Other articles in Spring 2009
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.