As anesthesia costs climb and workforce shortages persist, the conversation around who delivers care can often be oversimplified, according to Brian Cohen, MD, administrative chief of Miami Anesthesia Services.
Dr. Cohen joined Becker’s to discuss how the anesthesia care team can demonstrate its full perioperative value beyond the operating room.
Question: What are some key points from anesthesiologists that you feel are missing in current discussions about anesthesia workforce and cost challenges?
Editor’s note: This interview was edited lightly for clarity and flow.
Dr. Brian Cohen: There isn’t just one solution to the anesthesia workforce or cost challenges. If you look at costs specifically, in many areas CRNA costs are creeping up to the hourly or even annual cost of an anesthesiologist. There’s less and less delta between the numbers — which is something that usually self-corrects, but it’s important to keep in mind.
On the workforce side, it often appears that there are greater total numbers of CRNAs available. What we’ve found, and this can be somewhat regional, is that there’s a tendency for CRNAs to focus more on 1099 or independent contractor agreements. That lends them to share their time among multiple centers, meaning it actually requires more CRNAs to create one full-time equivalent for a specific center.
So, it’s not just ‘Are MDs the solution?’ or ‘Are CRNAs the solution?’ It’s more complicated, especially when you factor in different supervision models, CRNA opt-out state nuances and some aggressive payer tactics. All of this creates a system that can’t be approached as black-and-white, CRNA vs. physician anesthesiologist.
That forces us to take a step back and look at this more as a team approach. The key question is: How can the anesthesia team deliver value that’s on par with their cost? Too often, the discussion focuses only on ‘What’s the lowest cost per hour to get a patient through surgery?’ But anesthesia is really 360-degree management of the entire perioperative period — from preoperative clinics and screening to intraoperative management, specialized procedures like nerve blocks and postoperative management.
Some of that 360-degree management requires physician oversight, while other parts can be co-managed or performed independently by CRNAs. But from a liability and efficiency standpoint, there’s a reason the care team model remains standard. Ultimately, the onus falls back on the physician anesthesiologist to deliver perioperative leadership and value so that the conversation isn’t just about cost and workforce — it’s about the full value.
The perioperative period isn’t just when the anesthesiologist is in the OR with the patient. There’s financial value, billable events, but also nonfinancial efficiency value.
When anesthesiologists oversee preoperative optimization, it leads to fewer cancellations and complications. Those are dependent and independent values that come from oversight and the full view. But the focus has shifted toward ‘How can I do this case for the cheapest amount?’ and that broader value is being lost in the discussion.
Q: Do you think physician anesthesiologists have focused less on this in recent years? Has there been a shift?
BC: That’s a fair question. For a while, I was surprised by it too. I think it’s easy to assume anesthesiologists naturally take on all leadership responsibilities across the perioperative period, but that’s not always true — nor is it always necessary.
Within every organization, large or small, you have to allocate resources based on the strengths of the care team. There should be a leader — someone to conduct the orchestra — but also other members doing what’s needed to make the whole process work. It’s not that anesthesiologists are or aren’t doing this; it’s more that companies need to identify strengths and use them effectively.
Another factor is financial: we’re talking about this more now because margins aren’t what they used to be. There are more stakeholders deciding how dollars are allocated. Hospitals and ASCs that used to not pay subsidies now do — and they want accountability for performance. That’s not a bad thing, but it has forced conversations that weren’t happening before, when anesthesia was more self-sustaining.
