Dollars and Sense

  • Hertzberg, Linda, MD, FASA
| Sep 19, 2011

No CSA President ever really understands the job until they have done it for several months. We each enter the position with hopes for what we can help the CSA and its membership accomplish to further the mission and goals of the Society. In July 2009 we were in the very early stages of planning the “communications project” which included the CSA website redesign, the movement into social media, and a campaign to promote the profession of anesthesiology and anesthesiologists as the chosen professionals for anesthesia care. For me that world suddenly changed when then Governor Arnold Schwarzenegger chose to exercise an “Opt-Out” of the Medicare requirement for physician supervision of nurse anesthetists. Much has been written about what has happened since then with the CSA’s lawsuit and its appeal.

Several items recently posted on the CSA’s Hot Topics would seem to imply that not much has changed since the Governor of California sent the Opt-Out letter to CMS... If anything, the situation for physician supervision of anesthesia care and/or personally provided care continues to be under even more intense attack. A recent NY Times article about delays in the US Open Tennis tournament perhaps says it most clearly, “When Rafael Nadal muttered on Wednesday that ‘it’s always about money,’ he mostly had it right.” If this sounds cynical, consider the following excerpt from a CSA Hot Topic. Amr Abouleish, M.D. recently wrote in an Anesthesiology’s Page 2 blog:,

Why have two pilots flying the airplane? In fact, do you really need a fully trained and experienced pilot? All it does is increase the cost of operations.

When people talk about anesthesia care, the most common analogy used is to flying an airplane. So, when I read the reports this week about autopilot computers dulling pilots’ skills, I naturally thought about the implications for anesthesia care.

As a colleague who is married to a commercial pilot pointed out, pilots do more than just push the autopilot on and off. They evaluate the plane, weather conditions, double-check the settings and communicate as well as monitor the flight. They are also specially trained for rare but dangerous events.

Hold on…that sounds eerily similar to anesthesia care!

Then why doesn’t it sound batty and ludicrous to suggest that patients don’t need an anesthesiologist or even a physician involved in anesthesia care?

But for some, these lessons don’t seem to penetrate. A few months ago Kaweah Delta Medical Center (KDMC) in Visalia put its anesthesia contract up for bid in a Request for Proposal (RFP) process. Visalia Anesthesia Medical Associates (VAMA), a local, well-respected group, which had been the anesthesia professionals at KDMC for sixteen years, was not awarded the contract. Instead, the contract went to Somnia, a national anesthesia manpower organization known for its extensive use of nurse anesthetists in addition to anesthesiologists in covering the contracts it holds.

From the Valley Voice newspaper, August 18, 2011:

Somnia, which is owned and operated by physicians who provide clients with locally recruited teams of anesthesiologists, was selected by the hospital after a request for proposal process that VAMA contends was “incredibly flawed.”

The process also has been criticized by surgeons who say they should have been consulted about a possible change in the anesthesia contract. Physicians also have raised concern about patient safety because of what they described as the company's extensive use of Certified Registered Nurse Anesthetists (CRNAs) rather than physicians.

And from the Visalia Times-Delta, August 25, 2011:

"I believe the change was made because the group that is going to take over the contract is offering the services at a lower fee," said Dr. Russell Dounies, a general surgeon in Visalia specializing in breast cancer and skin cancer surgery.

While there is nothing wrong with seeking a cheaper service, Dounies said he's concerned that this area has such a high level of patients who are elderly and with multiple physical problems making them more susceptible to problems from anesthesia-related complications — one of the biggest risks in any surgery.

And in such situations, he said he'd prefer a doctor handling the anesthesia to deal with potentially life-threatening problems than a certified nurse anesthetist, also known as a "CRNA."

The word on the street in the Central Valley is that KDMC is allegedly saving several hundred thousand dollars in call coverage stipends by going this route.

In a recent CSA Online First, Rima Matevosian, M.D. eloquently described the many roles anesthesiologists play in coordinating medical care and working in administrative roles in the hospital setting. However, it would appear that in the face of a pure business calculation of the dollars and cents of hospital margins, good medical staff citizenship by anesthesiologists   will be undervalued and may not be enough in the eyes of hospital administrators.

The next frontier of ensuring patient access to physician involvement in and supervision of anesthesia care is likely to be at the level of the medical staff bylaws and credentialing and privileging process. The CMA Model Bylaws for hospital medical staff’s contain protections of the rights of hospital based physicians in contracted groups. Investigate whether or not your hospital has bylaws based on these CMA model bylaws, which requires medical staff input into contracting based on quality of care and service considerations. Furthermore, make certain that these provisions are followed and enforced. Ensure that credentialing and privileging criteria for anesthesiologists and other members of the anesthesia care team are appropriate and correct for the level of care and service required in your local setting. Unfortunately, as we have seen at KDMC, these protections may not be enough. It is important that we as individuals be personally vigilant in following what is going on with the business practices of the local hospital and health care facilities in the area where we practice. Otherwise the level of anesthesia care that your patients deserve may fall victim to the imaginary “margin of savings” that hospital administrators seek, instead of the “mission” of professional anesthesia care. 

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