The three traditional anesthesia practice models, medical direction, medical supervision, and non-medically directed care, are being reshaped by workforce shortages and cost pressure. Here is how the roles of anesthesiologists and CRNAs are changing inside each model, and what that means for patients and facilities.

The practice of anesthesiology has changed tremendously in the last 30 years. The advancements in technology have been astounding, but equally so are the advancements in pharmacology; particularly anesthesia medications. While our tools have evolved, one thing that has been slower to change is the anesthesia practice model. However, due to staffing shortages that remain from COVID and continued retirement of an aging workforce, the practice models in anesthesiology are indeed evolving. This change is becoming a necessity as labor costs continue to rise and hospital and reimbursement dollars are pressured. This is occurring during the same time that hospitals and insurance companies are seemingly reducing highly trained professionals to generic “providers.”

How have practice models changed? How can anesthesiologists and CRNAs bring professional expertise, enhance value in an OR, and provide a strong team example? These are the things that make us more than providers. As these roles evolve, our challenge lies in maintaining and ensuring a high standard of quality for patients. Below is a look at the traditional roles and how each is evolving.

The Three Traditional Anesthesia Practice Models

The traditional anesthesia practice models are distributed into three main categories, medical direction, medical supervision (which is rarely used), and non-medically directed practices.

Medical Direction: The Urban Standard

The urban market is where medical direction is the most common. There are still plenty of anesthesiologists in the cities, although the supply is tight. Medical direction requires one MD for every four operating rooms staffed by CRNAs. There are also seven conditions (commonly called the TEFRA conditions) that must be met by the MD in order to bill that way. MD presence is heavy and the MD directs the CRNA who is performing the anesthetic. CRNAs may not perform as many skill-based procedures like central lines because the MDs are generally taking care of that. The MDs are heavily involved in the intra-operative portion of the case in medical direction. The anesthesiologists will generally manage the pre-operative and post-operative portions of the cases as well.

The Non-Medically Directed Model: Where the Growth Is

The greatest growth in the past few years has been in the non-medically directed category. These hospitals tend to sit in the 200-300 bed size in smaller cities and towns. They generally are regional referral centers for the critical access hospitals. Anesthesiologist supply has been reduced in this sector the most due to labor and cost issues. The medical direction model has been standard in a lot of these hospitals, but that is now changing. While these mid-sized hospitals are often growing, they still have smaller budgets. Costs become critical for contracting. That is where the flexibility in staffing becomes an advantage.

How do these practices evolve and how do our roles as anesthesiologists and CRNAs change as well? Adaptation to changing situations is a hallmark of clinical anesthesia practice. In the day of being labeled as “providers” and analyzed on cost spreadsheets, clinicians need to show their value more than ever.

At LifeLinc, we design our practices to be physician led and CRNA driven. This is how we maximize every clinician's role and bring value. We leverage the MDs to utilize their medical background and expertise as perioperative physicians, while the CRNA's expertise is utilized in the OR performing the anesthetics. We do not adhere to strict MD/CRNA ratios in this model.

In the collaborative style practice, the MDs and CRNAs work together helping each other take the best care of the patient. Generally, the MD or CRNA will work with the Pre-Anesthetic Evaluation (PAE) team before the day of surgery preparing the patient for the day of procedure. This includes medication management, evaluation of current disease states, and preparation including possible medical consultation prior to surgery. On the day of surgery, the MD generally performs the preoperative evaluation, peripheral nerve blocks, and communicates any issues to the CRNA doing the case. The performance of the anesthetic and intraoperative management of the patient is handled by the CRNA, with assistance as needed from the Anesthesiologist.

The intraoperative care is much more independent for the CRNA than in the medical direction model. This can be a challenge for the MD moving out of a medical direction model as handing off control is sometimes not easy. CRNA performance correspondingly reaches a higher level as more independence is given in this model. CRNAs are allowed to practice to the top of their license. LifeLinc provides critical training to assist with their development and advancement. It is common to find CRNAs in this model performing peripheral nerve blocks, placing arterial and central lines, and performing transesophageal echocardiography (TEE). Many times, the MDs are providing the teaching in these practices, but CRNAs often teach as well. We all learn from each other. The roles are much more supportive of each other, and these practices can be some of the most satisfying to work in.

Leadership is key, and these practices will often have an anesthesiologist as the medical director alongside a Chief CRNA who manages the team on hiring, scheduling, and workflow. Together they set the tone and direction of the practice. We promote and grow our leaders by integrating both the MDs and CRNAs into hospital leadership committees and development programs.

Opt-Out States and Blended Teams

Our practices in states that have opted out of physician supervision tend to be both blended models, with the MDs and CRNAs working together, and all-CRNA models. Combining forces into supportive teams helps us bring the best possible care to patients.

We do not design our practices any differently whether a state has opted out of physician supervision. We base our anesthesia staffing on surgical and patient acuity, as well as hospital needs and culture. Whether the teams are MD/CRNA or all-CRNA, we work collaboratively, focusing on patient care.

The CRNA-Only Model

The third type of practice that we generally see in small hospitals and some ambulatory surgery centers is the CRNA only model. These practices will often have a collaborating physician offsite and are overseen by anesthesiologists at LifeLinc. They are run daily by CRNAs. Surgeons are sometimes designated as supervisors in non-opt-out states. While the CRNAs are allowed to practice to the top of their licenses, access to an offsite anesthesiologist is available if the CRNAs have clinical questions they would like to discuss.

Professionals, Not Providers

Remaining flexible and providing value are more critical than ever in today's healthcare market. We want to be professionals, not just providers. To do that well, we all have to be open minded and help support each other so that we can bring the best overall care to the patients. We do not work in a vacuum, and we must partner with our facilities to bring them flexible staffing models that satisfy both quality and budget goals. For anesthesiologists that means working collaboratively, teaching, and supporting CRNAs. For CRNAs that may mean developing new skills that have traditionally been performed by MDs. We are much better together.

About the author: Greg Thompson, MD, brings over two decades of clinical anesthesia practice and managerial experience to LifeLinc. A board-certified anesthesiologist, Greg has practiced in a variety of clinical settings from ambulatory surgery centers to tertiary care teaching hospitals.