subsumed under their organizational umbrellas many activities that are perhaps better suited to businesses based on value-adding processes or user-network models. The legacy institutions of health-care delivery are jumbled mixtures of multiple business models struggling to deliver value out of chaos, incorporating indecipherable systems of cost accounting, excessive overhead, pervasive cross-subsidization, and an unacceptable amount of variability and medical error.”

Instead, the authors suggest, we should separate the diagnostic and intellectual work of physicians (the solution shop) from the value-added processes of health care. In other words, it doesn’t make sense for me, as an expensive and highly trained anesthesiologist, to change the suction canister on the anesthesia machine, push the gurney down the hall, and watch the ventilator during a long, stable case. Those tasks could be done by someone else at far less cost, someone who wouldn’t be qualified to decide if the patient is in optimal condition for surgery or to formulate the anesthetic plan. Many of the predictable, routine processes of anesthesia care don’t require anesthesiologist-level training.

As the authors explain, “When the value-adding procedures are organizationally separated from the work of solution shops, the overhead costs of the value-adding process hospitals and clinics can deliver care at prices that are 60% lower than those at hospitals and physician practices in which the business models of value-adding businesses and solution shops are conflated.”

If anything, this approach values physician time and education more highly, pointing out that it is a mistake to focus on reducing physician pay. “Cutting reimbursement in an attempt to force the solution-shop business models of hospitals and physician practices to somehow figure out a way to become more efficient does little to improve health care delivery,” the authors conclude. “With lower reimbursement, hospitals and physicians struggle even more to fulfill their value propositions of providing complex, inherently expensive medical care, and they become even less inclined to hand off work to value-added process businesses.”

Starting over: Stop squeezing the bag

If we could start all over again and develop the optimal model for delivering anesthesia care, what would it look like? I bet that it would have little in common with anesthesia practices today. If we let go of the idea that squeezing the bag in person is the only anesthesia-related activity that deserves compensation, then a world of possibilities opens up.

Right now, there are three models of anesthesia care in the U.S.:

1. Personally provided care by an anesthesiologist;

2. The anesthesia care team model in which anesthesiologists supervise nurse anesthetists, anesthesiologist assistants, and/or residents;

3. Personally provided care by a nurse anesthetist.

When we look at delivery of care in different settings, it becomes clear how much irrationality there is to current practice patterns. Why is it routine for a cardiologist or a gastroenterologist to supervise a nurse who is administering sedation, but an anesthesiologist only supervises a much more expensive midlevel anesthesia practitioner or resident? Why is it routine for an ICU nurse to monitor a patient who is intubated and receiving medications like fentanyl, midazolam, and propofol, but the same nurse isn’t allowed to monitor the same patient the moment he crosses the OR threshold?

Perhaps we need to change the conversation, and draw a distinction between “giving anesthesia” and monitoring patients.

Consider the patients who need sedation in outpatient settings, cardiac catheterization labs, and gastroenterology suites, for instance. Envision a scenario where an anesthesiologist supervises several nurses who are trained to administer sedation. The anesthesiologist has evaluated the patients, and is capable of converting any case to deep sedation or general anesthesia if the need arises. We improve patient safety by eliminating the all too common crisis when the patient under sedation gets into trouble and an anesthesiologist must be paged stat from elsewhere in the hospital. We eliminate the chance of having a case canceled in midstream because the patient can’t be adequately sedated and “anesthesia” isn’t available. We provide better service to the hospital by taking responsibility for all these cases, and the problem of scheduling “anesthesia” for occasional cases disappears. Potential liability decreases for the hospital as well as the surgeon or proceduralist, and the cost is far less than it would be with an anesthesiologist or a midlevel anesthesia practitioner assigned to every case.

Now consider patients who are having procedures performed under regional block with sedation. Once the anesthesiologist has placed the block, the patient has been sedated, and vital signs are stable, is there really a compelling reason why a sedation nurse could not monitor the patient with the anesthesiologist immediately available?

Of course, under the current fee-for-service payment model, none of these options are feasible. Under an integrated care model, however, the facility could offer a reduced price for the entire procedure, which would include the anesthesiology and sedation services. We redefine the nurses’ role so that instead of “providing anesthesia” they are monitoring patients who are under the anesthesiologist’s care.

We can envision an intelligently designed operating suite where the appropriate level of care is determined for each patient after evaluation by an anesthesiologist. Nurse practitioners or physician assistants would facilitate patient evaluation and throughput in the preoperative area, and assist anesthesiologists in the placement of regional blocks. Aides or technicians would facilitate room turnover, setting up fresh circuits, suction, and airway equipment. Staggered case starts would ensure that an anesthesiologist is present at the onset of each case, and then would delegate to the appropriate level of care for monitoring: a sedation nurse or a critical care nurse, for instance. Today’s technology can enable an anesthesiologist to view operating rooms and vital sign monitors from a tablet computer, and respond to any change in patient status. Anesthesiologists would provide personal care for complex cases or very high-risk patients, or might supervise a resident or a midlevel anesthesia practitioner.

As radical as such a proposal sounds, it offers an alternative vision for redesigning the delivery of anesthesia care and reducing costs. It would free the healthcare system from being held hostage by expensive midlevel anesthesia practitioners who believe their training makes them equivalent to physicians. I would rather supervise a nurse who understands her boundaries, and summons the responsible physician appropriately for consultation and further orders.

Barriers to change

Our colleagues in emergency medicine, gastroenterology, and pediatrics sail into the dangerous waters of deep sedation with hardly a glance back, while anesthesiologists hesitate to make any change in practice to adapt to an increasingly competitive environment. Until anesthesiologists come to terms with the fact that the world around us is changing rapidly and our business theory is failing, there is little hope that our specialty will survive as we know it. Certainly any anesthesiologist is living in a dream world if he believes that he can infuse propofol to one patient at a time in a GI suite or outpatient center for the next 20 or 30 years, and continue to enjoy a handsome six-figure income.

California anesthesiologists are understandably reluctant to embrace the anesthesia care team model if the only option is to work with nurse anesthetists. The American Association of Nurse Anesthetists (AANA) has clearly established itself as our opponent, and believes that there is no need for supervision by or consultation with anesthesiologists.

The California Society of Anesthesiologists stands in support of state regulation that would enable anesthesiologist assistants (AAs) to practice in California. Hiring AAs would be an excellent option for any group seeking to move toward the anesthesia care model. As opposed to nurse anesthetists, AAs practice under the authority of the state medical board and must be supervised by anesthesiologists. However, there are not nearly enough AAs in practice or in training to fill the need for cost-effective anesthesia services.

So we need to break the mold and look at different ways of providing anesthesia care, taking advantage of the technology that has made anesthesia remarkably safe. Sadly, some of the major barriers to our progress come from within. Leaders of anesthesiology groups tend to be near retirement age, and are more interested in protecting the status quo than in leading into the future. As Dr. Hicks of EmCare puts it, “Many anesthesia practices, like other medical practices and physicians in general, equate leadership with longevity and wisdom with accommodation.” Their resistance to change is driven by a desire to maintain political power and maximize current income.

Even our professional societies are failing us, in Dr. Hicks’ view. “Unfortunately, from my perspective,” he writes, “many leaders in anesthesiology are poorly equipped for this broader discussion and continue to view the care we deliver, and how we deliver it, through the lens of history. These leaders are clinging to what has worked or what is desired by our profession over what is needed or affordable by those who receive care, benefit by its delivery, or are responsible for its funding.”

We have an opportunity now to accept the fact that the Affordable Care Act is reality, and to use its principles to create new models of anesthesia care. The ACA promotes increasing scope of practice, and we can capitalize on that to make better use of nurses and physician assistants to extend our reach. We can encourage them to expand their career horizons and to work with us in the operating rooms and procedural suites. Instead of using an earpiece to monitor the heart rate and respirations of one patient, we can use technology to supervise the monitoring of multiple patients. By reducing the number of anesthesiologists needed in any given surgical or procedural suite, we can enable the anesthesiologists of the future to practice as the specialists they truly will be.

If I have any advice to give to residents today, it would be this: Gain all the specialty expertise you can. Do a fellowship; seek out the tough cases; differentiate yourself from a midlevel anesthesia practitioner. Use your specialist education to its fullest extent, and learn to work with other clinicians to manage the cases that don’t require your continuous expertise. They don’t need to know advanced interventional pain techniques or transesophageal echo in order to monitor a patient who is having a knee arthroscopy or an inguinal hernia repair. You can survive the winds of change if you’re well prepared and flexible. Too many anesthesiologists are in denial, and are irrationally optimistic that their current practices will never be at risk. In anesthesia, as in the rest of life, pessimists may be more likely to learn to survive.

Karen S. Sibert is an associate professor of anesthesiology, Cedars-Sinai Medical Center. She blogs at A Penned Point.

actually this is an excellent post.
 
Very pessimistic. I'll retire from the practice of medicine before I work as an anesthesiologist in a PSH.
I don't often agree with your outlook on the specialty, but I totally agree with this.

I can see myself sticking up liquor stores before playing that game.
 
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agreed on all points. not sure what the male to female ratio is for CRNA's but we have plenty of females that want daytime hours only......
Plus female crnas or srnas probably 30-40% of them are child bearing ages (26-40) these days.

Most are bound to want to have a family lifestyle.

Male anesthesioogists still far out number female anesthesioogists.

But Crnas the ratio is way different.

Talked to one of my Crnas friends up north. She's saying 4 are already on maternity leave and another 3 are pregnant in their practice of 40 MDs and 50 Crnas. Down south. My old practice has had 4 Crnas deliver in past 12 months. And 3 more are pregnant also.

Just baby factories.
 
actually this is an excellent post.

I agree. The article is extremely intelligent. Utilize anesthesiologist in their highest capacity while keeping militant CRNAs out of it. Create competition for CRNAs by bringing in other nurses and PAs into anesthesia care. This seems like a great solution to the current dilema that we face as a specialty. If CRNAs want to practice independently, great, let them. In fact, we should encourage CRNAs to practice independently. For two long they have been having their cake and eating it too. Let them have a piece of the pie and take on the responsibility of solo practitioners. We can practice under the care model with less militant nurses and PAs who know their boundaries. I realize that we have AAs as competition to CRNAs but let's bring in other nurses and PAs. CRNAs claim that they can do an anesthesiologist's job just as well. Anesthesiologist should demonstrate that any RN or PA can learn to do their job just as well. They will be begging for jobs if this were to happen. This is the type of things that the ASA should be working on. Practice innovation and new business model for providing anesthesia. Not the stupid PSH garbage.

CRNAs will have no way to compete with a practice model where MDs supervise PAs or ICU nurses 4:1. Why do we need CRNAs to be stool sitters? Does it really take a CRNA to sit there and chart vitals, raise the bed, etc.? Any nurse or PA can do this at a much lower cost. That will be real money saving. Supervise PAs or ICU nurses 4:1 and pay them 50-60k per year. If we are destined to be supervisors why do we have to supervise CRNAs? Who the hell needs CRNAs?!
 
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The average income of Crnas who is around $140k working 35 hours a week. Meaning they aren't cheap when compared to MDs who work 50 hours a week. It's the fat cats anesthesiologists who are really selling out (the ones who supervised and collect $500-600k).

There simply are not enough Crnas to "take over anesthesia". Plus many Crnas are not equipped to handle high acuity cases. Thousands or maybe 100k Crnas probably are in work situations where they haven't done a spinal or epidural in 10 years or more.

We be all dead by the time Crna supposely tAke over anesthesia.

And explain how Crnas are going to fill the gap with hospital calls when probably half aren't even going to want to work weekend (day shift).


Let me explain briefly some of my thoughts of why I posted this thread:

1. 60 minutes ran a piece on the ACA regarding its lack of cost control. Hence, in 3-5 years the ACA is a budget buster which requires major tweaking or the public option. I, for one, think that in 3-5 years the Democrats will push through the public option just like they did the ACA.

2. The public option means Anesthesiologists are reimbursed at CRNA level income. If we continue to supervise 4:1 or even 6:1 expect more work and vastly lower pay for such work. This is the course we are on and I don't see the PSH changing that outcome. I do see that young graduates, the med students of today, will likely earn a lot less money in this field. This job is a lot of stress and high acuity work which deserves fair market compensation. CMS does not reimburse anesthesia anything close to fair market value.

3. CRNAs are winning the propaganda war and the ACA favors CRNAs as the primary provider of anesthesia. Again, when cost cutting starts to occur the CRNA wage may fall to $100K per year. Are you willing to work for that level of CRNA pay?

4. I totally agree with Karen Sibert that we should hire RN's with their CCRN to staff the ORs. in the new paradigm of global fees we can reduce costs by utilizing PAs, AAs or RNs to staff the ORs. Unfortunately, we still take a huge pay cut but the hospital gets M.D. coverage for the O.R.s instead of CRNAs.


Our future depends on taking action while there is still time. Instead of the PSH, the ASA could embrace improved technology which allows Nurses to monitor patients while we administer the anesthetic itself.

We are losing the war to the AANA and the ACA will likely not be favorable to the medical specialty of Anesthesiology over the long run.
 
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Some of the older folks on SDN are well aware of the bleak economic future of this field. Many have sold or will sell their practices to AMCs. These changes will occur slowly with the time frame being at least 3-5 years from now. The real driver behind our demise is pressure from the AANA, Legislative losses concerning opt out at the State level, the gradual but continual erosion of anesthesiology as a medical specialty, more solo CRNA work with each passing year, improving technology which allows CRNAs to perform the same tasks as we do now and finally, the ACA which will likely lead to a medicare option on the exchange or a single payer system.

I wish I had the answers to solve all these issues. I do not; instead, all I know is we are a facing a crisis of epic proportions which will redefine this specialty permanently.

My advice to those who are able to do so is work hard, save your money and budget appropriately. Winter is coming to Anesthesiology.
 
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The average income of Crnas who is around $140k working 35 hours a week. Meaning they aren't cheap when compared to MDs who work 50 hours a week. It's the fat cats anesthesiologists who are really selling out (the ones who supervised and collect $500-600k).

There simply are not enough Crnas to "take over anesthesia". Plus many Crnas are not equipped to handle high acuity cases. Thousands or maybe 100k Crnas probably are in work situations where they haven't done a spinal or epidural in 10 years or more.

We be all dead by the time Crna supposely tAke over anesthesia.

And explain how Crnas are going to fill the gap with hospital calls when probably half aren't even going to want to work weekend (day shift).


When I say "take over anesthesia" I am referencing the AANA's goal to equate CRNA with MDA. Once we allow ourselves to be equated with CRNAs we have lost the medical specialty of Anesthesiology and entered the realm of Nursing. Semantics defines who we are and the value society places on us. The term anesthesia provider, colleague, MDA, etc are all utilized in an effort to reduce us to the level of the lower provider. The DNP is now in place to truly confuse the CFO, the lay public and anyone else foolish enough to believe the propaganda that all anesthesia training and all anesthesia providers are equal. The end result is we are demoted to a field of nursing and the compensation from CMS is appropriate for such a field.

Those who do Nursing level work deserve Nursing level pay.
 
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We anesthesiologists are so busy in our ivory towers trying to understand the molecular basis of lung ventilation in the name of patient safety that we have failed to see the soul of anesthesiology is being hijacked by the nurses. While the AANA is cranking out multiple papers per year on why they are at least equivalent to MDAs for less cost, we haven't produced a study demonstrating the value of anesthesiologists in today's health care environment. The nurses only need to prove they provide care as well as doctors to have an advantage, because if all else being equal, the deciding factor will be cost, their ultimate trump card. If that situation should come to pass, the only way we anesthesiologists can stay gainfully employed is if we lower ourselves to an equivalent salary. That will indeed be a sad day for anesthesiology.

ZMD
 
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For the life of me, I cannot understand CRNA motivation to equate themselves to MDs. Why are they trying to gain independence and more responsibility, hours, call, etc.? It seems like they have a pretty sweet set up right now. If they equate themselves fully with us, it will only drive down theirs and our salary and will put us in direct competition with them for jobs. They will surely lose this competition and the end result will be record low salaries for anesthesiologists with a A LOT of unemployed CRNAs. Seems like a lose, lose situation. Do they not see this coming?! Why not keep the set up that we currently have going, the ACT model.
 
4. I totally agree with Karen Sibert that we should hire RN's with their CCRN to staff the ORs. in the new paradigm of global fees we can reduce costs by utilizing PAs, AAs or RNs to staff the ORs. Unfortunately, we still take a huge pay cut but the hospital gets M.D. coverage for the O.R.s instead of CRNAs.

What will it take to make this a reality? How can we put PAs and CCRNs in direct competition with CRNAs? What is preventing this at the moment? Seems like a great way for PP solo MD groups to expand and start making some major $$$
 
While pessimism is "healthy" for an individual, it works to our detriment as a specialty to proclaim anesthesiology will die and our salaries will be reduced to nuclear rubble.

There is such a thing as self-fulfilling prophecy. Many economic models utilize the "expected price" in the short run which slowly becomes the "actual price" in the medium to long run. We shouldn't set expected price so low now. If everyone expects their salary to go down it will.

We should breed optimism in our profession so that people will stop
prophesizing and thus making reality that, for example, 1. a public option is the only way, 2. if a public option is adopted they will not reconfigure DRG / CPT reimbursement schematics to more fairly represent anesthesia, primary care, etc. 3. nursing propaganda will reign supreme and demons will rise to reclaim earth.
 
While pessimism is "healthy" for an individual, it works to our detriment as a specialty to proclaim anesthesiology will die and our salaries will be reduced to nuclear rubble.

There is such a thing as self-fulfilling prophecy. Many economic models utilize the "expected price" in the short run which slowly becomes the "actual price" in the medium to long run. We shouldn't set expected price so low now. If everyone expects their salary to go down it will.

We should breed optimism in our profession so that people will stop
prophesizing and thus making reality that, for example, 1. a public option is the only way, 2. if a public option is adopted they will not reconfigure DRG / CPT reimbursement schematics to more fairly represent anesthesia, primary care, etc. 3. nursing propaganda will reign supreme and demons will rise to reclaim earth.


Demons will rise to reclaim the earth? Is that what we are posting on here? There is a paradigm shift going on in this field. The AMCs know it, I know and soon all the CEOs will know it. Either we adjust to the new paradigm and prove our worth or we are relegated to the dust bin of history. The likely scenario/model going forward is indeed higher supervision ratios and/or the collaborative model promoted by the AANA. As for salaries, they are already decreasing across the USA due to the increasing presence of AMCs. Those of you fortunate to have good jobs should be happy about it as the downward spiral of the specialty has begun for a lot of CA3s.

The market will set salaries for our field. This means AMCs, hospital CEOs and of course, CMS all have a say in that market. There is still time to earn good money and save for the future.
 
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Demons will rise to reclaim the earth? Is that what we are posting on here? There is a paradigm shift going on in this field. The AMCs know it, I know and soon all the CEOs will know it. Either we adjust to the new paradigm and prove our worth or we are relegated to the dust bin of history. The likely scenario/model going forward is indeed higher supervision ratios and/or the collaborative model promoted by the AANA. As for salaries, they are already decreasing across the USA due to the increasing presence of AMCs. Those of you fortunate to have good jobs should be happy about it as the downward spiral of the specialty has begun for a lot of CA3s.

The market will set salaries for our field. This means AMCs, hospital CEOs and of course, CMS all have a say in that market. There is still time to earn good money and save for the future.

You should run for president
 
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I don't often agree with your outlook on the specialty, but I totally agree with this.

I can see myself sticking up liquor stores before playing that game.
I'm certainly not rooting for PSH but could it be that by owning "a larger part of the peri-operative patient" we would be at an advantage for claiming a bigger share of a bundle payment? I can see that political battle happening in academics (maybe why they are pushing for it...?).
 
I hope that the additional funding created by the ACA is handled in another manner rather than the Medicare Option. I hope that the ASA holds the ground against the AANA. I hope you all get great jobs and/or make 75th% income or more. But, hope isn't a strategy for going forward or something we can count on. Instead, we must plan for the worst case scenario and be realistic what the future holds in store for our specialty due to the ACA and its budget buster subsidy programs.
 
I don't understand how the asa has so little teeth when the president is a former nurse anesthetist. I mean, what greater trump card can you have than that?
 
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Blade,
How do you expect AMC's to fare under a single-payer system where reimbursements would be far less?
My guess is that docs and crnas alike will both get cuts while executive's salaries stay the same...
 
My guess is that docs and crnas alike will both get cuts while executive's salaries stay the same...


Executive's salaries will go up. That's the way it always happens.

They will cut the salaries and number of employees (replacing MDs with NPs as possible), then be praised for "balancing" the budget and secure themselves a nice raise at the same time.
 
I am hoping for Romney/Carson 2016 to bring respect and order back to America. Doctors will once again be the undisputed leaders of hospitals and all this advanced nurse practitioner BS will be killed.

With all the bad press Obamacare seems to be getting nowadays, it's as if the Supreme Court is prepping the nation for a big repeal.
 
I am hoping for Romney/Carson 2016 to bring respect and order back to America. Doctors will once again be the undisputed leaders of hospitals and all this advanced nurse practitioner BS will be killed.

With all the bad press Obamacare seems to be getting nowadays, it's as if the Supreme Court is prepping the nation for a big repeal.

You do realize Romney
1. Basically implemented Obamacare in Massachusetts when he was governor
2. Already managed to lose a presidential election running against a fairly unpopular opponent
3. Is a total dweeb
4. Is a businessman who would praise hospital CEOs for cutting costs

Carson would be good, though.
 
You do realize Romney
1. Basically implemented Obamacare in Massachusetts when he was governor
2. Already managed to lose a presidential election running against a fairly unpopular opponent
3. Is a total dweeb
4. Is a businessman who would praise hospital CEOs for cutting costs

Carson would be good, though.
I think there is a difference between Obamacare is one state vs. socialized health care for the entire nation though.
 
I am hoping for Romney/Carson 2016 to bring respect and order back to America. Doctors will once again be the undisputed leaders of hospitals and all this advanced nurse practitioner BS will be killed.

With all the bad press Obamacare seems to be getting nowadays, it's as if the Supreme Court is prepping the nation for a big repeal.

:laugh:
 
Crnas I stated earlier average $140k give or take.

Let's say if you take out all the anesthesioogist and drive Crnas salary down to say $100k a year.

Consider many Icu nurses can make close to $80--90k easily. Many travelers I know pull over $120-130k.

Would a nurse commit 3 years more in a highly stressful training with no pay. Accumulate close to $100k plus or more (3 years Crna school with dnp)or more of debt for a measly $10-20k a year bump in income.

That's the million dollar question.

The jump in salary wouldn't be much.

Look at NPs. Most jump from $40-50k RN salaries to $70-90k income. That makes it worth it if their income about doubles.

If we all think salaries are going down for anesthesia overall. Than Crnas will have to take $100k a year as well (my brother is cardiac anesthesia fellowship trained and was making only $110k starting out in 1996). Times were tough than.

So will Crnas works for $100k a year thAr includes overnight shifts and weekends?
 
Crnas I stated earlier average $140k give or take.

Let's say if you take out all the anesthesioogist and drive Crnas salary down to say $100k a year.

Consider many Icu nurses can make close to $80--90k easily. Many travelers I know pull over $120-130k.

Would a nurse commit 3 years more in a highly stressful training with no pay. Accumulate close to $100k plus or more (3 years Crna school with dnp)or more of debt for a measly $10-20k a year bump in income.

That's the million dollar question.

The jump in salary wouldn't be much.

Look at NPs. Most jump from $40-50k RN salaries to $70-90k income. That makes it worth it if their income about doubles.

If we all think salaries are going down for anesthesia overall. Than Crnas will have to take $100k a year as well (my brother is cardiac anesthesia fellowship trained and was making only $110k starting out in 1996). Times were tough than.

So will Crnas works for $100k a year thAr includes overnight shifts and weekends?

I think that the answer is no. I don't think many CRNAs want to have anything to do with independent practice. They love their cush job where they take home 6 figure salaries without any of the stress and responsibility of an anesthesiologist. It's only a few idiotic militant ones that are pushing for independence. Most are perfectly happy with the care model. This is a big reason why CRNAs will never replace anesthesiologists. In general, they have a totally different "punch in, punch out" work ethic.
 
I think that the answer is no. I don't think many CRNAs want to have anything to do with independent practice. They love their cush job where they take home 6 figure salaries without any of the stress and responsibility of an anesthesiologist. It's only a few idiotic militant ones that are pushing for independence. Most are perfectly happy with the care model. This is a big reason why CRNAs will never replace anesthesiologists. In general, they have a totally different "punch in, punch out" work ethic.

I have noticed this for sure.
 
I think that the answer is no. I don't think many CRNAs want to have anything to do with independent practice. They love their cush job where they take home 6 figure salaries without any of the stress and responsibility of an anesthesiologist. It's only a few idiotic militant ones that are pushing for independence. Most are perfectly happy with the care model. This is a big reason why CRNAs will never replace anesthesiologists. In general, they have a totally different "punch in, punch out" work ethic.
Once we become mostly employees (as a specialty), we will get exactly the same work ethic. There is no incentive in working more for the same money, and time at work.
 
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Once we become mostly employees (as a specialty), we will get exactly the same work ethic. There is no incentive in working more for the same money, and time at work.

I'm not sure how this will work. Hospitals need physicians willing to work physician hours to make the system work. If physicians start to develop this "CRNA like" work ethic, there will be a lot of voids in the system and need for people to cover call, nights, weekends, etc. I think if this ends up happening and all physicians become employees, they will likely all form unions. This will likely restrict physician work hours to 40 hr/week with hospitals having to pay extra to cover nights, weekends, holidays, call, etc. This may put those physicians still willing to bust their tales at a financial advantage.
 
I'm not sure how this will work. Hospitals need physicians willing to work physician hours to make the system work. If physicians start to develop this "CRNA like" work ethic, there will be a lot of voids in the system and need for people to cover call, nights, weekends, etc. I think if this ends up happening and all physicians become employees, they will likely all form unions. This will likely restrict physician work hours to 40 hr/week with hospitals having to pay extra to cover nights, weekends, holidays, call, etc. This may put those physicians still willing to bust their tales at a financial advantage.
Anesthesia will be shift work. Like ICU, ER, radiology, nursing. Unpopular shifts will be paid more than popular ones. Nothing complicated here.
 
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