By: Robert Stiefel, M.D.
On average, the OR generates 70 percent of a hospitalâ€™s total revenue. As reimbursements shrink, healthcare leaders are looking for every advantage to optimize this profit center. This is the first of a multi-part blog series designed to shed some light on how anesthesia departments work and their role in the quest for OR quality, efficiency and profitability.
To begin, we will focus on a high level review of the most common anesthesia coverage models:
- All MD
- Anesthesia Care Team (ACT)
- CRNA Only
Each of these models has unique characteristics which will affect how the OR functions. The choice of model will impact the OR flow, anesthesia subsidy, perception of your facility with the surgeons, and OR profitability. There have been no definitive studies pointing to better surgical outcomes based on the type of anesthesia coverage model utilized. Therefore, there is not a singular â€śrightâ€ť answer regarding which coverage model is best. Every hospital must analyze its current and projected coverage needs as well as goals around OR efficiency and surgeon satisfaction to determine which model will work best for its facility.
Within each category, there are two distinct models: Closed Staff, where an anesthesia group has an exclusive contract to provide all anesthesia services at the facility; and Open Staff, which allows for any qualified anesthesiologist or anesthetist to gain staff privileges and provide services to surgeons at that facility.
In this model, all work is performed by anesthesiologists. Since a physician is present during all aspects of care, there are fewer providers to coordinate and no supervision requirements to manage. However, these groups are oftentimes unable or unwilling to fulfill a hospitalâ€™s request for non-revenue producing, value added services such as providing additional physicians to perform pre-op evaluations or to manage the daily flow in the OR.
All MD models are oftentimes more expensive than other models, and with all other things being equal often result in a higher subsidy requirement from the hospital or health system.
Anesthesia Care Team (ACT)
An ACT is a combination of anesthesiologists, certified registered nurse anesthetists (CRNA) and/or anesthesia assistants. This model provides excellent patient care for a wide variety of cases. It also allows the availability of physicians to assist with pre-operative assessment, line placement and post-op pain control. In addition, physicians are readily available to work collaboratively with OR nursing to increase efficiency in the OR.
However, this model does require a higher level of coordination due to the increased number of providers. And, in some instances, friction may develop among the different types of providers. In addition, there can be management issues related to employing CRNAs and supervision requirements for non-physician providers can sometimes impede first case starts.
The ACT model is often the intermediate cost option of the three models outlined here.
In this model, certified registered nurse anesthetists work independently without the assistance or supervision of an anesthesiologist.Â Under a CRNA Only model, the surgeon assumes the liability for the clinical outcomes of the anesthetic as well as the surgical care. In addition, there is no anesthesiologist to consult with or assist CRNAs with difficult cases. Therefore, some surgeons are uncomfortable with a CRNA Only model and may choose to perform procedures at another facility that utilizes a different model.Â Typically the CRNA Only model is the most affordable of these three staffing models.
The decision of which anesthesia model to use is multi-factorial and the pros and cons should be understood as they relate to a specific facility. Knowing your options, as well as understanding your needs, will help you to make an informed decision regarding which model is best for your hospital, your surgical staff and your community.