#14 – Anesthesia Care Models – Ian Hewer, MSN, MA, CRNA

Jon and Ian discuss the history and economics of anesthesia delivery models.  Ian overviews the various types of anesthesia care models, some of the historical context for the development of those models and explains how anesthesia providers can optimize the delivery of anesthesia care in terms of billing, efficiency and quality outcomes.  We also discuss some of the challenges facing researchers in terms of gathering and interpreting “big data” on quality outcomes related to anesthesia care.  If you’re interested in the behind-the-scenes story on anesthesia care in the United States, this podcast is a good place to start!

Ian Hewer, MSN, MA, CRNA is an Assistant Professor and the Assistant Director of the Graduate Nurse Anesthesia Program at Western Carolina University.  He is a Fellow of the American Association of Nurse Anesthetists’ Journal Writing Fellowship Program and has published articles in the AANA Journal, the International Journal of Nursing Research and the Social Science Journal.  Ian is currently pursuing his PhD at the University of North Carolina – Charlotte in Health Services Research with research focusing on the economics and outcomes of various anesthesia care delivery models.

Topics discussed:

  • Types of anesthesia care models in the United States
  • Types of specific billing modalities for anesthesia services and the implications for anesthesia care models
  • The difference between medical direction and medical supervision and defining these terms in relation to billing & reimbursement verses standards of care of anesthesia providers
  • What “opt-out” means in terms of reimbursement and CRNA practice autonomy
  • Historical economic and political evolution & context of anesthesia care
  • The challenge of gathering & interpreting anesthesia quality data
  • Current trends in anesthesia quality research
  • Ideas on structuring anesthesia care models for success in a future where healthcare must become more efficient and cost-effective while maintaining safety and high quality
  • Suggestions for anesthesia providers in educating themselves on trends in healthcare economics
  • Thoughts on CRNAs becoming doctorally prepared clinicians and how this evolution will influence anesthesia in the United States


Background information:

Kane & Smith’s 2004 article titled An American tale – professional conflicts in anaesthesia in the United States: implications for the United Kingdom, published in the 2004, vol 59 edition of Anaesthesia, provides a particularly in-depth review of the development of anesthesia in the United States.  The types of anesthesia providers and models of practice are reviewed along with many of the key dates, legislation and publications that have influenced the anesthesia field in the United States over the last 100 years.  Professor Hewer touches on many of these dates and developments and we encourage listeners to reference Kane (2004) for more detail.

Chronology of important dates in US anaesthesia (quoted from Kane, 2004)

1846  First anaesthetic administered

1847  American Society of Anaesthesiologists formed

1909  First formal Nurse Anaesthetist training program

1931  American Association of Nurse Anaesthetists formed

1932  Anaesthesia recognised as a medical Specialty by the American Medical Association

1960s  Johnson administration healthcare reforms

1966  Medicare program allows anaesthesiologists to bill them directly for overseeing hospital-employed CRNAs as well as personally administered anaesthetics. Graduate Medical Education program

1980  Forrest study published

1981  Bechtoldt study published

1982  Medicare stipulates seven conditions which anaesthesiologists must satisfy to claim payment for overseeing nurses (‘medical direction’, see text)

1989  CRNAs allowed to submit bills directly to Medicare program

1993  Total payment for anaesthesia care team capped at 120% of solo anaesthesiologist’s fee. Providers also obliged to split payment equally if both involved in a case.

1994  ASA publishes ‘The limitations on the role of CRNAs in anaesthesia care, 1996’. Abenstein & Warner’s review published in Anaesthesia and Analgesia

1997  Total payment for anaesthesia care team limited to 100% of solo anaesthesiologist’s fee 2001  CRNAs granted independent billing rights

2003  Pine et al. study published


In 2014, the Cochrane Collaboration published a literature review titled Physician anaesthetists versus non-physician providers of anaesthesia for surgical patients (Lewis, 2014).  Following are the article’s background, objectives and conclusions:


With increasing demand for surgery, pressure on healthcare providers to reduce costs, and a predicted shortfall in the number of medically qualified anaesthetists it is important to consider whether non-physician anaesthetists (NPAs), who do not have a medical qualification, are able to provide equivalent anaesthetic services to medically qualified anaesthesia providers (Lewis, 2014).


To assess the safety and effectiveness of different anaesthetic providers for patients undergoing surgical procedures under general, regional or epidural anaesthesia. We planned to consider results from studies across countries worldwide (including developed and developing countries) (Lewis, 2014).


No definitive statement can be made about the possible superiority of one type of anaesthesia care over another. The complexity of perioperative care, the low intrinsic rate of complications relating directly to anaesthesia, and the potential confounding effects within the studies reviewed, all of which were non-randomized, make it impossible to provide a definitive answer to the review question (Lewis, 2014).




Anesthesia Quality Institute

(from https://www.asahq.org/resources/quality-improvement/qcdr): The American Society of Anesthesiologists (ASA), through its affiliate, Anesthesia Quality Institute (AQI), has developed a meaningful way for physician anesthesiologists to successfully participate in the Physician Quality Reporting System (PQRS).

The National Anesthesia Clinical Outcomes Registry (NACOR), maintained by the AQI, has been designated as a Qualified Clinical Data Registry (QCDR) by the Centers for Medicare & Medicaid Services (CMS) for PQRS reporting. NACOR is the only anesthesia QCDR. Through AQI, ASA now offers ASA QCDR, a PQRS reporting service powered by NACOR, to all eligible professionals (EPs).

Read more at:  https://www.aqihq.org/index.aspx


Multicenter Preoperative Outcomes Group (MPOG)

The Multicenter Perioperative Outcomes Group was formed to develop the necessary policies, procedures, and technical infrastructure required for multicenter perioperative outcomes research.

Read more at:  https://www.mpogresearch.org



Dulisse, B., & Cromwell, J. (2010). No harm found when nurse anesthetists work without supervision by physicians. Health Affairs, 29(8), 1469-1475. doi:10.1377/hlthaff.2008.0966

Kane, M., & Smith, A. F. (2004). An American tale – professional conflicts in anaesthesia in the United States: implications for the United Kingdom. Anaesthesia, 59(8), 793-802.

Lewis, S. R. (2014). Physician anaesthetists versus non-physician providers of anaesthesia for surgical patients. Cochrane Database Of Systematic Reviews, (7), doi:10.1002/14651858.CD010357.pub2

This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.

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