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Given the potential costs of anesthesiology, it is critical for both patients and providers alike to utilize delivery modalities that provide economically efficient administration of care without diminished quality. Although MDs and CRNAs can provide the same quality of care, MDs earn a higher income on average. The added healthcare costs of employing an MD over a CRNA is placed on patients, hospitals, and society at large. According to “Cost Analysis of Anaesthesia Providers” by the Lewin Group along with other studies, increasing the market share of CRNA anesthesia providers, especially those who function without MD supervision, is a potential economic cost saving mechanism.

There exists several distinct MD and CRNA anesthesia delivery modalities. One of which is the all MD model, which may be economically inefficient for consumers relative to its peers [3,5]. However, the all MD model is common in the smallest surgery centers, since equipping MDs with CRNAs adds unnecessary costs for anesthesiologists running smaller scale operations [3]. At the opposite end of the modality spectrum, all CRNA centers allow CRNAs to practice without anesthesiologist supervision [5].

 Where these modalities mesh is both the supervisory MD/CRNA model and the directory MD/CRNA model. The former allows physicians and CRNAs the ability to work in conjunction with flexible supervision requirements [3,5]. The latter requires an anesthesiologist to play a more in depth role in monitoring CRNAs and other qualified assistants such as resident physicians [3,5]. Of the aforementioned types, there is ample research suggesting that an all CRNA care model is most cost effective. The discrepancy in education requirements for both professions is a key element of this phenomenon.

While CRNAs require a significant amount of education and training, the time and financial investment for this preparation is less than that of anesthesiologists. CRNAs are required to possess a nursing or similarly appropriate bachelor’s degree, register as a licensed nurse, and possess one year of experience as a critical care RN [5,13]. In addition, they must complete an accredited graduate level anesthesiology degree spanning 24 – 36 months, before ultimately passing a certification exam [5,13].

 Conversely, anesthesiologists require a pre-med bachelor’s degree, four years of medical school, base residency, as well as three years of anesthesiology related residency [5,13]. For board certification, they require four years of post-graduate training as well as passing score on the American Board of Anesthesiology Exams (written and oral) [5,13].

In 2017, American anesthesiologists earned average salaries of $265,990, while the CRNA average was $169,450 [6,7]. Although MDs enjoy this higher level of compensation as a result of their more extensive education and training, there is minimal evidence for a difference in quality for anesthesiology administered by MDs over CRNAs for most types of cases. Studies including the “Cost Analysis of Anaesthesia Providers” by the Lewin Group, consistently highlight unsupervised CRNAs as the most cost effective model. Their research indicates that an all CRNA model also generates the highest profitability level, and is not as hindered by requiring hospital subsidies or lower rates of demand like the medical direction model [5]

Anesthesia has yielded fantastic patient outcomes in recent decades. Between the late 80’s and late 2000’s, mortality rates were about 1 death for every 240,000 anesthesia procedures [1,5]. Additionally, complication rates were reported to be as low as 1.25/10,000 cases in as early as 1988 [5,9]. For over half a century, multiple research studies, including those conducted by the Veteran’s Administration, the Institute of Medicine, the Minnesota Department of Health, the Research Triangle Institute, as well as by famed anesthesiologist W. H. Forrest, showed little to no difference in care quality between CRNAs and anesthesiologists [2, 4, 5, 8, 10, 11, 12].

Regardless, taxpayers, patients, and healthcare facilities shoulder the financial burden of extra costs for similar quality treatment [5]. With the US currently spending approximately 18% of its GDP on healthcare, properly utilizing the cost effectiveness of CRNAs is a potential major step in securing US economic healthcare efficiency [10]. Although the challenge is formidable, the continued utilization of various CRNA models may not only reap continued economic benefit, but also help set a precedent for the value of skilled nurses.   

Bibliography

1. American Association of Nurse Anesthetists (AANA). “National Nurse Anesthetists Week Celebrates Anesthesia Patient Safety.” 2008. Retrieved from http://www.anesthesiapatient safety.com/na_glance/nnaw.asp
2. Dulisse, Brian, and Jerry Cromwell. “No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians.” Healthaffairs.org, Project Hope – The People-to-People Health Foundation, Inc., 8 Nov. 2010, www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2008.0966.
3. Fields, Rachel. “MDs, CRNAs and Care Teams: The Ins and Outs of 4 Anesthesia Care Models.” Becker’s ASC Review, 23 Aug. 2011, www.beckersasc.com/anesthesia/ins-and-outs-of-4-asc-anesthesia-provider-models.html.
4. “The Future of Nursing: Leading Change, Advancing Health.” The Future of Nursing: Leading Change, Advancing Health, Institute of Medicine , 19 Oct. 2018, nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx.
5. Hogan, Paul F., et al. “Cost Effectiveness Analysis of Anesthesia Providers.” AANA.com, American Association of Nurse Anesthetists, June 2010, www.aana.com/docs/default-source/research-aana.com-web-documents-(all)/nec_mj_10_hogan.pdf.
6. “How Much Can a Anesthesiologist Expect to Get Paid?” U.S. News & World Report, U.S. News & World Report, money.usnews.com/careers/best-jobs/anesthesiologist/salary.
7. “How Much Can a Nurse Anesthetist Expect to Get Paid?” U.S. News & World Report, U.S. News & World Report, money.usnews.com/careers/best-jobs/nurse-anesthetist/salary.
8. Institute of Medicine of The National Academies. The Future of Nursing LEADING CHANGE, ADVANCING HEALTH. The National Academies Press , 2011, The Future of Nursing LEADING CHANGE, ADVANCING HEALTH, www.nap.edu/read/12956/chapter/1.
9. Klaucke, D., et al., “Investigation of mortality and severe morbidity associated with anesthesia: Pilot study final report.” Washington, DC: Battelle Human Affairs Research Centers,1988.
10. Minnesota Department of Health. Anesthesia Practices Study. Minnesota Department of Health , 1995, pp. 24–24, Anesthesia Practices Study.
11. O’Neill, Nicolle A. “Anesthesia Policies- Increasing Costs with No Improvement in Value.” Journal of Healthcare Communications, IMedPub, 5 Oct. 2017, healthcare-communications.imedpub.com/anesthesia-policies-increasing-costs-with-no-improvement-in-value.php?aid=20801.
12. Quintana, Juan. “Answering Today’s Need for High-Quality Anesthesia Care at a Lower Cost: Remaining States Need to Consider Opting out of Physician Supervision for CRNAs.” Becker’s Hospital Review, ASC COMMUNICATIONS 2019, 20 Jan. 2016, www.beckershospitalreview.com/hospital-physician-relationships/answering-today-s-need-for-high-quality-anesthesia-care-at-a-lower-cost.html.