NAPA?

[abolt18]

what does AHA stand for?

American hospital association

Also, very much not your friends. They want to crush you and all of us measly pawns.

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[coffeebythelake]

what does AHA stand for?

american hospital association

 

[Gasworks]

I can tell you that Napa walked away from one of the biggest hospitals in tampa and the hospital opted to employ everyone left behind. They came in with a pay and vacation bump for everyone but are still struggling to fully staff since there just aren’t enough bodies to go around. It’s also interesting to note that things like QZ billing and solo CRNA’s were absolutely forbidden in the contract with Napa but now the hospital is pushing hard to increase ratios and let crnas run OB on their own.

 

[Howard888]

That’s the future of anesthesia. Hospital employment with that exact model. Hospitals don’t have to worry about anesthesia billing in same capacity as can bill as part of facility fee or a line item. This will hit some areas in 2 years others in 15, but that’s it. High levels of CRNAs with a few MDs around to put out fires, do procedures, or supervise higher acuity cases in lower ratios. Get used to it

 

[The kitchen sink]

what does AHA stand for?

American Hospital Association?

 

[neutro]

That’s the future of anesthesia. Hospital employment with that exact model. Hospitals don’t have to worry about anesthesia billing in same capacity as can bill as part of facility fee or a line item. This will hit some areas in 2 years others in 15, but that’s it. High levels of CRNAs with a few MDs around to put out fires, do procedures, or supervise higher acuity cases in lower ratios. Get used to it

Yeah

A lot of hospital systems in north east and PA have this model

 

[GassYous]

That’s the future of anesthesia. Hospital employment with that exact model. Hospitals don’t have to worry about anesthesia billing in same capacity as can bill as part of facility fee or a line item. This will hit some areas in 2 years others in 15, but that’s it. High levels of CRNAs with a few MDs around to put out fires, do procedures, or supervise higher acuity cases in lower ratios. Get used to it

This sounds horrible

 

[Bertelman]

That’s the future of anesthesia. Hospital employment with that exact model. Hospitals don’t have to worry about anesthesia billing in same capacity as can bill as part of facility fee or a line item. This will hit some areas in 2 years others in 15, but that’s it. High levels of CRNAs with a few MDs around to put out fires, do procedures, or supervise higher acuity cases in lower ratios. Get used to it

Seems short-sighted. The minute they do that, anesthetists become even more empowered. Increase their salaries, essentially get paid as physicians but with a small fraction of the training.

Glad I live in a state that doesn't allow solo practice. For now.

 

[Beeftenderloin]

That’s the future of anesthesia. Hospital employment with that exact model. Hospitals don’t have to worry about anesthesia billing in same capacity as can bill as part of facility fee or a line item. This will hit some areas in 2 years others in 15, but that’s it. High levels of CRNAs with a few MDs around to put out fires, do procedures, or supervise higher acuity cases in lower ratios. Get used to it

I’m recently transitioned from PP to hospital employed model. Pre-transition we were about 45 docs and 10 CRNAs. Post, we’re about 40 docs with 4 CRNAs. Admin plans to hire 10+ docs and 4-5 CRNAs. They’ve already got contracts signed for half the doc positions, and offers out for the rest. Can’t even find anyone to interview for the full time CRNAs positions. I’m not concerned.

 

[aneftp]

That’s the future of anesthesia. Hospital employment with that exact model. Hospitals don’t have to worry about anesthesia billing in same capacity as can bill as part of facility fee or a line item. This will hit some areas in 2 years others in 15, but that’s it. High levels of CRNAs with a few MDs around to put out fires, do procedures, or supervise higher acuity cases in lower ratios. Get used to it

Crna solo aren’t cheap. And they want to work when they want to work.

I’m not worried about crnas. They are very fickle. They want money and time off

 

[Pharmado]

Crna solo aren’t cheap. And they want to work when they want to work.

I’m not worried about crnas. They are very fickle. They want money and time off

Hospitals rarely appreciate all that the things physicians do to keep things running. Stay late, work post call, take phone calls and meetings from home and on vacation, create schedules on personal time etc. These things go unnoticed and unappreciated. Then you’ve got CRNAs who do things how we probably should and only work from work, during work hours and give little/nothing of their personal time and lives to the job. It isn’t nearly as cheap as it seems when you pay someone for every single minute of work and give them 3 breaks every day.

 

[nycitygas]

That’s the future of anesthesia. Hospital employment with that exact model. Hospitals don’t have to worry about anesthesia billing in same capacity as can bill as part of facility fee or a line item. This will hit some areas in 2 years others in 15, but that’s it. High levels of CRNAs with a few MDs around to put out fires, do procedures, or supervise higher acuity cases in lower ratios. Get used to it

I agree with his 100%. The CRNA/AA shortage is a short term issue similar to travel nursing saga. In Texas alone, there are 4 CRNA and 2 AA programs opening up.

 

[circleK]

An important thing to consider when contemplating a hospital employed job is the specific hospital system’s history. If the models they’ve instituted at other locations and their attitudes toward physicians are historically bad, then move on. They are not all created equal.

Also a good hospital system realizes there is much more stability with physicians as employed CRNAs tend to move around much more frequently.

 

[anbuitachi]

agree. there are tons of new programs opening up. soon there will be tons of crnas getting these jobs, their salary may go down because of it, and it will impact you too

 

[neutro]

I don’t think shortage for anesthesiologists will go down given a huge surge in ASCs that necessitate anesthesiologists

yeah there are more crna schools etc etc but there are more surgeons/ob/ortho/GI/ proceduralists also

There’s only one anesthesia service

We’ll be fine

I actually like it when facilities want a billion crna and want their non anesthesiologist proceduralists to supervise them. Or have ridiculous ratios. Or have a 3 month recently graduated crna herself mentoring an srna student….yeah…

It tells me to stay away from those places.

 

[Drwine]

Facility fees go up.

vs. Anesthesia (and physician) billing that is always on the chopping block.

This is the AHA long game.

When the "smartest people in the room" in private equity came up with the brilliant idea in the era of essentially free money that running anesthesia practices was a great way to generate a flow of income things were different. Fast forward to 2024.
The pandemic created a labor shortage and has driven up payroll costs.
They can't surprise bill.
Physician fees are stagnant while facility fees are going up.

The canary in the coal mine is that the hospital system where NAPA started is phasing them out and directly employing their anesthesia staff.

Medical school deans who were used to in the past taking money from anesthesia departments to subsidize departments who don't generate enough clinical income are also in for a rude awakening as long as the labor shortage persists.

 

[Howard888]

Look Im not happy about it but it’s going to be reality. Commercial payment can no longer subsidize poor govt payment with no surprises act basically capping commercial rates. Only other solution is hospital employment as the hospital can get better payments in facility fees and such. CRNAs are half cost of MD. They don’t need to abide to 1:4, etc. A 6 room low acuity hopd will likely have one MD and 6 CRNAs. Whereas a high acuity neonate may be 1 on 1 or MD only even. Either way you can reduce your overall cost in a large hospital system with half MDs and continue to negotiate up facility fees. This will be much more attractive than paying stipends to private equity, md only practices, etc.

Again I don’t like it but it’s economics. The one way to combat this a little, as pointed out already, is to negotiate like a crna at least on payment with hospitals. Whatever salary you take is based on a 40 hour work week. Anything more, call, extra hours-extra pay.

 

[sevo00]

Look Im not happy about it but it’s going to be reality. Commercial payment can no longer subsidize poor govt payment with no surprises act basically capping commercial rates. Only other solution is hospital employment as the hospital can get better payments in facility fees and such. CRNAs are half cost of MD. They don’t need to abide to 1:4, etc. A 6 room low acuity hopd will likely have one MD and 6 CRNAs. Whereas a high acuity neonate may be 1 on 1 or MD only even. Either way you can reduce your overall cost in a large hospital system with half MDs and continue to negotiate up facility fees. This will be much more attractive than paying stipends to private equity, md only practices, etc.

Again I don’t like it but it’s economics. The one way to combat this a little, as pointed out already, is to negotiate like a crna at least on payment with hospitals. Whatever salary you take is based on a 40 hour work week. Anything more, call, extra hours-extra pay.

I’d quit anesthesia before I have to be forced to supervise 4 CRNAs or more at a time. I also know plenty of other docs who would rather quit than do that. Good luck to the hospital then to find enough MDs

 

[Dr. Rude]

I’d quit anesthesia before I have to be forced to supervise 4 CRNAs or more at a time. I also know plenty of other docs who would rather quit than do that. Good luck to the hospital then to find enough MDs

They will find them. People will do what they have to to pay the mortgage and raise their kids.

 

[Dr. Rude]

Look Im not happy about it but it’s going to be reality. Commercial payment can no longer subsidize poor govt payment with no surprises act basically capping commercial rates. Only other solution is hospital employment as the hospital can get better payments in facility fees and such. CRNAs are half cost of MD. They don’t need to abide to 1:4, etc. A 6 room low acuity hopd will likely have one MD and 6 CRNAs. Whereas a high acuity neonate may be 1 on 1 or MD only even. Either way you can reduce your overall cost in a large hospital system with half MDs and continue to negotiate up facility fees. This will be much more attractive than paying stipends to private equity, md only practices, etc.

Again I don’t like it but it’s economics. The one way to combat this a little, as pointed out already, is to negotiate like a crna at least on payment with hospitals. Whatever salary you take is based on a 40 hour work week. Anything more, call, extra hours-extra pay.

Last line of defense: Letters signed by multiple docs in a department addressed to multiple system leadership even the hospital board that are crafted with the assistance of private counsel. highlighting cases like this:

Texas jury awards $21 million over nurse anesthetist (CRNA) operating room care that left 27-year-old man with brain injury | Painter Law Firm Medical Malpractice Attorneys

Also highlighting the U of M study on supervision ratios and its effect on outcome. The obvious implication is that this correspondence will be discovered when the inevitable bad outcome happens. If one is really willing to risk dying on this hill e.g., leaving their position, might as well take the shot. If not...suck it up buttercup.

 

[Howard888]

It’s already happening. No one takes that Michigan study seriously. It’s very flawed. So many hospitals are already doing this

Many OB floors, busy ones are staffed by all CRNAs. Many HCA hospitals already use this system.

Again this will take 15 years in some markets, 2 years in others, but it will happen.

 

[Dr. Rude]

It’s already happening. No one takes that Michigan study seriously. It’s very flawed. So many hospitals are already doing this

Many OB floors, busy ones are staffed by all CRNAs. Many HCA hospitals already use this system.

Again this will take 15 years in some markets, 2 years in others, but it will happen.

Better to be one of the places it takes 15 years. Threatening to put senior hospital leadership skin in the game might delay the inevitable.

 

[Howard888]

Agree better to be one of the last. Better your economy/payer mix, longer you’ll survive without hospital employment. It’s pretty simple -problem is amcs dominate a lot of these strong economy markets and ask for 25% returns in firms of stipends and so it’s accelerating hospital employment in those markets despite strong economies

 

[aneftp]

Look Im not happy about it but it’s going to be reality. Commercial payment can no longer subsidize poor govt payment with no surprises act basically capping commercial rates. Only other solution is hospital employment as the hospital can get better payments in facility fees and such. CRNAs are half cost of MD. They don’t need to abide to 1:4, etc. A 6 room low acuity hopd will likely have one MD and 6 CRNAs. Whereas a high acuity neonate may be 1 on 1 or MD only even. Either way you can reduce your overall cost in a large hospital system with half MDs and continue to negotiate up facility fees. This will be much more attractive than paying stipends to private equity, md only practices, etc.

Again I don’t like it but it’s economics. The one way to combat this a little, as pointed out already, is to negotiate like a crna at least on payment with hospitals. Whatever salary you take is based on a 40 hour work week. Anything more, call, extra hours-extra pay.

Wrong. A crna will demand just the same money for their “availability “ as an MD.

Meaning a crna will not want to be on beeper. They demand in hospital pay the same as beeper

I’ve been telling people this over and over. Crnas are not cheap. Most of our crnas are over 350k plus generous w2 benefit PLUS HAVE more time off than doc. You rate adjust for actual days available to work. They are not that far off from docs available daily.

Crnas pick and choose what days they want to work and when they want to work. Piss them off and then off they just got elsewhere. Guess who gets stuck working post call on a Friday? The post call doc. That’s what happens. Docs are dumb to think that if they work 5 hrs and go home early. It’s nice day. When the crna works 24/16 hours for a two day work week. While the doc works 5 days a week.

 

[Dr. Rude]

It is (often) cheaper to pay a doc a salary and work the snot out of them than to pay CRNAs as hourly employees.

 

[GravelRider]

Look Im not happy about it but it’s going to be reality. Commercial payment can no longer subsidize poor govt payment with no surprises act basically capping commercial rates. Only other solution is hospital employment as the hospital can get better payments in facility fees and such. CRNAs are half cost of MD. They don’t need to abide to 1:4, etc. A 6 room low acuity hopd will likely have one MD and 6 CRNAs. Whereas a high acuity neonate may be 1 on 1 or MD only even. Either way you can reduce your overall cost in a large hospital system with half MDs and continue to negotiate up facility fees. This will be much more attractive than paying stipends to private equity, md only practices, etc.

Again I don’t like it but it’s economics. The one way to combat this a little, as pointed out already, is to negotiate like a crna at least on payment with hospitals. Whatever salary you take is based on a 40 hour work week. Anything more, call, extra hours-extra pay.

I don’t necessarily disagree on your outlook, but one way to combat it is with simple economics. As a specialty, we need to demand some kind of multiplier effect as supervision ratios increase. Not only do we need to take better control of our hours to pay ratio (the way CRNAs do), but we also need some kind of cost increase for more supervision. That could be some kind of bonus based on units generated or average supervision ratios. The cost of high ratio supervision has to be high enough where an admin will have to really think twice about not hiring an extra physician. Theoretically, someone supervising 1:4 should be making close to double that of someone supervising 1:2 at the same institution.

I really think the next few years will be extremely important for anesthesia departments to properly advocate for themselves and to start establishing norms as hospital employment continues to expand. Things like workload hours and supervision ratios need to be discussed at every single meeting with hospital administrators. If the hospital administration says they are considering allowing increased supervision ratios then the response to that is that the anesthesiologists will then require a proportional increase in pay. If you are doubling my supervision ratio and thus doubling my workload, I expect my salary to be doubled. RNs stage walkouts and strikes over ratios. We should be just as aggressive.

 

[Howard888]

I agree many CRNAs 300+ these days but MDs command 600+ in many markets right now. It’s still a large enough discrepancy that administrators view the cost very differently-md only being much higher cost than direction or super vision. Then supervision much cheaper than direction.

Take a 24 OR hospital. MD only cost to administrator: 16 million . Medical direction cost: 13-14 million. Medical supervision cost: 11-12 million.

Lots of variability in those numbers depending on weeks vacation, shift length, work days per week, call etc -but you can look at it as 1.5-2 million dollar cost savings going from MD only to direction and another 1.5-2 million cost savings going from direction to supervision or QZ AND….another 1.5-2 million going from QZ/supervision to crna only.

Now..if you are using 350-400 for MD salary sure it’s different math, but it’s very easy to find jobs as MDs at 550-600k right now and locum MD cost for these admins is usually $350+/hr or 7-800k per year md minimum

These are the numbers that matter. What admins see when calculating cost

 

[aneftp]

It is (often) cheaper to pay a doc a salary and work the snot out of them than to pay CRNAs as hourly employees.

Docs are finally getting smarter. No loyalty. No partnership track available. The new generation will gladly walk away.

It’s the 40 hour base workweek for docs. No once docs figure out what call is worth and what beeper time is worth. The whole system implodes. Hospitals are dreading that day.

 

[aneftp]

I agree many CRNAs 300+ these days but MDs command 600+ in many markets right now. It’s still a large enough discrepancy that administrators view the cost very differently-md only being much higher cost than direction or super vision. Then supervision much cheaper than direction.

Take a 24 OR hospital. MD only cost to administrator: 16 million . Medical direction cost: 13-14 million. Medical supervision cost: 11-12 million.

Lots of variability in those numbers depending on weeks vacation, shift length, work days per week, call etc -but you can look at it as 1.5-2 million dollar cost savings going from MD only to direction and another 1.5-2 million cost savings going from direction to supervision or QZ AND….another 1.5-2 million going from QZ/supervision to crna only.

Now..if you are using 350-400 for MD salary sure it’s different math, but it’s very easy to find jobs as MDs at 550-600k right now and locum MD cost for these admins is usually $350+/hr or 7-800k per year md minimum

These are the numbers that matter. What admins see when calculating cost

I’m basing on number of days docs work

I make 450k working essentially 5 days a week no calls no weekend. I sleep in my own bed.

The crnas work 24/16 with rest of the week off. For base pay 225k. Plus in addition to 5 days off. They get 11 weeks off paid as wel.

Do the math.
Time and money. Crnas get way more days off hustle elsewhere or do internal overtime. Their internal overtime rate high as well. Over $215/hr.

So i advocate docs to try to find some hybrid job 0.5 or some other some that gives you 20 weeks off.

People value either sleeping in own bed like me. Or. Value have tons of time off (to make extra money or just vacation). But they get to choose what they want to do.

 

[Howard888]

You’re paid low. And most crna jobs are not 24/16. They are 5 8s.,4 10s, or 3 12s. They usually get 6-7 weeks vacation. This is pretty standard at major hospitals.

Your job exists for CRNAs-24/16 but that’s the low minority. And your MD pay is low compared to what admins are paying either in locums or in stipends. 600 pretty much what they are going with now when they look at md cost.

And it’s not your math that matters at all. It’s admin. There’s a reason HCA is going to this type model everywhere. They see the cost savings-and I agree it’s not as much as they think but….

As someone already said on here the only reason this hasn’t accelerated already was the mass exodus of CRNAs with Covid. But with these new schools opening it will catch fire. And yes admins will get burned in process but they won’t go back to the old ways-md only or lower ratios.

 

[aneftp]

You’re paid low. And most crna jobs are not 24/16. They are 5 8s.,4 10s, or 3 12s. They usually get 6-7 weeks vacation. This is pretty standard at major hospitals.

Your job exists for CRNAs-24/16 but that’s the low minority. And your MD pay is low compared to what admins are paying either in locums or in stipends. 600 pretty much what they are going with now when they look at md cost.

And it’s not your math that matters at all. It’s admin. There’s a reason HCA is going to this type model everywhere. They see the cost savings-and I agree it’s not as much as they think but….

As someone already said on here the only reason this hasn’t accelerated already was the mass exodus of CRNAs with Covid. But with these new schools opening it will catch fire. And yes admins will get burned in process but they won’t go back to the old ways-md only or lower ratios.

Well my pay is “low” but somehow we have no open positions. If that tells you anything. We have no locums docs. I work around 36 hours a week. With free healthcare and other benefits. It’s not a bad deal for someone who wants no calls or weekends. Leave early some days 10/11am Stay past 3pm a couple of days. Extremely rare to stay past 430p.

The market dictates what people want

Anyways it opens me up to cover almost any hospitals I want to cover within a 45 mile radius to show up for call at 3pm to make even more money.

The stipend for our place is close to 25 million lol It’s ridiculous. It’s cough cough unlimited resources

Crna paid vacation in the south is 9-10 weeks these days.

 

[gunnershow]

It's a little sad that RNs will aggressively fight increased ratios in complete lockstep but I don't have faith in my fellow MDs to do the same. I will quit and relocate before I agree to higher ratios. I hope my colleagues will do the same.

 

[Dr. Rude]

It's a little sad that RNs will aggressively fight increased ratios in complete lockstep but I don't have faith in my fellow MDs to do the same. I will quit and relocate before I agree to higher ratios. I hope my colleagues will do the same.

they often have the advantage of union membership and no noncompete in their pockets, so the consequences of failing to achieve their goals aren't as substantial.

 

[makemoney2024]

I’m recently transitioned from PP to hospital employed model. Pre-transition we were about 45 docs and 10 CRNAs. Post, we’re about 40 docs with 4 CRNAs. Admin plans to hire 10+ docs and 4-5 CRNAs. They’ve already got contracts signed for half the doc positions, and offers out for the rest. Can’t even find anyone to interview for the full time CRNAs positions. I’m not concerned.

Why do you think they can't find CRNAs? Too greedy?

 

[aneftp]

Why do you think they can't find CRNAs? Too greedy?

1. It’s easy to find prn w2 crna jobs in most cities (compared to md w2 prn jobs)

Crnas have figured why work for 200k w2 with restricted schedule where they are TOLD WHICH DAYS they can work and TOLD we prime vacation weeks they can take off.

The math is very simple especially if the crna doesn’t need the healthcare benefits

$150-200/hr whatever the prn w2 rate is in many cities give crnas vast options to work anytime any place they want and make the same w2 income with incredible flexibility