Bundled Care / Value Based Care: Certified Registered Nurse Anesthetists (CRNAs) will be impacted by the challenges of bundled and value based care as the trend continues. As we move away from fee for service and toward bundled care, where every specialty has to carve out their portion of the pie, CRNAs want to ensure anesthesia services are valued appropriately. Proponents of bundled care suggest it will lead to increased accountability for health care spending by ensuring that care given is actually needed, ultimately resulting in better care coordination. Opponents suggest that there is no evidence bundled care would decrease costs, and argue that it will end up with contention between provider groups for reimbursement. For anesthesia providers this may translate into lower reimbursement and increased workload. The unfortunate unintended consequence of this might wind up being decreased interest in anesthesia by nursing and medical students, as well as more CRNAs and anesthesiologists leaving the profession early, thereby increasing the provider shortage we are already experiencing today.
Full Practice Authority: Certified Registered Nurse Anesthetists (CRNAs) identify full practice as one of their most important issues for job satisfaction. Per all research evidence since 2000, CRNAs provide cost effective, high quality, safe anesthesia care equivalent to anesthesiologists. The recent proposed rule to utilize all Veterans Administration (VA) APRNs, including CRNAs, to their full practice authority aims to expand access to care for our veterans and reduce the dangerously long wait times too many veterans routinely experience. The VA’s proposed rule would allow all APRNs to work to the full extent of their education, training, licensure, and certification just as they now do in all service branches of the U.S. military, Indian Health Services, and most states. Removing barriers to full practice authority has been recommended by the Institute of Medicine as well as the RAND corporation, which the VA retained to perform a review of this issue. This desperately needed common-sense initiative has met significant resistance from organized medicine, including the American Society of Anesthesiologists; however, physician groups have yet to produce any evidence-based rationale for their opposition to the proposed rule. It is sad to see our physician colleagues’ professional organizations put ‘incomes’ ahead of ‘outcomes.’
Proliferation of AMCs: Certified Registered Nurse Anesthetists (CRNAs) have taken notice as Anesthesia management companies (AMCs) have expanded their market share of anesthesia services significantly over the last decade. These companies leverage their large networks to negotiate higher rates from commercial insurance providers and use their market control to decrease employee compensation costs. They are rapidly purchasing private practices across the nation and are owned by profit-driven investors. Proponents of AMCs suggest the economy of scale decreases the costs of benefits and that negotiating higher commercial insurance rates drives down the costs of subsidies which are paid for by hospitals. While these are accurate assertions, there are other ways to achieve the same results. For instance, CRNA-only and collaborative models instead of directed/supervised practices can realize superior employment cost savings by eliminating high-cost, low-revenue generating providers. Opponents suggest that adding a third entity demanding revenue and increased profitability quarterly can only result in providers working harder and making less money without any benefit of ownership because of it. Additionally, AMCs often come with “the AMC way” of doing things, which does not take into account the unique needs of individual facilities. Lastly, the largest negative is the disincentive to go the extra mile. Providers who are paid a flat hourly rate or salary with no incentives or ownership tend to stop working when their shift is done. Staying later for extra cases and helping to move along OR turnover is the norm in a fee for service environment, as every case adds to income and delays only cost the providers revenue. When providers get paid the same if the turnover is 10 minutes or 45 minutes, there is a disincentive to working harder that can result in decreased productivity. Additionally, as anesthesia reimbursement stays relatively stagnant, it seems that eventually the only way for AMCs to increase their bottom line quarterly will be by decreasing salaries.
Predictions for the future: Certified Registered Nurse Anesthetists (CRNAs), like all healthcare professionals, face a variety of challenges in today’s healthcare environment. The anesthesia profession is faced with a future where stagnant reimbursement, a focus on safety/quality, and the demand for evidence will drive policy and practice. At the same time, the growing number of Baby Boomers who are retiring will increase the demand for healthcare services, including anesthesia services. The current anesthesia care team model, where there is one anesthesiologist for every four CRNAs, is a healthcare-system albatross which is not tenable to maintain in the future. It is fiscally irresponsible to pay a non-revenue generating anesthesiologist two to three times the salary of a CRNA when the evidence has shown such a provider does not improve quality, outcomes, morbidity or mortality. The future will see an expansion of collaborative anesthesia models where CRNAs and anesthesiologists are doing their own cases and they will be judged on performance and quality metrics, not initials. There will be an expansion of CRNA-only anesthesia services across the country in light of CRNAs near six sigma safety record and ability to provide high-quality, cost-effective anesthesia care. Facilities are not going to continue to pay millions a year in subsidies for providers who do not add concrete value to the process—they simply cannot afford to.