Sunday, April 01, 2007

Physicians Upset About Nurse Anesthetist Incomes

KevinMD blogged about the high incomes of Certified Registered Nurse Anesthetists (CRNA's). It seems that salary estimates vary significantly depending on the source.

One survey performed by a website gives a range of salaries broken down by work setting. They run anywhere from $88,000 in a private practice/office setting to $116,000 in "other" (whatever that is).

The American Medical Group Association survey notes an average salary of over $143,000 for 2006. No information is given the distribution of salaries.

This data for 2006 comes from a survey performed by a locum tenens company. It suggests that the average income is over $164,000. Notably, 6% of respondents claimed an salary between $230,000 and $250,000 and another 6% earned over $250,000. These number don't include bonuses. The survey participants are apparently all locum tenens practitioners (temporary workers). These numbers may be higher than might be expected among all CRNA's many of whom presumably trade job security for lower incomes.

The reason I'm writing about this is that some doctors are apparently upset with these numbers noting that many CRNA's appear to make more than the average primary care physician (PCP) and have much less formal education.

In fact, Kevin's blog mistakenly states that only two years of college are required to be a CRNA. However, according to the American Association of Nurse Anesthetists, a 24 to 36 month training program is required at a Master's level (which requires the equivalent of a Bachelor's degree). The total training therefore requires six to seven years of college/graduate school. Obviously, this is still significantly less than the eleven or so years required to be an internist, family practitioner or pediatrician.

It is understandable that physicians might be upset to discover these numbers and some have even asked 'what can be done about this inequity?' However, this perceived "disparity" is really a reflection of an often misunderstood concept of economics. The price of labor (or of any good or service) is arrived at by a balance of supply and demand in a free market. If supply is low or demand is high, the price rises. As supply rises or demand falls, the price falls.

That's just the way it is! In a free market, buyer and seller both freely enter into an transaction the price of which is determined by the above interplay.

What people don't get is that the price of something is independent of the expense and effort that went into creating that thing (except to the extent that greater expense and effort tends to lower the supply of that thing). The result of this often painful reality is that great effort may be expended in producing something but if no one wants it, its price will inevitably be low.

This explains why movie stars make more than teachers: extraordinarily high demand, relatively low supply of talented stars. It also explains why some products fail despite extraordinary labor, capital and effort that may have been required to develop them. Supply may be tight, but if demand (perceived desirability) is low, the producer won't be able to sell them at a price that is high enough to recover the expense of producing it.

And it seems to explain why CRNA's may make more money than some doctors notably primary care doctors. The number of years of training is essentially irrelevent to price determination. If the value of a PCP is unappreciated by the consumer (and indirectly by third party payers) then his or her reimbursement will be low compared to the value of a CRNA. From the point of view of the physician, this may not seem fair. Unfortunately for them, in this setting it's the public who decides how high to value the PCP.

I think that there's pretty good empiric evidence that although patients in general like their PCP's, they don't want to pay them much. Even minimal increases in co-payments for primary care doctors dramatically reduce doctor visits. I've personally seen this in reverse when I worked in an office setting. A managed care insurer unilaterally dropped PCP co-pays from five dollars to zero. Amazingly, that small difference caused utilization in our office to explode for members of that health plan.

Five lousy dollars had such an impact in patients' willingness to see us!

Of course the arguments I've made assume a free market. This is of course a question open for discussion in the healthcare setting. But right now, the current market we have is closer to being "free" then the healthcare system almost anywhere in the developed world.

ONLY when patients decide that they value their PCP's more will PCP reimbursement and incomes rise. Until then, nurse anesthetists who facilitate lucrative surgeries will have greater value in the open marketplace.

So if you want to pull down a huge income, work on your jump shot or your singing or your airway management technique until you've established a skill people REALLY value.

More on this topic here.


Blogger Richard A Schoor MD FACS said...

Very nice summary.

April 03, 2007 7:50 AM  
Anonymous Anonymous said...

Good and important issue and post. A wonderful stuff to look forward which needs some attention for all the nurses where there income should increase it.

May 14, 2007 9:40 PM  
Anonymous Anonymous said...

But it isn't just nurse anesthetists - as a 29-year veteran of nursing, I will average about 100,000 gross this year working 64 hours a pay period (night shift).

I work under an agreement with the California Nurses Association, who act as my collective bargaining agent.

I'm not even a CRNA, I'm just an RN with an ADN degree and almost 30 years experience.

We would be able to do more and practice preventative health if the primary care physicians were paid what they are worth!
It's all backwards. The specialists make the money and the primary doctor, the one who can help you STAY healthy is given the short shrift.

It's just wrong.

(PS - I see you're a Hugh Hewitt fan, too!)

May 16, 2007 6:11 PM  
Blogger Angel ARNP said...

as an ARNP in Women's Health, I don't even come near a CRNA salary. Isn't sad that our culture focuses on Celebrity and not taking care of humans. I can see how MD's get upset about salaries but as a ARNP I am not trying to replace anything at a shorter education. I have been in nursing for over 20 years. I went to school for more than 8 years and that doesn't include the amount of time spent in reading journals and going to seminars. We are an extention and partner not trying to replace, MD's. It is a partnership. I wish more people would give us a chance and not fight about it.

We are in a severe health provider crisis. I think we should just go back to Fee for service and get rid of insurance companies. If we went to the grocery store and said I am only paying $1.00 for your milk, the store would tell you no thanks why do we stand for this?

Thanks for you comment

June 15, 2007 4:08 PM  
Anonymous Anonymous said...

I couldn't have said it better myself. I'll have to link to your RSS twice from now on.

July 12, 2007 2:28 PM  
Anonymous Anonymous said...

It seems the other commenters missed the point: If your services are in demand, then you will be paid more, just like if you produce more you are paid more.

The man (or woman) with the shovel digging the ditch works much harder than the man with tractor, but the tractor produces much more ditch than the shovel and the tractor driver has skills that the shovel man does not.

When you spend 36 months EARNING your CRNA you will be rewarded.

In fact I am attemting to start a private practice of CRNA in Las Vegas right now and when we form as a group WE will hire our "supervising Physician" WE will be in control of our lives and if MD's are upset, so be it.

We will provide services at a SAVINGS and still make $300K a year plus work reasonable hours, imagine that, nurses taking charge!

February 08, 2008 9:55 AM  
Blogger jenna0528 said...

I am responding to lvcrna. I live in Vegas and am interested in becoming a CRNA. There is a new program that is starting that allows a student to stay in their community and study to become a CRNA. However, I need to find a preceptor that is a CRNA/MDA that can help facilitate my clinical learning. Please respond. Thanks!

February 27, 2008 8:30 AM  
Anonymous Anonymous said...

CRNAs get paid more than PCPs because of the supply demand issue as well as the nature of the work. A CRNA's work is 80% bordem and 20% shere panic! A PCP's job simply isn't the same. If something goes wrong in the OR, the CRNA will get looked at by the atty before the MD.

March 15, 2008 6:26 PM  
Anonymous Anonymous said...

Let's not forget that the first 4 years of an MD's education in the US is completely useless. They need a four year degree in English Lit before going to ONLY 4 years of medical school. The residancy is only for their specialty training and they get paid for it. I know MDs who make 7 figures a year. Yeah, that was not a typo. A CRNA may require 8 years of education, but 6 is totally dedicated to the study of health care. An MD only has 4 years of health care education.

March 15, 2008 6:49 PM  
Anonymous Anonymous said...

I agree totally about the supply and demand issue regarding CRNA income. A persons income has nothing to do with their education or the amount of time and effort, but strictly based on the laws of economics. On the issue of education, MD's spend a significantly more time and effort than any nurse. They have four years of college education, yes you can do a english major but have to do all the basic sciences that any science major requires, four years of medical school and any where from 3-10 years of residency. Also requires many night awake and on call and working 80 hours a week for many year. Nursing requires an AA or BA/BS and two years of Nursing. CRNA requires a nursing degree, one year of work in a acute care setting and a two year masters. Never on call, usually never working more than 40 hours a week, with a ciriculum that MUCH less strenuous.

April 12, 2008 10:19 AM  
Anonymous Anonymous said...

Many great points here. Supply and demand. Education and knowledge. Skills and practice. A few comments from a CRNA. There is a great demand for anesthesia services. Supply can be provided by MD or CRNA or AA. Price - MD($$$$-$$$$$) vs. CRNA/AA ($$ to $$$). Basically, there is a 40-60% savings realized when anesthesia services are provided by CRNA/AA vs MD. The system works and currently, there is a balance in most markets in terms of income. Skills and practice - No difference in outcome in quality or safety regarding anesthesia provider. Many studies. Look them up. Education and knowledge. Currently, to become a CRNA. 4 year BSN with basic science. 1-2 yrs critical care experience. 27-36 months anesthesia training. It's more than a year or two. Consider this - Aircraft mechanic. Aerospace engineer. Pilot. All know something about the aircraft. The mechanic ($) has less education but much knowledge about the aircraft. Can't fly the plane (not job title). Aerospace engineer ($$-$$$) has much education and knowledge. Can't fly the plane (not job title). Pilot ($$$-$$$$) has some education and much knowledge about flying the plane (in job title). Want to fly with the person with the most education or the person with the most knowlede and skill about flying the plane? Assuming education is directly linked with the ability to perform a job will get you killed. Want anesthesia? Go with the person who is skilled in providing it. That may be a CRNA, AA or MD. That's where you get into supply and demand. That's where you get into the the justified income of CRNAs.

May 16, 2008 6:19 PM  
Anonymous Anonymous said...

its according to the nature of the work.

“A lot of it is just based on economics,” Phil Miller, a VP at the firm explained. “An investment in a [nurse anesthetist] who can do all your anesthesiology and keep your operating room going and ensure you’re getting all those high-dollar procedures coming in to your hospital or your surgery center makes sense, particularly in rural areas where you may not have an anesthesiologist.”

Nurse anesthetists typically receive an undergraduate nursing degree, have experience working as registered nurses and complete two to three years of post-graduate training. They can perform many (but not all) of the tasks often performed by anesthesiologists. The anesthesiologists recruited through Merritt Hawkins averaged $336,000 per year.

averages for some other medical specialties:

* Cardiology: $392,000
* Dermatology: $315,000
* Emergency medecine: $240,000
* Gastroenterology: $379,000
* General surgery: $321,000
* OBGYN: $255,000
* Orthopedic surgery: $439,000
* Pediatrics: $159,000
* Psychiatry:$189,000
* Radiology: $401,000
Great post!

July 19, 2008 7:45 PM  
Anonymous Anonymous said...

I am a CRNA with my own practice. I provide anesthesia svcs to 2 free-standing surgery centers(along with 1 FT and 2 PT CRNA employees. I provide what many MDA's apparently will not, i.e. top quality, people-friendly,surgeon-friendly service. Our patients are all treated like VIPs. This has helped our Surgeon's practices flourish as a result,eclipsing their competition, many of whom utilize MDA's. We ALWAYS introduce ourselves as "Nurse Anesthetists" to avoid any misrepresentation. I earned well over $600,000 last year. Welcome to free enterprise; rewarding quality and value for a desired service. MDAs, take note. Surgeons want their patients treated well...period. Smoke and mirrors alleging increased liability are just that. Only the most uminformed Surgeons buy that load,and continuing to tout is makes MDAs appear small and desparate. I challenge any anesthesia provider to come and compete with me. In the end, the patient will benefit from true competition on a level playing field.

September 10, 2008 10:27 AM  
Anonymous Anonymous said...

Bravo to the CRNA with his/her own practice. The bottom line is who will deliver safe, vigilant, top quality anesthesia care to the consumer AND keep the surgeon and staff happy without huge egos/demands. It has been proven in many studies that CRNA care is just as safe as MD's. You can argue all you want about education; a nurse anesthetist is highly skilled and trained and is sole provider of anesthesia in upwards of 65% of rural locations. People who live there depend on us; they are not disappointed. As to income, this is still America and free enterprise rules.

February 14, 2009 8:33 PM  
Anonymous Anonymous said...

Amusing comments just had to weigh in. Truly those who yap the most say the least.

The idea that a CRNA and Anesthesiologist's education are similar is wishful thinking on the part of the AANA and its members.

The four years of undergrad education were useless? Uh not sure I agree. The knowledge/discipline hurdle required to pass the MCAT and gain admission to medical school is waaaaay higher then the crna entry requirements. Sorry but these are the facts.

The knowledge/discipline hurdle required to pass the USMLE step 1 (which build on the MCAT knowledge) are even further beyond that anything a CRNA will be asked to know.

Can Crna's do the job? Sure, with supervision, some more than others. Most would love to see MD's out of the picture entirely but the truth is it'll never happen because physiology and its perioperative pertubations are best handled by the specialist with the most knowledge and that is Anesthesia MDs.

Feel free to do all the ASA 1 buttscopes and cataracts under topical though.

I've seen the nursing coursework and exams and I'm sorry but your knowledge base just isn't the same.

I've worked with crnas, even good ones and sorry but your knowledge base just isn't the same.

October 17, 2009 5:43 AM  
Anonymous Anonymous said...

Actually, the biggest multi center study 10 yr ago said basically add in a CRNA and your M&M(morbidity and mortality went up. Didn't change adding in a resident. Study had flaws, wasn't prospective and was never repeated because the AANA(nurse anesthetist national organization) and ASA(anesthesiologist - controlled by people who have groups of CRNA's) don't want the study done.
In healthy people, anesthesia is very safe and hard to mess up, sick people are another matter-only the system pays better for healthy people care.

March 12, 2010 10:25 AM  
Anonymous Anonymous said...

I agree totally with last posting. As a practicing MDA(anesthesiologist), there is no comparison b/n md's knowledge and crna. CRNA's are tought how to take care of patients anesthetic needs in 4 to 6 week total intervals of specific areas like pediatrics or outpatient surgery. Whereas, MDA's train in peds,outpatient,regional and neuro etc for 4-6 months each. The crna is a skilled technician with a 7a-3p mindset. If you want to get any work out of them beyond their shift then expect to pay significantly more for their services. This is why mda's make significantly more b/c they carry the call burdens 24 hrs a day 365 days a year and they bring experienced skillsets to care for patients that crna's don't have the training to handle.

March 12, 2010 6:47 PM  
Anonymous Anonymous said...

Interesting article; I agree with the supply/demand scenerio. But despite all of the "me too" chest-beating and hand-wringing by some CRNA's who think that they are "equal" to anesthesiologists, most educated, thinking people will never equate nursing with the practice of medicine. CRNA's are technicians who need to be supervised by anesthesiologists; the fact that some are not is a crock.

June 02, 2010 7:23 PM  
Anonymous Anonymous said...

Why do the MDAs want supervison over the CRNAs? Its all about billing! Why to over see four CRNAs and bill at 200%. Why do a single case and bill for 100% and do all the work? Just be present at induction and sit in the lounge drinking coffee and watching the stock markets. Ah the life of an anesthesiologist. The CRNA is always present and vigilant.

November 20, 2010 5:28 PM  
Anonymous Nurse Anesthetist Schools said...

Most CRNA's deserve that income range - I mean to become a CRNA takes just as long as becoming a physician.

December 03, 2010 7:06 PM  
Anonymous Mixed Martial Arts said...

If you take into consideration bonuses some CRNA's are making over 300,000k. Of course this is an exception and not the rule.

December 03, 2010 7:08 PM  
Anonymous Anonymous said...

Do I detect a bit of egoism? I have more education than YOU so I am better than YOU, you lowly CRNA.
Grow up MDs. It is obvious that you are intimidated by the thought of a nurse doing your job as well as you do. God forbid your patients think that a nurse is on the same level as you.

April 02, 2011 10:12 PM  
Blogger dancilhoney said...

The article also provided relevant experiences of
anesthesia nurse programs both from an academical, as well as a personal viewpoint. It is definitely a blueprint for success, which I can speak on personally from my own experiences.

August 30, 2011 1:49 AM  
Blogger Technician 101 said...

can you define any further registered nurse average earnings in California? I am still in vague about the topic though.

December 12, 2011 4:36 PM  
Anonymous Anonymous said...

I am a practicing Anesthesiologist. I find the comments here from CRNA's petty and inaccurate. MDs have much more training than CRNAs, sorry. I graduated with a double major in physics and chemistry Summa Cum Laude from an Ivy League school (4 years). I then studied and stayed up all night working in a hospital setting 60-80 hrs per week in medical school (4 years). I then worked 60-80 hours a week in residency on high acuity cases in an academic medical center (4 years). I have published extensively in the literature. Ever do anesthesia for the surgical separation of conjoined twins? Ever look at a pediatric heart with complex congenital abnormalities under 3d echocardiography? I agree that for ASA 1 patients in an ambulatory setting there is probably little difference in outcome (If there were it would take a colossal study to find it because anesthesia in that population is so safe, right)? I also agree there is a role for CRNAs and other physician extenders in medicine. But don't tell me we are exactly the same, because that's not being honest. PS if your lobby keeps this up maybe we will hire only AA's and not admit you to training courses provided almost universally by MDs.

January 17, 2012 9:04 PM  
Anonymous Pete said...

Good and important issue and post. A wonderful stuff to look forward which needs some attention for all the nurses where there income should increase it.

May 29, 2012 8:58 AM  

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