1. How Cost- Effective are CRNA-provided Services in Missouri Sallie Poepsel, PhD, CRNA, APRN Jeanie Skibiski, CRNA, MHA, APRN

2. OBJECTIVES Name the three most common provider models of anesthesia care delivery. Describe the Lewin method for determining cost-effectiveness based on provider models of anesthesia care delivery.

3. OBJECTIVES Describe the methods for conducting a cost- effective analysis of anesthesia services in Missouri. Discuss the findings of the 2015 Missouri cost-effectiveness analysis (CEA) of anesthesia services.

4. Methods Stochastic Simulation (Lewin Model) Anesthesia Care Delivery Models Defined payer mix Defined fixed demand for Revenue Defined fixed salary for cost

5. Basic Assumptions Acute care hospitals have 12 ORs and appropriate anesthesia staff Acute care hospitals have the same payer mix Acute care hospitals have the same procedure complexity with same base units, time units and can only do 4 cases Acute care hospitals employ providers the same Acute care hospitals only use one provider model and bill accordingly Providers work the same number of hours

6. Limitations Cannot account for: hospitals with varying number of ORs Anesthesia provider arrangements (contracted or employed) Work hours, fringe benefits, stipends, payer mix, Mixed provider models, procedures & billing practices

7. KEY PARAMETERS Payer Parameter s MEDICAREMEDICAIDPRIVATEOTHER Missouri Payer Proportion 0.430.1570.3350.061 Conversion Factors $21.43$6.94$54.87$0 Mean Value for Anesthesia Billing Anesthesia Base Unit 6.2 Anesthesia Time Unit 7.1

8. KEY PARAMETERS No of Procedures per OR 4 Annual Procedure Days 260 Anesthesia Provider Salary CRNA $186,458 Anesthesiologist $501,755

9. Est. Revenue & Cost in $$ per Hospital to Sustain Anesthesia Services for Inpatient Operating Rooms only Anesthesia Delivery Model No of Staff Needed to Sustain Anesthesia Services for 12 ORs Annual Total Revenue/Ho spital Annual Total Cost per Hospital (Revenue- Cost) per Hospital (Revenue- Cost) per OR CRNA only13.8 CRNAs4,761,427.652,573,123.162,188,304.49182,358 MDA only13.8 MDs4,761,427.656,924,222.86-2,162,795.22-180,232.93 Medical Direction 1:4 3.5MD/ 13.8CRNAs4,761,427.654,329,266.64432,161.0136,013.42 Medical Direction 1:2 6.9 MD/ 13.8CRNAs4,761,427.656,035,234.59-1,273,806.95-106,150.58 Supervision 1:6 2.3 MD/ 13.8CRNAS3,812,722.143,727,160.3085,561.837,130.15

10. Conclusion Based on this analysis, the most cost-effective anesthesia delivery model is the CRNA-provided anesthesia services

11. Policy Implications for Anesthesia Practice Triple Aim Framework for Advocacy Access to Services Quality Anesthesia Care At an Affordable Cost