eAlerts

The Future of the Anesthesia Care Team

Jody Locke, CPC
Vice President of Anesthesia and Pain Management Services, ABC
Frank Rosinia, MD
Chair, Department of Anesthesiology, Tulane University

has been said that very often the beliefs and strategies that got us to where we are today will not get us to where we need to be tomorrow. There is no more acid test of this proposition than the current economic environment. There is no more appropriate application than to the unique feature of anesthesia services: the variety of configurations of the anesthesia care team (ACT) that exist across the country. Many will view the current challenges as a threat but others may find them an opportunity to reevaluate old assumptions and reconsider new options. Despite the potential emotion associated with such discussions this could well be a timely and strategic issue for the specialty. As is so often the case, the option facing individual practices may well be a question of taking control of one’s destiny or being at its mercy.



rently, all anesthesia care is provided in essentially one of three ways. The vast majority of anesthesia services are provided by a team of anesthesia clinicians, typically involving an anesthesiologist and a CRNA, AA (anesthesiologist assistant) or resident. Some anesthesiologists, mainly in the western states, prefer to provide care themselves, referred to as a physician-only model. There are also hospitals where CRNAs work alone; historically, such practices tended to be in isolated rural areas, but opt-out legislation has encouraged the expansion of such a model.

special note is the distinction within the largest category of anesthesia care: the medical direction model. For a combination of historical and financial reasons some anesthesia practices employ the CRNAs they work with, while in other facilities it is the hospital that employs the CRNAs. There is an ongoing debate as to whether hospitals actually profit from the employment of CRNAs. Some administrations have been known to threaten their private anesthesia groups with the prospect of the groups’ having to employ their CRNAs. The fact is that employment of CRNAs by a hospital is clearly a form of subsidy. There is some speculation that ultimately hospitals prefer not to employ the CRNAs, but despite all the discussion of options few facilities have effected the change in the past few years.



Advisory Board white paper published in 2004, “Navigating the Anesthesia Shortage” clearly recommends the increased use of CRNAs: #7 Integrated CRNA model leverages anesthesiologists, boosts physician revenues.The most effective way to boost individual anesthesiologist productivity and income potential is by using integrated CRNA teams. A fully leveraged team allows anesthesiologists to nearly double anesthesia revenues per hour of coverage. Successful implementation will necessitate overcoming several political hurdles, as many surgeons and anesthesiologists are opposed to integrated care teams.

While such categorical recommendations tend to support the position of proponents of the care team, they also give pause for thought to those who for a variety of historical and philosophical reasons have chosen not to work with CRNAs. It is one thing to say that a particular model has distinct financial advantages, but it is quite another to agree to the necessary transition plan; what is desirable in principle may actually be impractical in its execution. Such observations and the inherently logical perspective that the leveraging of more expensive physician time over less expensive CRNA time will reduce the overall cost of care has clearly conditioned the thinking of many a hospital administrator. Rare is the administration that does not ask the question, “Wouldn’t more CRNAs reduce your need for financial support?” It is a good and important question. Unfortunately, the answer is not as simple or clear as the question would suggest.

As is always the case when the same service is provided in a variety of ways, the very diversity of delivery options tends to encourage a discussion of best practices. Historical preferences and cultural norms tend to prejudice an objective evaluation of the facts. Nowhere is this more evident that in the heated debate that has accompanied the revision and refinement of Medicare reimbursement for anesthesia in Washington.



The politics of clinical autonomy versus supervision and of anesthesia reimbursement have pitted the Association of Nurse Anesthetists (AANA) against the American Society of Anesthesiologists (ASA) since the late 1970s. The year 1984 saw the implementation of the first set of reimbursement rules that would attempt to define the monies due the medically directing anesthesiologist and the medically directed CRNA. (The first step was fairly modest in that it carved a portion out of the physician’s payment and redirected it to hospital CRNAs.) Before long the scope of the discussion would be expanded to include independent practice for CRNAs. The ensuing evolution and refinement of the Medicare payment system for anesthesia was anything but a smooth and orderly process. Certainly many anesthesiologists expressed profound concern in 1994 that splitting the allowable equally between the medically directing anesthesiologist and the medically directed anesthetist would undermine the value of physician anesthesia. Anesthesiologists were convinced that a reimbursement system that allowed the same level of reimbursement irrespective of whether the care was provided by a physician alone, a physician directing a CRNA or a CRNA alone would ultimately compromise the quality of care provided. Perhaps the jury is still out, but despite the dire predictions, the ratio of physicians to nurses has remained relatively constant and the quality of care, as measured by the rarity of adverse outcomes, continues to improve across the board.

Any issue viewed through the lens of politics becomes distorted. Battles fought in the political arena tend to turn more on sound bites and exaggerated claims than those in the board room. The AANA contends that more extensive reliance on nurse anesthesia will allow for more cost-effective care without compromising quality. Unfortunately for the AANA, the facts simply do not support this argument. To put it another way, it is true that CRNAs tend to have lower salaries than anesthesiologists, but this does not mean that the cost of anesthesia care to the patient or the patient’s insurance goes down when there is a higher reliance on nurses.



Surveys by a variety of organizations including the AARP tend to reflect the reality that to the extent that a patient understands the potential risks associated with anesthesia they prefer to have a physician involved. Whether patients fully understand the relationship between the anesthesiologist and the CRNA in the operating room is not the key issue; they simply want to know that they are in the best possible hands. There is no turning back the clock. Those hospital administrators and surgeons who make such decisions no longer give much consideration to operating rooms without anesthesiologists. The operative question is simply can they afford the cost. The evidence supporting this view is borne out by current levels of hospital subsidy for anesthesia.

Politics notwithstanding, economic factors have a compelling way of influencing business decision-making. Economists are convinced that in a free and competitive market the forces of supply and demand will ultimately determine both how services are provided and what their value will be. The real economic question in medicine is to what extent a truly competitive market exists. Some would argue that medical economics are conditioned by a phenomenon known as supplier-induced demand which suggests that since providers of medical care have more knowledge of the options than patients, they unduly influence decision-making. While this may have been true historically the government and insurance industry have taken the lead in outmaneuvering the provider in determining the true value of medical services.

The economics of anesthesia are actually quite simple. Since rates are set irrespective of the mode of delivery (personally performed versus the care team), then the most important consideration is not revenue potential but cost. This is where the analysis and the conclusions can vary dramatically from practice to practice. It is at this level that three factors must be considered: cost, productivity and profitability.

The calculation of the cost of anesthesia care begins with a basic assessment of provider compensation as defined by some unit of measure such as a case, an hour of care or a day of coverage. Given the level of compensation paid to each category of provider, it is relatively easy to establish the most cost-effective mode of providing anesthesia services. In fact, as the following examples clearly indicate, it is the ratio of total physician compensation to total CRNA compensation that determines when the use of CRNAs will reduce the overall cost of the service and when it will not.



Our analysis begins with the establishment of some assumptions for our baseline calculations. The following are based on the most recent MGMA compensation survey data for the country as a whole. The assumptions are then used to calculate per hour and per day costs per category of provider. For purposes of analysis we should note that in the baseline data the total cost of a physician is 2.3 times the cost of a CRNA. These costs include W2 compensation, benefits, malpractice and overhead costs. (See Table 1).

Given these calculations we can compare basic staffing models and assess the impact of each option. Most practices will view these data through one of two lenses. Many will ask what level of medical direction is necessary to materially reduce the cost of anesthesia care. The answer is that the savings at a consistent level of 1 physician to 2 CRNAs is nominal. It takes at least three CRNAs for each physician to effect a meaningful cost savings. (See Table 2). Other practices that have revenue guarantees per anesthetizing location with their hospital will ask what level of coverage is necessary to meet the compensation expectations of the physicians. In other words, they will back into the cost per day calculations by adjusting the ratio of physicians to CRNAs.



It should also be noted here that it is the ratio of total physician cost to total CRNA cost that has the greatest impact on profitability. The greater the delta between the two, the more the practice will benefit financially from a reliance on CRNAs. It also follows, then, that the lower the delta the less the potential value of the care team. Historically, this has explained the preference for physician only anesthesia in the West where physician compensation is lower as is consistently identified in MGMA compensation surveys.

Such calculations and the conclusions they appear to suggest raise a number of very significant questions. The first is why any physician, given this information would choose to personally provide care, and yet many do. The second is why don’t all practices default to the highest level of medical direction allowed, which would be one physician to four CRNAs. Hospital administrators might even look at these numbers and ask why they need anesthesiologists at all. The answers to these questions speak to the complexity of the anesthesia market place and the other factors that condition such decisions. They are the real keys to predicting the future of the care team.

But if one were to look for examples of the market imposing a solution on an anesthesia practice, one need look no further than the Baylor Medical Center in Dallas. Having long supported independent anesthesiologists in a unique practice model called surgeon request, the administration has finally concluded that it does not really need to be in the business of employing CRNAs. In one fell swoop a contract was negotiated with Pinnacle, one of the nation’s largest anesthesia groups to take over the entire practice and employ the CRNAs. It was one of those career altering events that could have been anticipated but which wasn’t. It was also a good example of the truth of Nikita Khrushchev’s observation that economics is not a discipline that respects one’s wishes.

Clearly the specialty of anesthesia has evolved significantly over the past few decades. The complexity of anesthesia practice management has increased as individual practices have coalesced into groups and mega groups. One might even suggest that the evolution has been from the ‘I’ to the ‘us.’ Various factors and considerations drove this process. Generally, they were practical, financial and cultural. In many cases, it took a hospital contract proposal or a managed care contract to force the change. As Peter Senge reminds us in The Fifth Discipline, medical decision-making is often subject to a lag. Information and insight takes a while to sink in and take effect. The management of anesthesia practices is fundamentally conservative and cautious. Organizationally, most anesthesia groups are actually structured to resist change and maintain the status quo. Changes do occur, but usually only after all other options have been exhausted. Many are the practices that have considered a change in staffing model, but few are those that have actually taken the next step to effect the restructuring.

The most obvious and practical consideration is the availability of providers. Certain markets such as California have thwarted the growth of CRNA care for so long that a decision to increase the number of CRNAs in a given practice will be difficult to implement. Any increased reliance on CRNAs must presuppose a consistent standard of care.

Most physician-only practices simply do not have the infrastructure and management expertise to deal with the recruiting and human resource issues associated with the employment of non-physician providers. Many of the physicians in such practices also worry about the potential impact on retirement plan benefits if they change the mix of highly compensated employees. Clearly, these are not insurmountable challenges, but they do engender second thoughts about a fundamental restructuring of the practice.



There is also the issue of what happens to the down-sized physicians. Few shareholders are going to endorse a transition plan that marginalizes them. Conventional wisdom suggests that physician partners are tenured, while CRNAs are expendable. More often than not any potential changes in ratio of doctors to CRNAs must be based on attrition and phased in over time, which obviously diminishes the potential benefit.

An argument can also be made that a change in the structure of an organization that introduces non-shareholder employees will inevitably have a significant impact on the culture of the organization. Physicians who practice alone tend to assume that they are solely responsible for the care they provide, that their group practice is a confederation of equally committed providers, and that they never have to worry about what is happening in the room next door. They may not be willing or comfortable delegating decision-making to non-physician providers. Many anesthesiologists pride themselves on having chosen practices that are physician-only.

The result of regional approaches to anesthesia care has created unique cultures and patterns that tend to permeate the medical staff. Not only do the anesthesiologists tend to have a preference for one model over another, but their preference has rubbed off on the surgeons. A CRNA in Jackson, Mississippi was once quoted as saying that the surgeons would never put up with having to deal with the anesthesiologist in the room all the time. She believed that the CRNAs were more responsive to the surgeons’ needs. By contrast, of course, certain markets such as Las Vegas, Phoenix and Honolulu have evolved as a partnership between an individual anesthesiologist and a specific surgeon.

The focus and orientation of the specialty is changing. For much of its history, the evolution of anesthesia has focused on the mastery of pain, the pursuit of safety and the enhancement of the patient’s surgical and obstetric experience. The administration of good anesthesia care is often described as both art and science. Committed practitioners have learned to create something magical in that crucible of experience defined by their skills, experience and insight, the requirements and expectations of the surgeon and the unique requirements, fears and concerns of each patient. The world is now coming to understand and appreciate the powerful role of anesthesia in medicine. As the light shines in on the specialty, its practitioners are having to come to terms with the expectations they have created in the market. It is no longer enough to just have good outcomes, customers now want good service. They have bought the promise of a pain-free and pleasant surgical experience. Anesthesiologists and CRNAs no longer operate in a vacuum. They are partners in a service proposition. The time has come to deliver more than good outcomes. The means is now as important as the end.



It is time to revisit the three goals of an anesthesia practice: ability, availability and affability. They represent a new hierarchy of objectives: ability is now a given; availability a must and affability an essential survival skill. Each of these highlights different advantages and disadvantages of the care team. The Silver study supports the view that a team of providers is better equipped to manage unanticipated complications. The fundamental challenge of meeting a variety of coverage requirements may also suggest a team approach to the delivery of care. Nurse anesthetists may even play a critical role in enhancing the public face of the specialty. Achieving optimum results and good customer service is more a matter of commitment than means. Just as there is no one right way to deliver a safe and artful anesthetic, there is no one way to structure an anesthesia practice: form must follow function, and each function is unique. Just as anesthesia is an ongoing process of feedback and modification, so too, is the effective management of the successful practice.

So what can we conclude about the respective roles anesthesiologists and nurse anesthetists will play in the provision of anesthesia services in the years to come? History suggests that change is inevitable. For some practices, change will come too quickly and as result of a combination of political, economic and social factors seemingly beyond their control. Others will seize the opportunity to shape their own destiny. They will be the serious students of the market who have mastered the tools of business management, whose environmental scanning is more finely tuned, and whose vision is focused not on what is but what isn’t. There is no doubt that tough times test organizations in ways that they often do not want to be tested. One thing is for sure, though: anesthesia is an essential component to the success of any operating suite and hospital. The country needs reliably consistent, cost effective and customer-oriented anesthesia care. There is no one best solution, just many very good options. While the discussion of best practices was once considered a good idea, it is now an essential survival skill.

The Constancy of Change



Tony Mira President and CEO

I am very happy to provide you with another carefully researched and thought-provoking issue of our Communiqué. Our staff and contributors have provided a significant body of material related to the ongoing challenges managing an anesthesia practice effectively in these ever-changing times and particularly challenging economy. Our goal is to give you fresh perspectives on topics of the day and practical suggestions you can implement to enhance the strategic position of your practice.

While our many authors touch on a range of topics, there is a common theme to their perspectives. Change is not only inevitable but coming at us with increasing intensity. Successful practices cannot afford to be caught off guard. The calibration of our environmental scanning must be fine-tuned. No aspect of practice management is exempt from the tinkering of legislators, regulators, payors and hospital administrators. Gone are the days of happy oblivion when strong collections and consistent cash flow made for a stable practice. It is no longer enough to simply have good outcomes. The market is always pushing us all to do more for less and to be all things to all customers.

I hope you will study each of these articles as they have all been chosen to give you a balanced perspective. I am especially proud of our core series of pieces on the Anesthesia Care Team. We have had so many questions about our view of anesthesia staffing issues we wanted to make sure we included a variety of perspectives. Our main article, The Future of the Care Team, was written jointly by our own Jody Locke and Frank Rosinia, MD of New Orleans. For balance we have also included contributions from three clients: Trevor Myers, MD of Arlington, Virginia who is president of a care team practice; Richard Bindseil, DO and Steve Weddel, MD from Longmont, Colorado, who are part of an all physician practice; and Robert Hague, CRNA who is the president of a practice of physicians and CRNAs in Idaho Falls, Idaho. Jackie Popiela, one of our vice presidents of client management also shares her experiences working with practices as the work through the issues of modifying their staffing model. This is probably one of the most timely and challenging topics of the day. I can only hope we have done it justice.

Do not shortchange yourselves, though, each of the other pieces is sure to stimulate reflection and possibly inspire some internal discussion within your organization about opportunities to either refine your governance, manage your expenses or prepare for any of the other regulatory changes being considered. Our writers are all recognized experts in their respective fields. Just as they advise us, let them advise you.

This is why we produce the Communiqué: to stimulate debate and flush out best practices. We gets lots of useful feedback on all of our issues. Please let us hear from you. If something interests you and ultimately leads to a refinement of your practice, let us know. By the same token, if we have missed or mis-stated a topic that is near and dear to your heart let us know this as well. We are committed to providing a forum for the sharing of ideas and the cultivation of successful strategies for success.

Many thanks for your continued support. All the best in this season of rebirth and recovery.

The Modified Anesthesia Care Team Model

Trevor P. Myers, M.D.
Dominion Anesthesia, PLLC, Arlington, Virginia

As a single location group in the mid-Atlantic region, our practice relies heavily on the modified anesthesia care team model for financial success. While some larger practice management companies and anesthesia super-groups have predicted the death of “orphan” groups such as ours, we continue to thrive, in large part due to our focus on OR coverage models, a strong infrastructure including effective AR management, and a healthy relationship with our administration.

As discussed at the January 2009 ASA Practice Management Conference, our group focuses strongly on customer service, recently assuming a role as OR Director, remaining active with the medical staff, and generally carrying a high profile within the hospital. We have a consistent, healthy and ongoing dialogue with the hospital administration. This relationship is a key component to our success.



Historically, CRNAs have been employed in our facility for many years, both as hospital employees and as corporate employees, at various times. The transition of CRNAs from hospital employees to corporate employees began over a decade ago, with the reorganization of the previous anesthesia group into its current structure. Fortunately, we have a deep and talented pool of CRNAs, some of whom have tenure extending to decades at this facility. This level of experience is balanced by a steady influx of new CRNA graduates, who bring in their energy and excitement. We share the financial success of the practice with the nurse anesthetists via a profit sharing and a year-end bonus system. This wealth sharing keeps the entire anesthesia care team interested in efficiency and turnover. The CRNAs work WITH us, not just FOR us. They are a key part of our practice, and we value them highly. As a result, we have an extremely high retention rate of our anesthetists, which is difficult in our area. We trust them not only with our patients, but with also with ourselves and our families when we inevitably become patients.

Our current focus on the modified anesthesia care team model really became acute about six years ago, when our facility underwent new construction, expanding the existing OR base by approximately 33%. While the hospital supported us financially until OR volumes matched staffed locations, we realized that we needed a deeper appreciation of the staffing-revenue balance. An exhaustive analysis of OR utilization, coverage models, reimbursement, growth projections, and cost structures led us to shift from predominately anesthesiologist-only anesthesia coverage with a CRNA “kicker” to a modified anesthesia care team model with a denser CRNA coverage model. The hospital administration was active in supporting this transition, since they perceived this strategy to be a more cost effective model. This transition has taken the practice from well below the MGMA mean salary for our region to a more financially stable situation.

Currently, we run 18 anesthetizing locations on a daily basis, with a disparate case mix including cardiac, neurosurgery, healthy pediatrics, general surgery, orthopedics, ENT, and gynecology. We also have an active obstetrical service with 3500 deliveries a year. We provide anesthesia for 2-3 rooms in the gastroenterology suite daily, as well as various off site locations in the hospital (cath. lab, MRI, etc).

Typically, we cover rooms in a 3:1 CRNA:MD ratio for 9-12 of the anesthetizing locations, depending on the day. This ratio allows us to flex up to a 4:1 ratio in cases of emergency/add-on cases or flex down to a 2:1 model for labor intensive cases. While the CRNAs are working in the OR, the covering anesthesiologist has the opportunity to interview patients, place blocks or lines for the next cases, and cover any issues in the PACU that may need attention. The surgeons are also very appreciative of this staffing model, since they don’t have to “wait on anesthesia.” While a 4:1 coverage model is optimal for maximizing income, our physicians feel strongly that a 3:1 model allows us to provide a consistent level of anesthesia excellence while maintaining patient safety. Occasionally, we sometimes cover rooms at a 2:1 or even 1:1 ratio, if patient safety and circumstances dictate. If rooms are idle, the CRNAs are able to give each other breaks or complete other tasks that arise during the day. Off site locations (GI, Cath lab, etc.) and cardiac surgery are generally covered by anesthesiologists only, since the distance away from the main OR often makes it difficult to meet the “induction, emergence, and immediately available” requirements. At night, we have two CRNAs in house along with one anesthesiologist, keeping the reserve call team at home, since we can cover one OR case, plus any C-sections that might crop up.

The relationship between anesthesiologists and nurse anesthetists has been tumultuous in some regions of the country, but we have been very successful in insulating our practice from controversy. By following a consistent model of anesthesia coverage based on compliance guidelines, we have established clear precedents for any physician or nurse anesthetist in our practice. There are no “cowboys” or “cowgirls” here, and any issue or difficulty is dealt with promptly and decisively. While we do have some physicians who prefer to do their own cases, we also have a solid core who find the multi-tasking nature of the anesthesia care team model challenging and invigorating. Personally, I find that meeting three times as many patients gives me that much more satisfaction, particularly if I’m doing a peds case in one room, an ortho case in another, and a GYN case in the third. Diversity is the spice of life, perhaps not in marriage, but certainly, in my anesthesia practice.

As CRNA salaries continue to rise beyond the rate of inflation, the anesthesia care team model must be continually reevaluated. In our area, the CRNA market is highly competitive, and falling behind on the financial package can lead to rapid and wholesale defections. We examine our budget quarterly and project expenses, revenue, and income out for at least two years. In the latest Practice Management update, projections indicate a surplus of CRNAs through 2020, and a relative shortfall of anesthesiologists, so perhaps the demographics will be on our side as time wears on.

Ultimately, for our practice at this snapshot in time, a modified anesthesia care team model is working beautifully. Our physicians are happy, our CRNAs are happy, the administration is pleased, and the surgeons want to bring cases to our hospital. Fortunately, that combination tends to be a financial win for all parties involved.

The All-Anesthesiologist Model of Anesthesia Care

Richard Bindseil, O.D. and Stephen Weddell, M.D.
Longmont Anesthesia Associates, Longmont, Colorado

The more we experience life and work, the more we realize there are many ways to accomplish a goal. As anesthesiologists, we know different anesthetic techniques can each yield acceptable results. Likewise, different anesthesia group models can each provide acceptable anesthesia services for their respective communities. Why different models have developed in communities depends on many factors including manpower availability, number of anesthetizing locations, and professional goals.

In our community, Longmont, Colorado, these factors have allowed us to be able to provide our clients (surgeons, medical institutions, and our patients) with an all-anesthesiologist care team. We are blessed to have a cohesive, cooperative, and happily inter-dependent group that can offer high level anesthesia care at all times for all our clients. We find the all-anesthesiologist model to be the best for us and feel it is the best for our clients.

Not only have CRNAs worked in our community, but some of our group members have worked as part of an anesthesia care team before coming to work here in Colorado. We have certainly considered integrating CRNAs into out practice on numerous occasions we have simply never reached a consensus that it was the right thing to do.

One of our members observed that “anesthesiology is probably the most boring specialty to watch someone do, but the most exciting and fun to actually do yourself.” It can be a challenge to gain a patient’s trust and confidence during the pre-surgical period when they are anxious and concerned about the outcome of their procedure, but it is very rewarding to manage them safely and successfully through the trauma of surgery and recovery. We take full responsibility for knowing the patient’s history and medical circumstances so that when a problem develops, we can quickly and effectively provide a solution. It is not as if we do not already work as a team with the surgeon and the medical staff, we just do not choose to share our responsibilities for the management of the anesthesia with CRNAs.

Individually and collectively, the members of our group take responsibility for a positive peri-operative experience for our patients. We share all responsibilities such as call equally. We also share all benefits equally. Even financially, we have a shared incentive to do what is right for the patients and our customers. It has been our view that the inclusion of non-physician employees would needlessly complicate the equation. We may be forgoing some income in the process, but this is a price we have chosen to pay.



It should also be noted that since we are a relatively small practice, the logistics of coverage do not lend themselves to a care team model. Our group currently covers 11 anesthetizing locations, including OB coverage, between an outpatient surgery center and a community hospital. We seldom run more than one operating room after normal hours or on the weekends. It makes little sense to have an employed CRNA working during these times, as it would mean one anesthesiologist would be supervising one CRNA. It makes no sense, economically or otherwise, for the employed CRNA to share in the after-hours call for only one case at a time while being appropriately supervised by an anesthesiologist. Thus, were we to have CRNAs in our group, only the physicians would be working the after hours and weekend call. It makes more sense to us to dilute the undesirable working hours among all of us, rather than among a lesser number of supervisory physicians.

Some members are very familiar with the medical direction of CRNAs and have found this role to be difficult at best. From a standpoint of delivering proper medical care, adhering to the seven basic principles of medical direction can be nearly impossible when directing multiple CRNAs, especially when providing anesthesia for short cases. From a standpoint of a well coordinated team, some CRNAs have resented supervision, at times waiting too long to call for assistance. Some have addressed themselves to the patients as “Doctor.” While seeming to want equal medical status as the supervisory anesthesiologist (or other physician), the CRNAs have been notably less interested in assuming the responsibilities and commitments required of the physicians.

On the other hand, each member of our anesthesia team is an equal partner and therefore each has a vested interest in the overall success of the group. This is manifested by each member’s willingness to step up to not only help cover any anesthesia need, but to participate in administrative functions with our institutional clients and the medical staffs. Each member of our team realizes how essential extra effort is to fulfill the contractual obligations of the group. It has not been our experience that medically directed CRNAs have the same level of commitment to the other members of the anesthesia group, nor to the efforts that must be put forward to assure the continuing excellence and success of the group.

We recognize that an anesthesia model that includes employed CRNAs can work well in many situations. We feel our all-anesthesiologist group can give the best and most consistent care to our patients, the best service to our institutional customers, and the most professional satisfaction to the members of the group. We hope that the demographics of our community and our manpower resources will allow us to continue this model of anesthesia practice for years to come.
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The MGMA AAA 2009 Conference Provides Exceptional Education and Networking Opportunities
Brenda Dorman, MBA
President, MGMA AAA; Executive Administrator, Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston
It is my pleasure to announce that this year’s MGMA AAA 2009 Conference will be held May 17-20, 2009 at the alluring InterContinental Miami on Biscayne Bay in Miami, Florida. For those who are new to anesthesia or have never attended this conference, it is the premier anesthesia practice management event. While we continue to offer sessions on Pain Management, this year we have created a new pre-conference program. Due to the popularity of our “new to anesthesia” forum offered in previous years, we’ve expanded that series to a full day pre-conference on Sunday, May 17th. These sessions will cover many of the issues unique to anesthesia that every new or seasoned administrator usually spends years learning! Physicians wanting to learn more about how their practice works and how their administrator keeps it running smoothly will also find this pre-conference enlightening.
On Monday morning, physicians who attend the conference are invited to join Dr. Stanley Stead, Chair, American Society of Anesthesiologists’ (ASA) Committee on Economics, and other colleagues for breakfast. As in past years, this “physician only” informal networking event gives physicians an opportunity to discuss current topics and exchange information pertinent to their practices.
Our keynote speaker (special thanks to Anesthesia Business Consultants, LLC for their generous sponsorship of this event) is M. Tray Dunaway, MD, FACS, CHCO, president and CEO of Healthcare Value Inc. Dr. Dunaway is a nationally known speaker who will share with us his vision on connecting the “dots of healthcare” by applying his Mutual Value Integration model to improve communications and find the chemistry to make business solutions viable. Afterward, he will follow up with a humorous look at working relationships with physicians in a concurrent session entitled Doctors are from Jupiter and You’re From . . . Well, Actually, We don’t Care Where You’re From!
In addition to these excellent speakers, many of whom are our own MGMA AAA members, roundtable discussions are moderated by members who facilitate discussion while attendees share their experiences on a variety of issues of common interests.
Social events are a perfect time to network with colleagues and catch up with friends and we offer many including breakfast, lunch and networking receptions. In addition, a special reception is held prior to the opening reception to allow first-time attendees an opportunity to meet people and start networking right away.
Each year we enjoy tremendous support from many key vendors of anesthesia services and products who are “on hand” as sponsors and exhibitors during the breaks to demonstrate their offerings, answer questions and solicit feedback. [Please visit the ABC booth to pick up copies of – or to subscribe in your own name to – the Communiqué and our companion publication, the regular Monday “Alert.” – Ed.] The exhibit hall provides a great forum for comparison shopping and evaluating products your practice may need either now or in the future.
The InterContinental Miami, 100 Chopin Plaza, overlooks Biscayne Bay in the heart of Miami and is just minutes from South Beach, the Port of Miami, Coconut Grove and Coral Gables. The hotel was originally built as a casino in anticipation of legalized gambling in Florida which never evolved. It boasts 641 redecorated guest rooms and suites and is an “oasis of sophistication and world-class service.” Miami itself is an incredible locale for our meeting. It offers brilliant beaches, fine dining, an exciting and diverse culture, world-class shopping, and a vibrant nightlife – what more could you ask for!
Act now! View the brochure to register, www.mgma.com/AAA or call 1-877-ASK-MGMA (275-6462) and request information. ASA members who sign up with their administrator who is currently an MGMA AAA member may attend at the member rate. There is also a special rate available for non-members to include purchase of their initial membership and obtain the membership price for the conference. Please do not hesitate to contact me at dormanb@musc.edu should you have questions or need more information about the conference or any aspect of MGMA AAA membership. We hope to see you in May, 2009!!
1. The History of Intermountain Anesthesia
2. The Taxation of Disability Insurance Premiums
3. Avoiding Pitfalls as Practices Move Toward Care Team Model
4. The “Care Team” Billing Rules