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Cost effectiveness analysis of anesthesia providers.

To the Editor:

I read the article "Cost Effectiveness Analysis of Anesthesia Providers," (Vol. 28, No. 3, pp. 159-169) and agree that CRNA-only anesthesia is more cost effective in comparison to other practice models. However, this study contains a crucial flaw. On page 163, Table 4, "CRNA-only yearly total revenue" is equal to "Anesthesiologist-only yearly total revenue." These amounts are not equal. In regard to Medicaid and private insurance payers, revenue to CRNA-only care per RVU is anywhere from 20%-30% lower than revenue collected from anesthesiologist-only care. Tables 5 and 6 on page 164 in regard to CRNA-only versus anesthesiologist-only revenues are also falsely equal. In Oklahoma, Medicaid reimburses CRNAs 20% less than MDAs and private insurers reimburse CRNAs 20%-30% less than MDAs. Therefore, the total revenue collected after costs could be up to 50% less than the authors claim, which if I may add, would still make CRNAs 100% (or twice) more cost effective than MDAs.

Brian Mackey, CRNA Edmond, OK

Authors' Response

In our simulations, the cases we presented used billing rules that were the same for anesthesiologists and certified registered nurse anesthetists when CRNAs were acting independently. In many states, CRNAs acting independently is counterfactual, particularly for Medicare. However, in those states where CRNAs are, by waiver, permitted to act independently, the billing rate for the Medicare service is the same as that of anesthesiologists. Based on discussions with practitioners, we decided that if CRNAs were able to act and bill independently, adopting the same billing rules as anesthesiologists was the most straightforward baseline case, in the absence of better information.

Our claims analysis, shown in a later table, suggested that for private claims, the billed amount was the same between CRNAs acting independently and anesthesiologists working alone. The allowed amount for CRNAs was less than for anesthesiologists. Hence, your general point is correct that in cases where CRNAs are acting independently, they may not receive the same revenue for the procedure as an anesthesiologist. However, we were reluctant to adopt this as our baseline because for many states and many payers, the policy does not suggest lower reimbursement for the same service when provided by CRNAs acting independently compared to anesthesiologists.

Moreover, if the service provided by CRNAs and anesthesiologists were perceived to be the same by payers, there is no reason for the reimbursement rate to differ. If it were the case that CRNAs acting independently were to become a generally acceptable model across all states and payers, the effective supply of anesthesia services would be greater. Average reimbursement rates for anesthesia may change because of this increase in supply, but there would be no reason for the rates to differ for the same service whether it was provided by a CRNA or anesthesiologist, if payers did (correctly) perceive of them as identical services.

Paul E Hogan, MS

Rita Furst Seifert, PhD

Carol S. Moore, PhD

Brian E. Simonson, MS

The Lewin Group

Falls Church, VA

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Author:Mackey, Brian
Publication:Nursing Economics
Article Type:Letter to the editor
Geographic Code:1USA
Date:Jul 1, 2010
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