Anesthesia staffing is driven by the complex interactions between regulations, insurances, reimbursements, local history, and, increasingly, the availability (or, more commonly, lack) of providers. The Centers for Medicare & Medicaid Services (CMS) regulation of hospital “conditions of participation” and professional billing processes set limits on how services can be provided and how we are reimbursed. All hospitals are obligated to ensure that anesthesia is provided within this regulatory framework, but the specific model of care delivery for anesthesia is increasingly likely to be driven more by history and availability of staff than by regulation.
“Economic pressures have caused the closure of many small hospitals, and a worsening economic climate for even larger health care entities will only accelerate this trend. Smaller rural hospitals must work together with one another to build economies of scale and share resources among sites, including anesthesia resources, simply to survive.”
In Rochester, New York, anesthesia was historically provided primarily by anesthesiologists directly delivering care. It may seem odd now, but with the introduction of CRNAs to the university practice at Strong Memorial Hospital in the 1980s, the cultural disruption was initially so significant that many felt bills should not even be generated for CRNA-provided care. That position has long since been abandoned.
Only a short drive south, in the ORs of the small rural hospitals that are now affiliated with the University of Rochester, anesthesiologists exclusively provide care in some settings, and supervised CRNAs exclusively provide care in others.
The anesthesia care model in use on any given day, or from one year to another in these small settings, has been more the product of local history and provider availability than as a result of an orchestrated strategy to address specific patient, surgical, or outcome interests. In most of these hospitals, budgeted margins are routinely less than the difference in average compensation between a CRNA and an anesthesiologist. Availability has been, and increasingly is, the compelling driver of the anesthesia coverage model in place. The difference in cost between a CRNA and an anesthesiologist is shrinking, while the cost of both is skyrocketing. Ultimately, the delivery of anesthesia care is evolving under cost pressures.
Simultaneously with these cost pressures, hospitals will face challenges related to staffing availability, the aging of patient populations, and the aging of surgeons and anesthesia professionals. Additionally, the younger generation of surgeons and anesthesia professionals are less tolerant of frequent call and of the surgeon supervision model.
Regardless of the model, costs of anesthesia can eliminate the margin of surgical revenue entirely in small settings. Unless ORs are run efficiently, and the deployment of anesthesia professionals maximizes the best use of all providers, rural surgery will be a cost rather than a revenue center. We assume that these factors, combined with high salary structures in urban practices (often requiring no call from CRNAs), will result in an increasingly physician-led but nonteam model of care over time.
We predict that the role of the rural consultant anesthesiologist will be increasingly one of organizing care, planning care, and direct delivery of care, over direct supervision of cases. This transition will require a transformation of training to the new role and an expansion of physician candidates. To develop and implement new models of anesthesia care, hospitals and providers must surrender traditional cultural mores and abandon evidence-deficient dogmas. Economic pressures have caused the closure of many small hospitals, and a worsening economic climate for even larger health care entities will only accelerate this trend. Smaller rural hospitals must work together with one another to build economies of scale and share resources among sites, including anesthesia resources, simply to survive. The benefits of group purchasing, management expertise, and clinical leadership, otherwise unavailable or unaffordable, are enhanced in affiliations, and clinical leadership increasingly will be provided by consultant anesthesiologists if the fullest range of services are to be provided in smaller settings. This is not to say that anesthesiologists need to provide all intraoperative care to achieve those goals. It is not the “who” but the “how” of care that matters.
In some rural OR suites, care has been, or is, provided by CRNAs supervised by the operating physician. CRNAs frequently cover call and provide labor analgesia and intraoperative care as well as central venous access and emergency airway care safely and efficiently. This is perhaps despite the fact that, in some cases, surgeon supervision may be less than optimal. It would be better for CRNAs currently practicing under the nominal direct “supervision” of surgeons to practice collaboratively with an anesthesiologist, even if the anesthesiologist was not physically present. After all, it is most often not hands that CRNAs need when faced with an acute problem, it is consultancy. Consultancy is frequently defined as “a professional practice that gives expert advice within a particular field.” Consultant anesthesiologists bring to the team the depth of knowledge of pharmacology, physiology, and pathophysiology and, most importantly, the ability to sort through possible causes of problems algorithmically, arriving at solutions quickly. An unprepared surgeon, who is concurrently involved with executing a surgery, may be the least desirable form of “supervisor” when things are not going as planned.
There are many ICU beds in this country that are now run as “e-ICUs.” Increasingly, intensivists are covering multiple units remotely, using technology to access real-time monitor data and video linkage, and supporting the bedside provider, who may be an advanced practice RN or simply a bedside RN. If technology-assisted remote coverage of critically ill patients by a remote consultant physician working with an advanced practice RN in an e-ICU is a safe model of care, then anesthesia delivered by a collaborative CRNA is an equally safe and efficient model of care as well. Such technology-based care enhancements are under development, and innovative solutions like the “Anesthesiology Control Tower” are currently being studied (JMIR Hum Factors 2019;6:e12155). Could these offer granularity of physician input and “optimized intraoperative vigilance” to the rural hospital setting when the facility can neither afford, nor actually need, a full-time, on-site consultant anesthesiologist? Similarly, (as described elsewhere in this issue) can remotely deployed screening and telemedicine processes drive preoperative optimization to ensure that patients having surgery in small communities access the same state-of-the-art preoperative care planning and optimization as is available at major academic medical centers?
“Access to rural anesthesiology e-consultants may ultimately be recognized as the real difference between the ‘who’ and the ‘how’ of anesthesiology’s contribution to care safety in small settings.”
We believe that innovative, perioperative, and intraoperative medical technologies will be developed and deployed to rural hospitals and that these will diminish the disparities that exist, and are currently worsening, between rural and urban care systems. Access to rural anesthesiology e-consultants may ultimately be recognized as the real difference between the “who” and the “how” of anesthesiology’s contribution to care safety in small settings.