Mike Mackinnon, certified registered nurse anesthetist and owner of Show Low, Ariz.-based Mackinnon Anesthesia, joined Becker's to share key things to know about CMS' rural pass-through program, which was was created to incentivize CRNAs and anesthesiologist assistants to work for small rural hospitals
Editor's note: This was edited lightly for clarity and length.
Mike MacKinnon:
The rural pass-through program was designed with specific criteria that align well with the capabilities and financial expectations of nurse anesthesiologists. Extending this program to physician anesthesiologists, while well-intentioned, overlooks the economic realities and practical implications of such a move. The significantly higher costs to the facility in the form of physician anesthesiologist pay expectations, additional costs for call and weekends, and other related expenses are burdens that rural facilities, already operating on thin margins, simply cannot bear. Over 130 rural hospitals have closed in the last decade due to financial strains, and adding these additional costs would only exacerbate this trend. Instead of revising reimbursement policies, focusing on utilizing the full potential of all anesthesia providers, including nurse anesthesiologists and physician anesthesiologists willing to engage directly in patient care, may offer a more practical solution to addressing rural anesthesia provider shortages.
Understanding the current rural pass-through program:
1. Case volume limitation: The rural pass-through program is designed for critical access hospitals performing under 800 cases per year. This low volume inherently limits the financial feasibility and sustainability of employing physician anesthesiologists who typically have a salary expectation of two to three times a nurse anesthesiologist in an urban area, let alone a rural one. It seems incredibly unlikely they will come directly to work in rural areas for significantly less than they make in urban areas where most supervise others performing anesthesia services.
2. Full-time equivalent basis: The reimbursement is based on ~2,048 hours, equivalent to one full-time employee. Rural pass through finding does not cover call or weekend coverage and that would be an additional cost burden if a facility wanted it. Again this cost would be 2-3 times a nurse anesthesiologist in an urban area let alone a rural one.
3. Medicare/Medicaid patient percentage: Reimbursement is tied to the percentage of Medicare/Medicaid patients served. For hospitals with an 80% mix, Medicare pays 80% of the "reasonable anesthesia costs," while the facility must cover the remaining 20%. This model does not support the higher compensation demands of physician anesthesiologists as the 20% would be significantly higher cost to the facility.
Challenges with extending the program to physician anesthesiologists:
1. Compensation expectations: Physician anesthesiologists generally expect 2-3 times higher salaries than nurse anesthesiologists. Given the financial constraints of the rural pass-through program and the facilities it serves, it is unlikely that physician anesthesiologists would find the compensation attractive enough to work in these settings or that the facility could afford the additional cost for the exact same service and equivalent outcomes.
2. Impact on shortages: The low case volume and the limited need for providers in these rural hospitals mean that extending the program to physician anesthesiologists would have minimal impact on overall provider shortages yet significantly increase the cost of coverage by 2-3 times. The primary reason for perceived shortages is that many physician anesthesiologists are not directly providing anesthesia care but are involved in supervisory or administrative roles. Encouraging them to take on direct care roles in urban centers where the vast majority of them work could address shortages more effectively than changing reimbursement policies.
Fiscal responsibility and outcomes:
The rural pass-through program was also designed to alleviate the financial burden on these facilities regarding the costs of anesthesia services, enabling them to provide care in rural areas. This approach is fiscally responsible for Medicare costs. However, with physician anesthesiologist salaries being at least two to three times higher than those of nurse anesthesiologists even in urban areas, extending the program to include MDAs would only add additional cost burdens to both the facility and Medicare, without any evidence of improved outcomes. The current model efficiently supports the provision of necessary anesthesia services in rural areas without escalating costs unnecessarily.