Nurse Anesthetists, Anesthesiologists, and the VA System: Are Changes Needed?

Susan B. Yox, RN, EdD; Bret S. Stetka, MD; Juan Quintana, CRNA, DNP, MHS; Daniel J. Cole, MD

Disclosures

July 08, 2016

Policy Change and Counting Costs

Medscape: Nurse anesthetists have a long history as independent anesthesia providers, particularly in the military. Does this history and experience support their autonomous practice in the VA system as well, or are these situations different?

Dr Quintana: Absolutely, the history and experience of CRNAs support autonomous practice in the VA. Caring for critically injured soldiers on the battlefields of every major US military action since World War I has shown the world that CRNAs have the education, training, and capabilities to treat veterans with serious health issues, whether they were acquired during their time in the service or after leaving the service.

Clearly, caring for wounded soldiers on the front lines is the very definition of handling "complicated cases" and "dealing with emergencies." Time is of the essence, and the providers must be able to think on their feet and provide the essential care needed at each critical juncture. Yet the ASA likes to claim that these situations are best handled by anesthesiologists in civilian and veterans facilities. To call this illogical is an understatement. CRNAs are more than qualified to handle complicated cases and emergency situations without anesthesiologist involvement, and do so safely all of the time.

Nurse anesthesia practice was born on the battlefields of the American Civil War and predates anesthesiology by several decades. Today, CRNAs practice in every type of healthcare setting where anesthesia is utilized, providing every type of anesthesia for every type of surgical and other healthcare procedure. CRNAs are the predominant providers of anesthesia care in the US military, in rural and other medically underserved areas of the country, and to women in labor.

Dr Cole: The VA's proposed policy change is unprecedented and would go far beyond the Department of Defense practice. We are especially concerned about veterans, a population of patients who are often sicker and frequently have multiple medical conditions that put them at greater risk for complications.

Although the ASA has concerns about anesthesia care being provided to any patient without the involvement of a physician anesthesiologist, the veteran population is very different from the much healthier active-duty military population and needs and deserves the high quality and safety of physician-led anesthesia care.

Medscape: Will there be substantial cost savings for the VA if full practice by CRNAs is implemented? Is there concern about loss of income by anesthesiologists?

Dr Cole: In opposing this change, we have stayed focused on one thing: the safety and quality of the anesthesia care provided to our veterans. We have not looked at such issues as employment.

In fact, eliminating the physician anesthesiologist can actually cost more, because other physicians may be needed to consult or provide the services of a physician anesthesiologist; these include evaluating the patient for preexisting conditions or handling emergencies and other medical issues.

And ultimately, we do not believe there is any cost savings that justifies lowering veterans' standard of care and risking their lives.

Dr Quintana: There is a substantial cost differential between anesthesiologists and CRNAs in both the public sector and the VA. In the public sector, the mean annual compensation for an anesthesiologist is about $400,000—nearly 2.5 times that of a CRNA, whose median total compensation is about $165,000. Because Medicare pays the same fee for an anesthesia service regardless of whether it is provided by a CRNA, an anesthesiologist, or both working together, the higher cost of the anesthesiologist is borne by someone: the hospital, the healthcare facility, or the patient.

In the VA, the current pay cap for an anesthesiologist is $295,000 compared with $199,700 for a CRNA. However, the Secretary of Veterans Affairs recently recommended raising the pay cap for anesthesiologists to $325,000 to assist in recruiting top healthcare providers. Therefore, it does not appear that anesthesiologist income or positions are in jeopardy.

It is not anticipated that the VA will realize an actual reduction in costs if the proposed rule is finalized, but savings are projected through the more efficient and effective utilization of existing APRN resources, preventing the VA from having to hire additional healthcare providers to solve the problem of long wait times for veterans.

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