1. CRNAs - Is This a Right Fit for My Center Elizabeth Wong, CRNA, MSN

2. Explain the Cost Effectiveness of Educating CRN As Explore the Quality and Claims Information Describe the cost effectiveness of the 4 Anesthesia Delivery Models Evaluate Access - the Value-added Component Learning Objectives

3. Cost Effectiveness Analysis Pro: “CEA lies at the heart of perhaps the ultimate health policy question: how can we get good value for our money?” (Neumann, 2005) Opposition: “Isn’t cost effectiveness analysis just a smoke-screen for cutting costs at the expense of quality? “ (Eddy, 1992)

4. Costs Include: Direct education costs Opportunity cost of student or resident Value of the student or resident services while training Salaries of employees - CRNA or Anesthesiologists

5. Educational Costs CRN A Direct: Pre-Anesthesia: $53,696 Anesthesia: $68,465 T otal: $161,809 Anesthesiologist Direct: PreAnesthesia: $623,818 Anesthesia:$494,420 T otal: $1,083,795

6. Anesthesia Providers Produced Educate 670 CRN As for every 100 Anesthesiologists

7. Conclusion: Educational Costs Direct costs and economic cost of educating CRNAs are significantly lower then the cost of educating Anesthesiologists Economic costs of graduate education for CRN A are 1/4th the cost of Anesthesiologists Total education costs of CRNAs are about 15% of the cost of Anesthesiologists The key cost drivers are faculty cost and student-faculty ratios, program length, student opportunity costs, and the productivity of students in the clinical portion of graduate education 670 CRNAs can be produced for every 100 Anesthesiologists

8. QUALITY: 6 SIGMA The level of errors per million procedures under anesthesia approaches 6 Sigma (L ema, 2003; Luchsinger & Pexton, 2004 ).

9. Anesthesia Practice Models CRNA Only Anesthesiologist Only Anesthesia Care Team (CRNA and Anesthesiologist Supervisor) Collaborative (CRNAs and Anesthesiologists)

10. Evidence-Based Quality Majority - no statistically significant difference between anesthesiologists and CRNAs after controlling for other relevant factors 1. Minnesota Department of Health, 1995 2. Cromwell, 1999 3. Posner & Freund, 1999 4. Hoffman, Thompson, Burke, & Derkay, 2002 5. Pine, Holt, & Lou, 2003 6. Smith, Kane, & Milne, 2004 7. Simonson, Ahern, & Hendryx, 200 7 8. Needleman & Minnick, 2008 9. Dulisse & Cromwell, 2010 Exceptions: 1. Silber et al 20002. 2. Donnelly & Buechner, 2001

11. Surveys Nationwide Inpatient Sample (NIS) 2007 data No Claims; No Complications 8,034,162 = 99.88% Ingenix National Database N = 52,636 claims; No complications National Survey of Ambulatory Surgery (NSAS) N = 52,233; No complications

12. Conclusions: Quality Incidence of complications due to anesthesia, regardless of delivery model is low and declining With some exceptions, the literature suggests no statistically significant difference in complication rates or mortality rates between CRNAs and Anesthesiologists Analysis of claims data is consistent with very low incidence of complications and no difference between provider type

13. Cost Effectiveness: Literature Review Abenstein et al (2004), data from Silber et al (2000) - Medical direction model is more cost effective than a model in which CRNAs act independently. Data is NOT based on mortality due to anesthesia (Silber Study). Variation in delivery models may be correlated with variation in other factors affecting quality of care or patient risk. Glance (2000) - Anesthesiologist model not cost-effective. Direction-models are cost effective, with ratios varying optimally based on risk class of case. Subjective estimates of risk. Not clear how a given setting could adjust quickly to different models depending on risk. Quintana (2009) - estimated costs associated with a number of different delivery models Quality outcomes are held constant. Anesthesiologist intensive forms of delivery are less efficient, and more likely to require subsidization by the hospital.

14. Delivery Model Average Number Billed Amount Anesthesiologist only 33,249 $1,087.15 Supervision 1:2-4 11, 022 $1434.19 Supervision 1:1 2021 $1544.36 CRNA only 6344 $1059.34

15. Average Salary CRNA Average Annual Salary - $150,000.00 Anesthesiologist Average Annual Salary - $350,000.00

16. Cost Effectiveness: Conclusions CRNAs acting independently is the MOST cost efficient model and MOST attractive financially - Where demand is high, supervisory model (1:4+) and direction model (1:4) become relatively more attractive financially - Supervisory (Collaborative) model is the second least costly model - When demand is constrained, models which require larger demand become less cost effective - There are no circumstances examined in which a 1:1 direction model is cost effective or financially viable - When demand is highly uncertain, CRNAs acting independently becomes relatively more attractive financially

17. Supervision of CRNAs Historical Overview - 1800s - women and nurses 1850 - discovery of anesthetic agents / nurses (Catherine Lawrence) provided anesthesia on the battlefield of the Civil War 1936 Nelson (nurse anesthetist) vs Chalmers-Francis (MD) California Supreme Court Case. Judgement Nelson - Not practicing medicine. She was practicing nursing. She was employed and worked under the supervision of the surgeon. No California State Law supervision requirement. August 2009 - Calif. Governor Schwarzennegger Opt-out of the Federal Supervision requirement. January 2010 CMA/CSA vs Governor/CANA Lawsuit - Judgement Governor/CANA - Opt-out stands. No Federal supervision requirement. February 2011 - Appeal (in progress).

18. Access: The Value-Added Component Urban - 80% CRNAs/Anesthesiologists; 16% CRNAs only; 4% Anesthesiologists only Rural - 34% CRNAs/Anesthesiologists; 33% CRNAs only; 33% no providers CRNAs are the primary provider in the rural United States and that is the Value Added Component.

19. Conclusion: Access CRNAs significantly expand access to anesthesia services across the county Lower Cost - Greater physical Access Particularly expand care to rural areas - value-added component

20. Summary CRNAs are 6 times more Cost Effective to Educate than Anesthesiologists Quality of Anesthesia services is better than it ever has been without significant differences between CRNAs and Anesthesiologists Increased CRNA autonomy and more precisely independence improves the practice models and cost efficiency. Cost and Efficiency - CRNAs provide the Healthcare system the Value Added Component of increased Access to anesthesia services in Rural America

21. Acknowledgements Sam Martinez, Administrator of Channel Islands Surgery Center Juan Quintana, CRN A, DNP California Association of Nurse Anesthetists Board of Directors