Evolving Anesthesia Care Models: Leveraging CRNAs for Sustainable Coverage

Daniel Marino:  

Welcome to Value-Based Care Insights. I'm your host, Daniel Marino. The U.S. healthcare system continues to experience significant shortage of anesthesia providers, and in particular, anesthesiologists. At the same time we're seeing surgical and procedural services continue to grow. Especially when you think about the need for procedural services done in an ASC. The number of anesthesiologists, just can't keep up with the demand. And it is placing a lot of pressure on hospitals. It has for the last number of years. Over the last few years, we've seen the cost of anesthesia services go up dramatically. And that cost hasn't just occurred with the… around the increase in compensation, but the reimbursement for anesthesia services is certainly not keeping up with the rising cost. So many hospitals are looking at what we would call these diverse anesthesia care models. And many hospitals over the last number of years have started to integrate CRNAs, Certified Registered Nurse anesthetists into the care models. And although CRNAs have been involved in the care models for some time there now is a growing reliance on CRNAs to expand their scope of practice. Anesthesiologists are moving into a role of supervising CRNAs, while others are creating more of a medical direction for CRNAs. And in some states, particularly rural or opt-out states, CRNAs are allowed to practice independently. And while this appears to be a nice opportunity to cover some of the shortage and keep up with some of the demand, it's not come without its own challenges. And many of these challenges are around how physicians, how hospital leaders are being asked to incorporate CRNAs into the coverage model, and really to make sure that we are fully leveraged, taking advantage of the opportunities around their scope of practice. Well, I'm really excited today to have one of the leading national experts in CRNAs, scope of practice, and so forth, Dr. Thomas Pallaria. Dr. Pallaria is a respected leader in educating nurse anesthetists, or nurse… I'm sorry, anesthesiologists, CRNAs. He is assistant professor and the director of a nurse anesthesiology program at Rutgers School of Nursing. Dr. Pallaria has also, with his extensive experience, have helped numerous hospitals introduce the CRNA practice model into their overall anesthesia scope of practice. Wealth of experience and knowledge. Tom, welcome to the program. 

Thomas Pallaria, DNP, APN, CRNA:  

Thank you, Daniel. How are you? 

Daniel Marino:  

Doing great, doing great. Let's jump into this. In your experience, and in working many of the hospitals, obviously you're a CRNA yourself, and leading the program here at Rutgers, how are you seeing the CRNA role changing, and especially in being able to cover some of the shortage or the growing demand that we're seeing in procedural services? 

Thomas Pallaria, DNP, APN, CRNA:  

Well, Dan, I can tell you that, I mean, I've been… I've been a CRNA for 25 years. This is actually my… my 25th anniversary, so I… 

Daniel Marino:

Oh, congratulations! Oh my goodness. 

Thomas Pallaria, DNP, APN, CRNA:  

Thank you, yeah, It's been quite a journey. When I started back in 2000, the use of CRNAs was very limited, certainly in my neck of the woods. Where you would maybe see 3 or 4 hospitals, in an area, utilizing CRNA services. As far as coverage models, it was usually a 2 to 1 ratio to CRNAs to a physician anesthesiologist. And even back then, that was in my area, and many areas across the country. However, rural America, even back then, it was CRNA, mostly solo CRNAs, and of course, with the military, that it's been that way before, it's still that way, where CRNAs are independent providers. But now, fast forward 25 years, we're everywhere. And in my neck of the woods, it's, we actually hit a huge milestone for the CRNA profession, and one of the last remaining major medical centers, in the area, in the state, has now converted to a care team model, finally bringing in CRNA practice. And as you said, I have a lot of experience in integrating CRNAs into historically physician-only models. It comes with a huge set of challenges, but, every single one, whether it was introduction or expansion, has been wildly successful to where, as you just said in your introduction, we're no longer, an add-on, we are… we're essential, or we're closing operating rooms.  

Daniel Marino:  

Yeah, p laying a major role on really being able to cover procedural services, and not only, you know, I don't mean to interrupt you, but not only playing a major role, but, you know, and I'd love to hear your opinion on this, but the expertise that, you know, many of the CRNAs are bringing to the overall procedural services or surgical services point of care has really been good, and I think as we start to think about further leveraging it, you know, that potentially is going to help cover some of the shortage. 

Thomas Pallaria, DNP, APN, CRNA:  

Right, and I mean, just as a numbers game, Dan, you know, right now there's somewhere over 60 to 62,000 CRNAs in the country, where our physician anesthesiologist, colleagues, they're around 52,000 or more, so we are… we are outnumbering them, which I think as a… I mean, it taking politics out of it, I think it's a great thing. Sure. Certainly, if you're focused on a care team model, you know, you don't need as many physician anesthesiologists. If you're following medical direction, it would be a 1 to 4 ratio. If you're following supervision, it can be anywhere as, you know, 7 to 1, 8 to 1, depending on comfort level, facility, bylaws and, and skills. So I think it's just a natural progression in serving our population. I mean, the boomers are just continuing to get healthier, and, you know, surgical services are going to continue to expand, so this is… it's a perfect way to provide some coverage. 

Daniel Marino:  

Sure, sure. Let's talk about scope of service for a second, and practice expertise. You know, I've worked with… we do quite a number of assessments of surgical services, perioperative services, you know, of what the anesthesia coverage model needs to look like, and as… and I'm a huge proponent of bringing in CRNAs to the practice model, because I think, you know, again, with the right level of expertise, there could be a tremendous value that we can provide to patients and to overall surgical services. But… but many anesthesiologists don't think the same way. Many of them are concerned with maybe their training or the level of knowledge. What are you seeing? How are you overcoming that stigma with CRNAs? 

Thomas Pallaria, DNP, APN, CRNA:  

Great question, and I think that I'm going to answer this based upon my own experience, of course, because, let me be very clear, I have colleagues all across the country, and we do keep in pretty consistent contact. So, you're going to find sections of the country that are wildly different. Sure. But in the Northeast, the Northeast is traditionally and historically a very physician-anesthesiologist-centric mindset. So for my own career and my various leadership roles it has been a challenge, and I've been very fortunate to have my academic career to offer, as part of the conversation of how a CRNA is trained. And I can tell you, down into the granular detail, that for Rutgers, and for all of the neighboring programs in my area, we're taught by CRNAs and physician anesthesiologists. For example, you know, one of my residents will be on a regional rotation, and they're learning how to do, you know, a popliteal block, whatever, from the physician anesthesiologist. And that… that really holds a lot of weight, because if that… if that resident completes the program and decides to work with that group or that company, the comfort level's already built in. And that's really how, in my experience, we've expanded the, the service delivery that everyone is comfortable with. We really don't have a lot of situations where the physician anesthesiologist will say something like, no, you're not qualified to do that, because they were right there with them training them. So that's a big advantage. Now, is there always a political aspect? There is. Because of my career in academia, I have always… try to turn away from anything that was politically based. You know, there's a lot of battles to fight, and I've chosen mine to be scope of practice and education. But I have a lot of colleagues who are on the other political side, and, you know, they give me their opinion, but I try to stay neutral, because at the end of the day, we're really all here to provide care for our patients. 

Daniel Marino:  

We are, absolutely, and I think the training has a lot to do with it. I think the integration and the collaboration with the anesthesiologist is probably the biggest factor, right? 

Thomas Pallaria, DNP, APN, CRNA:  

100%. 

Daniel Marino:

If you're able to really create strong alignment between the anesthesiologists and CRNA, that's what really gets you past the discomfort, if you will, and really the growing comfort and reliance that the anesthesiologists are going to have with the CRNAs. If you're just tuning in, I'm Daniel Marino, and you're listening to Value-Based Care Insights. I'm here talking with Tom Pallaria, and we are talking about the evolving role of CRNAs within the anesthesia care model, in particular, supporting surgical and procedural services. Tom, I want to talk a little bit, about governance. And, you know, one of the things that we push, or we talk a lot about, is having good communication in the operating room, within the ambulatory surgery center. Governance is really key, where you integrate anesthesia services with surgical services. And we're seeing the CRNAs starting to play a larger role. In your opinion, how is governance… how should it be coordinated? What should the role of the CRNAs be within anesthesia governance? 

Thomas Pallaria, DNP, APN, CRNA:  

Great, great point, Dan, and unfortunately not discussed a lot, so I'm glad that you're turning in that direction. It is so… it's critical, in my experience. Depending on where you are, what facility, how long CRNAs have been, providing services there. All the successful, practices had leadership roles for the CRNAs. It's actually not complicated. You have a department, you have a chairperson, you have a private group, maybe not so many anymore, but you have a president of the group. You know, and that chair is a representative of everyone in the department. But to have a chief who also… who governs the CRNA portion of that department is so important. In fact, right before we started this conversation. I had a call from a CRNA that works on my team who had some significant concerns about going forward with a procedure in a space that, frankly, was not going to meet standard of care. And I'm the touchpoint, touchpoint for her, to make sure that she feels comfortable in saying, you know, I don't think that we should do this. It's critical. They need to feel supported. By they, I mean every provider, and certainly a physician anesthesiologist has their section chiefs, or their chairperson. And a CRNA has their chief, and of course, the chairperson. You know, I'm also an ex-military man, so everything is about the reporting structure. And it's fantastic. And in addition, you know, I've had roles in large anesthesia management companies, and representation on the CRNA side from a CRNA leader, only, only provides the opportunity to build a culture in which you are valued equally. It's very important. If you feel marginalized, you're not gonna stay. 

Daniel Marino:  

Absolutely. And not only will that governance model or incorporating CRNAs into anesthesia governance, not only is it going to help the communication, but I think it would also help you work through some of the scope of practice concerns. 

Thomas Pallaria, DNP, APN, CRNA:  

Yes. 

Daniel Marino:  

Some of the… a lot of the CRNAs that, that have been in the field for, you know, like yourself, 15, 20, 25 years, feel very confident in their skills, but they also know what they can do and what they can't do, what they should be doing and what they shouldn't be doing, and frankly, the more experience that they get, their autonomy does come into play. So I would think without having governance, you're really doing the whole anesthesia coverage model, even procedure service, really a disservice. As you're thinking about taking care of patients and really meeting the needs of a lot of the community and surgical services that are out there. 

Thomas Pallaria, DNP, APN, CRNA:  

Agree 100%, Dan, without that type of culture, where you have an equal voice, or frankly, any voice at all, you know, you do become kind of a disenfranchised member of the team, you don't even feel like you're on a team. And, you know, when you develop a provider into someone who shows up, does their job, and goes home, and that's it, that's not sustainable. And just like physician anesthesiologists, you know, you want to feel like you're doing something… I mean, let's face it, Dan, we're…Compensation is very, very important. But I've been in this game a long time. People also want to feel valued and feel like they are making a difference. It may sound a little kumbaya, but it's true. You know, they want to feel like they added some value, and, you know, they want to feel like, you know what, if something needs to be changed, they have a voice and that they are at the table to discuss it. So, it's just so important. 

Daniel Marino:  

Yeah, you need to feel good about your role, right? And especially if you're investing in roles as CRNA, and you're, you know, you've got that, you know, good skills, you know, you definitely want to feel valued. Let me turn the attention to the hospitals. Recently, I was working with a hospital, and we were doing an evaluation of their perioperative services, and they pretty much have a predominant anesthesia coverage model, or anesthesiologists. Very few CRNAs. And the hospital, is new leadership there, and the leadership coming in was really pushing the envelope a little bit with the anesthesiologists, saying, okay, hey, let's think about the coverage model differently, let's start to think about adding CRNAs. When you've worked with hospitals and hospital leaders. How have you changed that paradigm? How have you started to kind of, work with either leadership or anesthesiologists to say, hey, look, we need to do something different here. There's not enough anesthesiologists to cover, we're doing a disservice to our community. Any advice, or what are the things that you've been able to do to kind of change that mindset? 

Thomas Pallaria, DNP, APN, CRNA:  

Dan, it all starts with strong leadership. If you don't have the right players in place during the planning sessions for this huge change, it will fail. I've been directly involved, and I've also been indirectly involved in a consulting manner for this type of change, and I've seen a lot of success, and I have seen some failure. You have to have strong leadership on the CRNA side, and of course, the physician-anesthesiologist side. The physician-anesthesiology side must, must, must support the integration of that CRNA practice, or the expansion of that CRNA scope of practice. You have to have a leader on the CRNA side that has thick skin, frankly. 

Daniel Marino:  

Right. 

Thomas Pallaria, DNP, APN, CRNA:

And can take all of the really negative narrative, soak it all in, and let it go, and make sure that it doesn't make it to the staff, because if it does, it's over. And I think the other component, specifically for the hospital side, is you absolutely have to have, again, strong leadership in the form of, you know, whatever the structure is. The AVP or the director of perioperative services, they have to be right in alignment. And they have to, very importantly, also, because this is new for them, support that leadership role for… of the CRNA so they can be there when a physician goes to them and says, this person can't be in my room. And by a physician, you know who I'm talking about, Dan. Our lovely surgeons who may not feel comfortable. I don't know who this person is. What is this person? Why don't I have Sam? Sam's been here for 35 years. Well, Sam's retiring. And this is our new model, and we need strong leadership on the perioperative leadership side. It's usually nursing, which is great for us, because that's where we come from, is nursing. So we usually do have kind of a built-in partner, but we all have to speak the same language. And if we don't, and there's one little crack, someone will find it exploited, and it will fail. 

Daniel Marino:  

Wow, I absolutely agree with you, and I've sort of referred to it as the triad model of anesthesia services, where you have the anesthesiologist, obviously, working closely with the lead CRNA, but the third leg of that stool has to be the hospital leadership, right? 

Thomas Pallaria, DNP, APN, CRNA:  

It has to be. 

Daniel Marino:  

And to be able to coordinate that in any anesthesia services coverage model, development plan, whatever you want to call it, those three individuals have to work close together, because most of the time, it's a culture change, right? Okay, there's some operational things, there's some clinical things that we need to kind of work through, but at the end of the day, it's how we communicate and how we integrate that new model into procedure services. 

Thomas Pallaria, DNP, APN, CRNA:  

Yes. And I mean, and again, I know, you know, you and I have had this conversation before, but, you know, it's getting… this is gonna sound funny… it's actually getting simpler to look at a plan and integrate it. 

Daniel Marino:  

Yeah. 

Thomas Pallaria, DNP, APN, CRNA:  

Like, what does the CRNA look for? And that… we've really gotten really good across the industry in saying, okay, here's what the CRNA is looking for. Now, maybe not me, Dan, because I'm 25 years in, but now, you have to build a team. It's usually a younger provider. And, you know, we can talk a whole other podcast about generational differences, but they want their comp, they want their life balance, you know, in the form of flexible scheduling, PTO, they want a full scope of practice, how they were trained, they don't want to now say, oh, now I'm a CRNA, I can't do this, I'm not allowed to do that, and they want a role in governance. And that sounds like a nod, but really, it's 4 simple concepts. 

Daniel Marino:  

Yeah, I agree, and I'll tell you, it's… for the new CRNAs coming out of school, and starting to really integrate now with the practice model, it does allow a lot of flexibility for anesthesia services. I had the opportunity to work with, you know, a couple young CRNAs, and it was interesting because a couple of them wanted to become employed, right? And they liked the security being unemployed. A couple of them wanted to remain 1099, and they were interested in having a lot of flexibility there. And I'll tell you, for the hospitals, that model was great, because having that flexibility allowed for stronger recruitment of CRNAs, and let's face it, right? CRNAs coming out, especially for hospitals that are embracing, you know, a more varied coverage model and so forth. Everybody's recruiting for CRNAs, right? So you need to have a differentiator there. That flexibility in being able to offer different type of structures of CRNA was really a game changer for the hospitals. 

Thomas Pallaria, DNP, APN, CRNA:  

Yes, I see the same thing. The only thing I would add to that is I love the flexibility of a per diem. The 1099, the 1099 price tag is really… it's already, out of control. I mean, I want to say the last thing I read was there's probably 5% of the CRNA workforce is 1099, and, like, 10% of the physician workforce. 

Daniel Marino:  

Yeah. 

Thomas Pallaria, DNP, APN, CRNA:  

I know from my experience, you know, facilities, they would rather not. They don't really have choice right now, so they're definitely leaning a little bit more on the recruitment for W-2, which I understand. But to your point, yeah, I want W-2s, but I would like a few per diems, if they have to be 1099, fine, because then, you know what, if you have a situation in which, you know, you have a light day, you can flex them down, although that's a whole other topic of, do you actually want to use that? Because if you flex someone down more than once, they may say, yeah, you know, I'm gonna go somewhere else. So, that gets a little tricky, too. 

Daniel Marino:  

It certainly does. Well, I'll tell you, I agree with you, Tom. I think the role of the CRNAs, they're just playing a much more important role in supporting surgical services, and I think when you really look at what that coverage model is, both in terms of patient care, economically, providing, you know, overcoming some of the access challenges, if we don't think about incorporating CRNAs, you know, in a very predominant way, I think we're going to continue to be challenged, because you know, as I said in my comments, you know, the shortage of anesthesiologists isn't going to change anytime soon. 

Thomas Pallaria, DNP, APN, CRNA:  

No. It's only gonna get worse. I mean, I think the average age of an anesthesiologist is somewhere in the 50s. 

Daniel Marino:  

Yeah, definitely. 

Thomas Pallaria, DNP, APN, CRNA: 

The CRNAs, I think it's, like, the late 40s, so it's… yeah, I…This is not gonna get better. 

Daniel Marino:  

Yeah, that's for sure. Well, Tom, thanks for coming on the program. This was a great discussion. You know, I know many of our hospital leaders, our physician leaders are working through a lot of these same challenges, and very interested in expanding the role of CRNA, so I really appreciate your time. If any of our listeners are interested in maybe connecting with you, can you maybe share your LinkedIn address, or how can they get ahold of you? 

Thomas Pallaria, DNP, APN, CRNA:  

Absolutely, I mean, I'm on LinkedIn, it's Thomas Pallaria. I'm the guy that also says Rutgers on it, so… I think I'm actually the only Thomas Pallaria. So, yeah, feel free to reach out on LinkedIn. 

Daniel Marino:  

Well, that's great. Well, thanks, Tom, for your time. This has been wonderful, and, you know, again, good luck to you with the program, and keep on, you know, bringing forth a lot of great CRNAs. Really appreciate it. 

Thomas Pallaria, DNP, APN, CRNA:  

Thank you, Dan, it was my pleasure. 

Daniel Marino:  

And I want to thank all of our listeners for tuning in. If you're interested in learning a little bit more about this topic, or any of our other topics that we discuss on Value-Based Care Insights. Please go to luminaHP.com/insights, or feel free to message me directly at dmarino@luminahp.com. I want to thank all of our listeners for tuning in. Until the next insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care. 

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners