Cost Effectiveness Analysis of Anesthesia Providers

Paul F. Hogan, MS; Rita Furst Seifert, PhD; Carol S. Moore, PhD; Brian E. Simonson, MS

Disclosures

Nurs Econ. 2010;28(3):159-169. 

In This Article

Abstract and Introduction

Introduction

In the United States, anesthesia services are administered predominately by two types of providers. Anesthesiologists are physicians who have completed medical school, a clinical base year residency, and 3 years as a resident in an anesthesia program. Certified registered nurse anesthetists (CRNAs) are advanced practice nurses who have earned a baccalaureate degree, practiced at least 1 year as an acute care nurse, and have successfully completed a graduate-level nurse anesthetist program. These graduate programs have an average duration of 28 months and may be as long as 36 months. Cur rently, there are approximately 40,000 practicing anesthesiologists in the United States (Health Resources and Services Administration, 2007) and over 36,000 CRNAs (American Association of Nurse Anesthetists [AANA], 2009). Both types of providers are critical to the safe, efficient provision of anesthesia services.

Anesthesia services are provided by CRNAs and by anesthesiologists in a variety of different delivery models. The delivery models vary by the degree of autonomy in which CRNAs may deliver anesthesia, as well as economic considerations. At one end of the spectrum, the CRNA may provide and bill for anesthesia services. At the other end, anesthesiologists may be the only providers administering and billing for anesthesia services in a particular practice setting. Between the two end points, CRNAs may work under varying degrees of supervision or medical direction. Delivery models may vary by practice setting based on the preferences and beliefs of the particular hospital or other setting, and because of state-specific and federal laws and regulations regarding the delivery and billing for services.

In this article, CRNAs who provide anesthesia for a patient under the care of an operating practitioner, but are not supervised nor medically directed, are referred to as "independent." CRNAs who provide anesthesia under anesthesiologist oversight are either "medically directed" or "supervised." These terms are used in the context of anesthesia staffing models and costs, not in terms of clinical decisions.

Analysis of the data examined the cost effectiveness of the alternative delivery models, and the implications of this for providing quality, cost-effective anesthesia services. Anesthesia is a component of surgical, medical, and diagnostic procedures as well as in pain management. The cost, access, and quality of health care services in general will be affected in no small measure by the availability of cost-effective anesthesia services.

In cost-effectiveness analysis, one compares the cost of alternative ways of achieving a given outcome. The issue of whether the quality of anesthesia services or outcomes is likely to vary across delivery models and providers was considered first. A reliance on literature review and a claims analysis to establish that there is no evidence to suggest that the quality of services or the outcomes will vary across the delivery models was considered. Next, a cost effectiveness of the alternative delivery models was examined. A stochastic simulation model was developed and applied, which simulates likely costs and revenues associated with each delivery model, holding constant other conditions likely to affect costs and revenues in the comparisons. Claims data for private payers were examined to determine how the costs to payers vary by delivery model. (Note that payments of the largest public payer, Medicare, are made according to a formula.) Finally, the costs to society of educating nurse anesthetists and anesthesiologists were examined and compared.

The information presented can help inform payers and employers (e.g., hospitals, anesthesia provider groups, public and private insurers) regarding the cost, quality, and access implications of alternate delivery models. The findings provide an evidence base to inform federal and state regulators and legislators who are formulating rules and regulations regarding the delivery of anesthesia. Further, information from this study can help federal and state legislators, education program directors, and other stakeholders regarding the potential return on investment from investing in anesthesia education and improving access to quality, cost-effective anesthesia care.

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