The answer to the question in the title is rhetorical, as it will be in the eye of the beholder. Each ASA member has his or her own unique practice situation, personal disposition, and life priorities, so the realities one perceives as “bad” might be “good” or “indifferent” for another. Still, it is useful to examine some of the widespread, pressing challenges facing our specialty – the exercise reveals sobering truths that reach across all practice settings.
Financial challenges: ‘Blood from a stone?’
The post-pandemic job market is burgeoning. For anesthesiologists and for CRNAs/CAAs, salaries in many areas have increased dramatically over the past 12-24 months. Meanwhile, practices incur significant costs unrelated to compensation: malpractice coverage, employee benefits, and administrative infrastructure (nonclinical staff for billing and human resources). Groups that operate “bare bones,” without a significant administrative arm, will typically retain a billing/management company, which brings its own cost (typically a 4%-6% fee as a portion of revenue).
It is vital to minimize staff turnover, which is hugely negative financially and logistically, so anesthesia professionals should be kept content. This means paying competitive salaries, offering attractive benefits, and allowing for a reasonable amount of time off.
Of course, “all this costs money!” Actually, quite a bit of it, considering the median salaries for anesthesiologists and CRNAs/CAAs right now. Who is going to foot the bill? Hospitals have notoriously razor-thin margins, and most are not flush with capital. Health systems are rarely enthusiastic when bestowing scarce dollars on a medical practice that does not directly provide referrals. Who has not heard the refrain, or a variation thereof, “You don't bring patients into the hospital, the surgeons do.” Many ASA members have experienced first-hand the difficulties of negotiating a contract with a C-suite when the proposed agreement includes a request for financial support.
What if we just abandon hospital support/stipends? Let's run our practices efficiently and prudently and count on billing/accounts receivable to keep us in the black! This might work if our coverage is limited to a cosmetic surgical center in an upscale community, where there is no off-hours coverage and patients pay up front. Note the intentional irony – not many of us practice in such a favorable environment. Most groups, whether academic or private, are asked to provide night and weekend call coverage, for general cases and often for specialized service lines like cardiac, obstetric, and trauma as well. Call usually includes a pre- and post-call day for the covering physician, leading in turn to one (or more) salary lines/FTEs allocated to an extended clinical time period that generates minimal (or no) revenue.
Let's put the burden of call coverage aside and focus on the copious reimbursements flowing into our coffers from doing scheduled daytime cases (again, intentional irony). As the U.S. population continues to age, and simultaneously the proportion of people in the active workforce (i.e., the privately insured) slowly declines, most practices find themselves with a generous proportion of governmental payers (Medicare/Medicaid) in their mix. The Medicare “33% problem” drives home the fact that public payer rates are NOT sufficient to sustain a practice anywhere in the country. Private insurers are the better option, but these companies, while “richer” than hospitals, are nevertheless equally reluctant to part with money. Further, conversion rates vary widely across the U.S., and the lower end of them is not necessarily a huge improvement over Medicare/Medicaid. Only those anesthesia practices at the higher end (who are getting hundreds of dollars per unit) find themselves with a degree of financial breathing room.
To sum up, it costs a lot to run an anesthesiology practice, and it is unclear exactly where the capital in question is going to come from in 2024 and beyond. Purely clinically based billing, obtained from aggregate base + time units, will not cut it.
Independent CRNA practice, medical title (mis)appropriation
These topics are familiar to us all, and not in a positive sense. Here in Florida, for the past 25 years running, advanced-practice RN advocacy and lobbying groups have introduced legislation proposing independent practice for APRNs/CRNAs. Each year, the Florida Society of Anesthesiologists expends time, money, and substantial effort to play “defense” on these bills. Fortunately, we have been successful each time around. A more recent but equally troubling nursing advocacy effort is the push to add terms to nurses' professional titles that are traditionally reserved for physicians, i.e., “nurse anesthesiologist” for CRNAs, and “doctor” for anyone who has obtained a Doctor of Nursing Practice degree.
The practice of medicine and the practice of nursing are discrete disciplines, with distinct training pathways and separate clinical roles. Traditionally, the two have been complementary, and professionals of the two disparate backgrounds have been able to work together harmoniously. Recently, however, such roles and relationships are threatened. Some believe that enough misleading rhetoric, the use of a particular title, and/or spending an arbitrary amount of time in a particular educational setting can magically transform people from one type of health care professional to another. In other words, if someone with a nursing background jumps through the proscribed hoops (not including attending medical school), he or she can then claim the responsibilities and titles that accompany physicians and have historically defined the practice of medicine.
These unfortunate developments pit anesthesiologists (and other physicians) as adversaries against nurses, who are supposed to be our indispensable partners in providing safe, effective, and compassionate care. Dismantling of the physician-led care team is, of course, a great concern for anesthesiologists who wish to maintain their clinical relevance and their livelihoods. However, the primary objection to autonomous nurse practice is not physicians' greed, pride, arrogance, nor anything of a base nature. Rather, it is the desire to preserve perioperative patient safety and autonomy. Put simply, each procedural patient is entitled to the care of an anesthesiologist, just as they rightly expect to be treated by an attending surgeon, GI physician, cardiologist, or other proceduralist. A patient would likely accept a PA or ARNP assisting a surgeon in abdominal exposure but would not accept these same individuals performing a bowel anastomosis! The practice of nursing is NOT the practice of medicine, and patients in our ORs have the right to physician expertise on both sides of the drapes. This is what we would want for ourselves and our loved ones.
Attempts to confuse the public, present inaccurate/inappropriate terminology, and claim nurse-physician equivalency are not going away. The most concerning scenario is when RN interest groups interact with uninformed/naive health executives, governmental regulators, and elected officials and tout independent practice as the solution to (real or imagined) provider cost and access-to-care issues.
Self-devaluation, losing ourselves in negativity
There is not a high level of awareness and recognition among lay people about what anesthesiologists do. This fact was the impetus for ASA's campaign to rebrand us as “physician anesthesiologists.” We function in a shadowy background role, meet our patients briefly on the day of a procedure, and often do our most important clinical work unnoticed, while patients are unconscious or sedated. Indeed, if we are barely noticed during the workday, most of us would consider that a resounding success. It may happen that unenlightened hospital systems and administrators may dismiss our specialty as a necessary evil – an underperforming loss-leader that exists only to facilitate proceduralist case flow. It is a fact that our specialty is mostly hospital-based, with no extended continuity of care, providing little to no source of patient referrals. In this context, assertions that we are clinically equivalent to advanced-practice nurses (and therefore superfluous and an unnecessary expense) constitute another blow to our profession's image and standing.
The negativity swirling around us can be insidious and demoralizing. For example, when a practice feels guilt or trepidation in negotiating financial support that is necessary and essential given the scope of coverage requested, it is an example of self-devaluation. Simply because we are a hospital-based specialty, must we in effect apologize for our very existence and “take the fall” for a suboptimal perioperative financial climate, over which we have little to no control? Other hospital-based disciplines exist, such as pathology, radiology, emergency medicine, and critical care. Like anesthesiology, not all these specialties necessarily directly make money for a hospital, but unlike anesthesiology, they are generally properly recognized/valued for providing essential services and for their indirect support of clinical and financial mission(s).
Consider also how anesthesiology is treated via hospital capital budgeting and resource allocation processes, in contrast with the surgical disciplines. It seems unlikely that a busy joint surgeon would be denied a particular set of implants (or instruments) that he/she deemed essential. Meanwhile, anesthesiology departments are often denied ready access to important medications such as intravenous acetaminophen and sugammadex. Similarly, requests for crucial, life-saving equipment such as videolaryngoscopes are not always granted. When we accept this double standard, we tacitly endorse a damaging external devaluation of our profession.
Regarding intrusive, unrealistic expectations from health systems and insurers, what happens when these entities pressure us to significantly change/alter our practices purely for the sake of what they perceive as appropriate cost-containment? If we agree, is this not a devaluation of ourselves? Put another way, what should be the proper response to the challenge, “You all are too expensive – you need to do X, Y, or Z to become cheaper”? Abandoning medical direction for medical supervision in procedural areas (e.g., unwillingly increasing staffing ratios above 1:4), delegating off-hours in-house obstetrical coverage to nurse anesthetists, and/or changing a group's structure from MD-only to care team model are all examples of misguided “cost-cutting” proposals that have been forced onto groups. Anesthesiologists by nature and training are excellent stewards of patient safety and of perioperative efficiency, and we should not allow others, who lack proper expertise and priorities, to dictate practice models or parameters to us based on incorrect operational/financial assumptions.
In closing, I thank Dr. Lilian Kanai for the opportunity to contribute to this important issue of the Monitor. I hope readers find this article thought-provoking and that it motivates all of us to work for a more positive, more secure future.