Quality, Costs, and Policy: Factors Influencing Choice of Anesthesia Staffing Models.

EXECUTIVE SUMMARY: Certified registered nurse anesthetists (CRNAs) can practice independently or with varying degrees of supervision by physicians or anesthesiologists. Before 2001, the Centers for Medicare & Medicaid Services (CMS) conditions of participation required CRNAs to be supervised by a physician. Starting in November 2001, CMS implemented an opt-out policy to give states greater autonomy in determining how anesthesia services are delivered. The policy also provided a mechanism to increase access to anesthesia services.We sought to understand and describe surgical facility leaders' perceptions of CRNA quality, safety, and cost-effectiveness; the motivation and rationale for using different anesthesia staffing models; and facilitators and barriers to using CRNAs. We applied a mixed-methods approach to understand surgical facility leadership decision-making for staffing arrangements.The use of anesthesia staffing models differed by location and surgical facility type. For example, the predominantly CRNA model was used in only 10% of large urban hospitals but in 61% of rural ambulatory surgical centers. Interviews with surgical facility leaders revealed that geographic location, surgeon preference, and organizational inertia were powerful contributors to a facility's choice of staffing model. Other factors included the Medicare opt-out provision, facility experience, and cost considerations. Differences in quality and safety between models were not contributing factors for most facilities.

Patient-controlled sedation with propofol for endoscopic procedures-A cost analysis.

BACKGROUND: Patient-controlled sedation (PCS) with propofol accompanied by a bedside nurse anaesthetist is an alternative sedation method for endoscopic procedures compared with midazolam administered by a nurse or endoscopist. Increasing costs in health care demands an economic perspective when introducing alternative methods. We applied a hospital perspective on a cost analysis comparing different methods of sedation and the resource use that were expected to affect cost differences related to the sedation. METHODS: Based on two randomised previous studies, the direct costs were determined for different sedation methods during two advanced endoscopic procedures: endoscopic retrograde cholangiopancreatography (ERCP) and flexible bronchoscopy including endobronchial ultrasound. ERCP comparisons were made between midazolam sedation by the endoscopic team, PCS with a bedside nurse anaesthetist and propofol sedation administered by a nurse anaesthetist. Bronchoscopy comparisons were made between midazolam sedation by the endoscopic team and PCS with a bedside nurse anaesthetist, categorised by premedication morphine-scopolamine or glycopyrronium. RESULTS: Propofol PCS with a bedside nurse anaesthetist resulted in lower costs per patient for sedation for both ERCP (233 USD) and bronchoscopy (premedication morphine-scopolamine 267 USD, premedication glycopyrronium 269 USD) compared with midazolam (ERCP 425 USD, bronchoscopy 337 USD). Aborted procedures that needed to be repeated and prolonged hospital stays significantly increased the cost for the midazolam groups. CONCLUSION: Propofol PCS with a bedside nurse anaesthetist reduces the direct sedation costs for ERCP and bronchoscopy procedures compared with midazolam sedation.

Advocacy, Research, and Anesthesia Practice Models: Key Studies of Safety and Cost-Effectiveness.

The practice of anesthesia includes multiple competing practice models, including services delivered by anesthesiologists, independent practice by certified registered nurse anesthetists (CRNAs), and team-based approaches incorporating anesthesiologist supervision or direction of CRNAs. Despite data demonstrating very low risk of death and complications associated with anesthesia, debate among professional societies and policymakers persists over the superiority or equivalence among these models. The American Society of Anesthesiologists uses published findings as evidence for claims that anesthesia is safer when anesthesiologists lead in providing care. The American Association of Nurse Anesthetists cites its own research on safety and cost-efficiency outcomes to defend against these claims. We review and critique studies of the safety outcomes and cost-effectiveness of anesthesia delivery that have been cited in the Federal Trade Commission comment letters related to competition in health care, where each profession has laid out their case for how they ought to be recognized in the market for anesthesia services. The Federal Trade Commission has a role in protecting consumers from anticompetitive conduct that has the potential to impact quality and cost in health care. Thus, it is important to evaluate the evidence used to make claims about these topics. We argue that while research in this area is imperfect, the strong safety record of anesthesia in general and CRNAs in particular suggest that politics and professional interests are the main drivers of supervision policy in anesthesia delivery.

History of anaesthesia: Nurse anaesthesia practice in the G7 countries (Canada, France, Germany, Italy, Japan, the United Kingdom and the United States of America).

: Many factors determine whether nurses, physicians or both administer anaesthesia in any country. We examined the status of nurse-administered anaesthesia in the Group of Seven (G7) countries (Canada, France, Germany, Italy, Japan, the United Kingdom and the United States of America) and explored how historical factors, mixing global and local contexts (such as professional relations, medical and nursing education, social status of nurses, demographics and World Wars in the 20th century), help explain observed differences. Nearly equal numbers of physicians and nurses are currently engaged in the delivery of anaesthesia care in the United States but, remarkably, although the introduction or re-introduction of nurse anaesthesia in the 20th century was attempted in all the other G7 countries (except Japan), it has been successful only in France because of the cooperation with the United States during World War II.

Cost impact of unexpected disposition after orthopedic ambulatory surgery associated with category of anesthesia provider.

STUDY OBJECTIVE: To provide estimates of the costs and health outcomes implications of the excess risk of unexpected disposition for nurse anesthetist (NA) procedures. DESIGN: A projection model was used to apply estimates of costs and health outcomes associated with the excess risk of unexpected disposition for NAs reported in a recent study. SETTING: Ambulatory and inpatient surgery. PATIENTS: Base-case model parameters were based on estimates taken from peer-reviewed publications when available, or from other sources including data for all hospital stays in the United States in 2013 from the Healthcare Cost and Utilization Project Web site. The impact of parameter uncertainty was assessed using 1-way and 2-way sensitivity analyses. INTERVENTIONS: Not applicable. MEASUREMENTS: Major complication rates, relative risks of complications, anesthesia costs, costs of complications, and cost-effectiveness ratios. MAIN RESULTS: In the base-case model, there were on average 2.3 fewer unexpected dispositions for physician anesthesiologists compared with NAs. Overall, anesthesia-related costs (including the cost of managing unexpected dispositions) were estimated to be about $31 higher per procedure for physician anesthesiologists compared with NAs. Alternative model scenarios in the sensitivity analysis produced estimates of smaller additional costs associated with physician anesthesia administration, to the point of cost savings in some scenarios. CONCLUSIONS: Provision of anesthesia for ambulatory knee and shoulder procedures by physician anesthesiologists results in better health outcomes, at a reasonable additional cost, compared with procedures with NA-administered anesthesia, at least when using updated cost-effectiveness willingness-to-pay benchmarks.

Contract anesthesia: the good news and the challenge.

The dramatic pace of change in health care is intimidating, and results can be unpredictable and often negative. The practice of contract anesthesia delivery is an excellent example of how a clinical microsystem interacts with the constant change common in today's health care environment. This article identifies many of the issues of concern in contract anesthesia. Awareness of issues will afford nurses, nurse anesthetists, and managers a structure for a smooth, safe, and effective transition of contracting providers.

Cost of education and earning potential for non-physician anesthesia providers.

Potential non-physician anesthesia students gauge many different aspects of a graduate program prior to applying, but cost of education and earning potential are typically high priorities for students. Our analysis evaluated the cost of tuition for all certified registered nurse anesthetist (CRNA) and anesthesiologist assistant (AA) programs in the United States, as well as earning potential for both professions. We collected educational cost data from school websites and salary data from the Medical Group Management Association's Physician Compensation and Production Survey: 2012 Report in order to compare the two groups. We found that the median cost of public CRNA programs is $40,195 and the median cost of private programs is $60,941, with an overall median of $51,720. Mean compensation for CRNAs in 2011 was $156,642. The median cost of public AA programs is $68,210 compared with $77,155 for private AA education, and an overall median cost of $76,037. Average compensation for AAs in 2011 was $123,328. Considering these factors, nurse anesthesia school is a better choice for candidates who already possess a nursing license; however, for those prospective students who are not nurses, AA school may be a more economical choice, depending on the type and location of practice desired.

Sevoflurane induction procedure: cost comparison between fixed 8% versus incremental techniques in pediatric patients.

This study compared 2 well-accepted and safe methods of pediatric inhalation induction using sevoflurane. Incremental and fixed 8% induction methods were evaluated for economic outcomes by comparing the amount of liquid sevoflurane consumed. We also tried to establish the relation between cost of induction and demographic parameters in both groups. One hundred pediatric patients scheduled for ophthalmologic examination under anesthesia were randomly divided into 2 equal groups. The amount of sevoflurane consumed in both groups was computed using the Dion method. Although the time to loss of consciousness was significantly lower using the 8% method (75.98 vs 135 seconds), the liquid sevoflurane consumption using the incremental method (2.25 mL) was almost half that of the fixed 8% method (4.46 mL). The overall procedural cost of induction (loss of consciousness plus intravenous cannulation and insertion of a laryngeal mask airway) was also almost double using the fixed 8% method. Use of the incremental method preferably over the fixed 8% method could save almost $18 US for each procedure. The volume of sevoflurane consumed during anesthesia induction was found to be independent of age, weight, or sex of pediatric patients. Both induction methods proved to be equally safe and acceptable to the patients.

Education and Practice Barriers for Certified Registered Nurse Anesthetists.

Of the recognized advanced practice registered nursing (APRN) specialties, Certified Registered Nurse Anesthetists (CRNAs) have historically experienced the most vigorous and organized resistance from outside entities regarding rights to practice to the full scope of their education and experience. Opposition to nurse anesthetists practicing to the full scope of their education and training is present in the clinical arena and educational milieu.

CMS proposal for interventional pain management by nurse anesthetists: evidence by proclamation with poor prognosis.

The Office of Inspector General (OIG), Department of Health and Human Services (HHS), in a 2009 report, showed that unqualified nonphysicians performed 21% of the services. These nonphysicians did not possess the necessary licenses, certifications, credentials, or training to perform the services. Since the time the medical profession was founded, advances in treatments and technology, as well as educational and training standards, have promoted a desire to go beyond the basic scope of practice. Many have sought to broaden the scope of practice through legislative efforts and proclamation rather than education and training. In 2001, President Clinton signed into law a rule that permitted states to "opt out" of the Centers for Medicare and Medicaid Services' (CMS) requirement for nurse anesthetists to be supervised by any physician. Since then, 17 states have adopted this rule. While it was originally intended to help rural areas improve access to care, the opt out rule essentially supports any hospital or organization that seeks to make a profit or cut costs by allowing nurse anesthetists to function as physicians. With the implementation of sweeping health care regulations under the Affordable Care Act (ACA, also popularly known as Obamacare), the future of nurses and other professionals has been empowered. In fact, it has been proposed that medical training may be reduced by 30%, which will in their minds equalize training between nonphysicians and physicians. In 2010, the Federal Trade Commission (FTC) issued an opinion exerting their power to empower CRNAs with unlimited practice, with threats to opposing parties. In the 2013 proposed physician payment rule, CMS is proposing that CRNAs may perform interventional pain management services. Interventional pain management is a medical discipline with defined interventional techniques to be performed by professionals who are well trained and qualified. Without considering the consequences of the lack of education and training qualifications for CRNAs to offer interventional techniques, the FTC issued their opinion and CMS proposed to expand these practice patterns with a policy of improved access and reduced cost. However, in reality, the opposite will happen and will increase fraud, reduce access due to inappropriate procedures, and increase complications, all as a result of privileges by legislation without education. The CMS proposal for interventional pain management by nurse anesthetists is a proclamation with a poor prognosis.

Endoscopist-directed propofol administration versus anesthesiologist assistance for colorectal cancer screening: a cost-effectiveness analysis.

BACKGROUND: Propofol for colonoscopy is largely administered by anesthesiologists or anesthesiology nurses in the United States (US) and Europe. Endoscopist-directed administration of propofol (EDP) by nonanesthesiologists has recently been proposed, with potential savings of anesthetist reimbursement costs. We aimed to assess potential EDP-related benefit in a screening setting. METHODS: In a Markov model the total number of screening and follow-up colonoscopies in a cohort of 100 000 US subjects were estimated. Anesthetist-assisted colonoscopy was compared with an EDP strategy. Model outputs were projected onto the 50 - 80-year-old US population, assuming 27 % as the current uptake for colonoscopy screening. Anesthetist costs were estimated using the mean reimbursement for the corresponding Medicare code (≥ 65-year-olds) and from commercial insurance information (50 - 64-year-olds). The proportion of colonoscopies with anesthesiologist assistance was estimated from the Medicare database. Mean nurse salary was used to estimate the cost of a 2-week EDP training. The absolute number of US endoscopists was estimated by inflating by 33 % the number of board-certified gastroenterologists. No EDP mortality was assumed in the reference scenario, and 0.0008 % mortality in the sensitivity analysis. US census data were adopted. Analogous inputs were used for France to assess EDP-related benefit in a European country. RESULTS: EDP training for 17 166 nurses (one for each US endoscopist) showed a cost of $ 47 million. Cost estimates for anesthesiologist assistance for colonoscopy were $ 95 (Medicare) and $ 450 (non-Medicare commercial insurance), with 34.8 % of colonoscopies requiring anesthesiologist assistance. US implementation of an EDP policy showed a 10-year saving of $ 3.2 billion (Monte Carlo analysis 5 - 95 % percentiles $ 2.7 - $ 11.9 billion). In the sensitivity analysis, assuming 50 % of colonoscopies were anesthetist-assisted showed an EDP benefit of $ 4.6 billion. Assuming a 0.0008 % mortality rate, the incremental cost - effectiveness of anesthetist-assisted colonoscopy versus an EDP policy was $ 1.5 million per life-year gained, supporting EDP as the optimal choice. A 31-fold increase of EDP-related mortality or a 17-fold cost reduction for anesthetist-assisted colonoscopy was required for EDP to become not cost-effective in this scenario. Implementation of an EDP policy in France, within a guaiac-fecal occult blood test (g-FOBT) screening program, was estimated to save € 0.8 billion in 10 years. CONCLUSIONS: The absolute economic benefit of EDP implementation in a screening setting is probably substantial with 10-year savings of $3.2 billion in the US and €0.8 billion in France. The impact of an eventual EDP-related mortality on EDP cost - effectiveness seems marginal. The huge economic and medical resources entailed by anesthetist-assisted colonoscopy could be more efficiently invested in other clinical fields.

No differences in job perceptions amongst Dutch nurse anaesthetists with and without nursing background.

BACKGROUND: In the Netherlands, the employment as a "nurse anaesthetist" is comparable to that of a registered nurse anaesthetist in the Scandinavian countries and Poland. However, the Dutch healthcare system employs nurse anaesthetists both with and without nursing backgrounds. This study has investigated whether a nursing background influences the attitudes and perceptions of nurse anaesthetists in the Netherlands. METHODS: A survey was distributed to all nurse anaesthetists working in Dutch hospitals to discover differences in their perceptions of their work context, job satisfaction, and work climate, as well as health and turnover intention. The questionnaire also sought basic information on socio-demographic factors and psychosomatic symptoms. Descriptive statistics, factor analyses and independent T-tests were computed. RESULTS: Overall 923 of a total of 2,000 questionnaires were completed and analysed (response rate of 46%). Independent T-tests showed no significant differences between nurse anaesthetists with and those without nursing backgrounds in all the areas examined. CONCLUSION: Dutch nurse anaesthetists with and without nursing backgrounds reported similar perceptions of and information about their work context, job satisfaction, work climate, psychosomatic symptoms, burnout, sickness absence, general health and turnover intention. Both academic tracks appeared to produce individuals who functioned similarly as professionals.

Workforce and finances of the United States anesthesiology training programs: 2009-2010.

Financial and workforce surveys were sent to 121 and 124 United States Anesthesiology training programs in 2009 and 2010, respectively. Seventy-two respondents (60%) and 81 respondents (65%) demonstrated median institutional support per faculty of $120,000 and $111,000; open faculty positions of 4% and 4.8%. Faculty billed an average of 11,050 units/year and collected $35.00/unit. In 2010, 56% of departments had installed anesthesia information management systems and 14% have signed a contract for an anesthesia information management system.

Cooperation and conflict between very similar occupations: the case of anesthesia.

This article examines the features of a labor market in which there are two professional groups that both cooperate and directly compete with each other: certified registered nurse anesthetists (CRNAs) and anesthesiologists (MDAs). We examine how the relative numbers of these two types of anesthesia providers, and differences in regulation, affect the earnings of CRNAs, and the extent of supervision of CRNAs by MDAs. We find that both the earnings, and the likelihood of medical supervision of CRNAs, are closely determined by their market share. As the market share of CRNAs increases from 0% to 50%, the gains to MDAs from restricting competition increase; over this range the likelihood that CRNAs are supervised increases and their expected earnings decline. However, as the CRNAs' market share increases beyond 50%, the costs to MDAs of anticompetitive measures become too large, therefore, the probability of supervision declines, and the earnings of CRNAs increase.

Medicare program: hospital outpatient prospective payment system and CY 2011 payment rates; ambulatory surgical center payment system and CY 2011 payment rates; payments to hospitals for graduate medical education costs; physician self-referral rules and related changes to provider agreement regulations; payment for certified registered nurse anesthetist services furnished in rural hospitals and critical access hospitals. Final rule with comment period; final rules; and interim final rule with comment period.

The final rule with comment period in this document revises the Medicare hospital outpatient prospective payment system (OPPS) to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain provisions of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (Affordable Care Act). In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2011. In addition, this final rule with comment period updates the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain provisions of the Affordable Care Act. In this final rule with comment period, we set forth the applicable relative payment weights and amounts for services furnished in ASCs, specific HCPCS codes to which these changes apply, and other pertinent ratesetting information for the CY 2011 ASC payment system. These changes are applicable to services furnished on or after January 1, 2011. In this document, we also are including two final rules that implement provisions of the Affordable Care Act relating to payments to hospitals for direct graduate medical education (GME) and indirect medical education (IME) costs; and new limitations on certain physician referrals to hospitals in which they have an ownership or investment interest. In the interim final rule with comment period that is included in this document, we are changing the effective date for otherwise eligible hospitals and critical access hospitals that have been reclassified from urban to rural under section 1886(d)(8)(E) of the Social Security Act and 42 CFR 412.103 to receive reasonable cost payments for anesthesia services and related care furnished by nonphysician anesthetists from cost reporting periods beginning on or after October 1, 2010, to December 2, 2010.

Cost effectiveness analysis of anesthesia providers.

Anesthesiologists and certified registered nurse anesthetists provide high-quality, efficacious anesthesia care to the U.S. population. This research and analyses indicate that CRNAs are less costly to train than anesthesiologists and have the potential for providing anesthesia care efficiently. Anesthesiologists and CRNAs can perform the same set of anesthesia services, including relatively rare and difficult procedures such as open heart surgeries and organ transplantations, pediatric procedures, and others. CRNAs are generally salaried, their compensation lags behind anesthesiologists, and they generally receive no overtime pay. As the demand for health care continues to grow, increasing the number of CRNAs, and permitting them to practice in the most efficient delivery models, will be a key to containing costs while maintaining quality care.