In the late 1990s there was a dramatic decrease in the number of medical students entering anesthesiology training programs in the United States (U.S.) (1). The entering residency class size not only decreased to less than half its previous size, but half of those residents in training were international medical graduates (IMG). Because many IMG residents train in the U.S. on J-1 visas, they are required to return to their home country at the completion of their training and, therefore, cannot enter the U.S. workforce for at least 2 yr (2,3). Starting in the year 2000 it became evident that there was a significant national shortage of anesthesiologists that could persist for more than a decade (2,3). This shortage of anesthesiologists affected not only community practice but also the ability of academic training programs to recruit and retain faculty (4–6). Competition for qualified anesthesiologists resulted in increasing salaries for faculty, which placed academic programs in financial jeopardy at a time when managed care had reduced professional fee income and academic medical centers (AMC) were also struggling to control costs (4–8). In the Fall of 1999, the Society of Academic Anesthesiology Chairs/Associate of Anesthesiology Program Directors (SAAC/AAPD) Counsel commissioned a white paper to be written to provide background information regarding these financial threats to the U.S. training programs (5). Data for this report were derived from a variety of sources, including a survey of the U.S. anesthesiology training programs conducted in the summer of 2000 and presented at the Fall 2000 SAAC/AAPD National Meeting (4,5). Follow-up surveys have been conducted in the Fall of 2001, 2002, and 2003; all have demonstrated a continued shortage of faculty and a progressive increase in financial support from their institutions (6,9). The purpose of this current article is to report the results of the most recent follow-up survey (Fall of 2004) and compare these data to those of the previous 4 years.
For the past 5 yr, email surveys have been sent to program directors of U.S. anesthesiology training programs (9). The follow-up surveys conducted in 2001, 2002, and 2003 have focused on open faculty positions, open certified registered nurse anesthetist (CRNA) positions, department financial margins, and the amount of institutional support received. In the previous surveys it was not determined whether the financial support from the institution included support for the salaries of CRNAs. Because the budgeting of CRNA salaries may occur under the hospital or the department, and may be funded independently or as a portion of the department’s overall institutional support, it is important to clarify the accounting of these funds. With these additional data, the institutional support for faculty and academic programs can be determined. Therefore, the 2004 survey asked specifically if the institutional support included funds used to pay for CRNA salaries and, if so, what was that dollar amount? (Appendix 1) After their Fall 2004 meeting, SAAC/AAPD leadership requested that the total number of anesthesia units billed by a department per year, also be surveyed (Appendix 2). The first email survey was sent in September and email reminders were sent approximately every 2 wk for the next 16 weeks to those who did not respond. The anesthesia unit survey was sent in November and email reminders were sent to nonresponders every 2 wk for the next 12 wk.
The surveys in Appendix 1 and Appendix 2 were distributed by email to 128 SAAC/AAPD member department chairs. An overall response rate of 73% (94/128) was achieved. The results are presented in Tables 1–6. The average department has 45 faculty, and for 91% of those departments who have CRNAs, they have 25 CRNAs (Table 1). There are an average of 3.3 open faculty positions in the 81% of responding departments who have open positions. Of the 91% of responding departments who employ CRNAs, 73% had an average of 4.2 open CRNA positions (Table 2). Overall, the departments provide faculty with 16.1% nonclinical time (Table 3), where 1 day/wk is considered 20% (Appendix 1). If faculty are not required to start clinical responsibilities until the afternoon, that pre-call day is considered nonclinical (academic) time.
From a financial funds flow perspective, U.S. anesthesiology training departments can be divided into three types: AMC Model programs are those with departments within medical schools; “budgeted departmental model” (Budgeted Model) are those in which departments are part of a larger clinical enterprise which manages the finances; and the “independent department model” (Independent Model) are those in which the departments are structured like private practice groups (6). The financial data for this report are from the AMC Model and Independent Model departments; the financial data are unavailable in the Budgeted Model.
For the purposes of this survey a faculty full-time equivalent (FTE) is an anesthesiologist who is on the department’s budget. (Appendix 1) For the fiscal year ending June 30, 2004, 55% of departments responded that they had achieved a positive margin of $949,386 ($27,416/FTE) while 42% responded they had a negative margin of $1,566,700 ($35,521/FTE) (Table 4). These margins were determined after the inclusion of institutional support which averaged $3,787,835 or $97,621/faculty FTE. (Table 5, Fig. 1, A and B) For 36.6% of the respondents this support included funds used to pay CRNA salaries, which averaged $1,888,111. Therefore, the institutional support for departments after CRNA support dollars are removed average $3,210,295 or $81,696/faculty FTE. (Table 4, Fig. 1, A and B) The majority of this support is being provided by the hospital; average hospital support = $2,968,068, medical school support = $745,035, and support from other sources = $1,064,207 (Table 6).
The average anesthesia unit value charge was $75.96 and the average number of units billed by a department was 483,747 U or 11,954/faculty FTE (Table 4).
Although there appears to be a continued shortage of anesthesiologists nationwide, data from this most recent survey reveal a slight decrease in open faculty positions per department from 3.7 in 78% of departments in 2003 to 3.3 open faculty positions in 81% of departments in 2004. This decrease in open positions is consistent with the results of the annual survey of the Society of Academic Anesthesiology Chairs (SAAC) which reported 192 open positions (or 2.4 positions/department) in 2004 where there were 266 open positions (or approximately 3.1 positions/department) for the survey in 2003 (2004 SAAC Salary Survey, personal communication with Rebecca Lovely, University of Florida, Gainesville, FL). This may be attributable to a greater availability of anesthesiologists or a larger percentage of graduating residents choosing an academic career. The progressive increases in academic salaries may make recruiting faculty easier. In the year 2000, according to the SAAC Salary Survey, an assistant professor paid at the 50th percentile received $183,000/year. This increased to $209,000 in 2002, $226,000 in 2003, and $242,821 in 2004. Over the last 4-year-period the average institutional support/FTE has increased from approximately $34,000 to more than $97,000 (Table 5, Fig. 1b). This $63,000 increase in institutional support is very similar to the salary increase of the average assistant professor over the same period of time. The salary increase found in the SAAC Salary Survey shows a similar trend as found in the Association of American Medical Colleges and Medical Group Management Association (MGMA) Salary Reports. Both of these reports lag 1 year behind the SAAC Salary Survey reports because of the time associated with data retrieval and publication (7,8). Although the average support for departments per faculty increased in the past year from $85,607 to $97,621, it is clear that in some departments a portion of the support has been used for CRNA salaries. It is unclear how much of the support to departments from previous years was attributed to CRNA salaries, but it is unlikely that the departmental support has decreased in 2004. It is more likely that a significant proportion (15% to 20%) of the support to departments in previous years had been associated with the support of CRNA salaries. From these most recent data, approximately one third of the departments received support for CRNA salaries included in their overall departmental support, whereas two thirds have CRNA salaries funded through another mechanism (e.g., they are hospital employees). The largest portion of department support is provided by the hospital and has increased over the past 5 years (Table 5). This willingness of the hospital to provide support to anesthesiology departments is most likely attributable to the hospital’s financial imperative to maintain operating room (OR) productivity and revenues. Without anesthesiology faculty this could not be accomplished. It is also clear that there is great variability among institutions and departments in their financial status and institutional support (Fig. 1A). These data are also not normally distributed, with mean support well above the median. The institutional support per faculty FTE has a mean of $97,621, a median of $75,000, and a 25% and 75% range of $37,467 and $127,087 (Fig. 1B, Table 5).
In addition to a slight decrease in the number of open faculty positions, it appears the average amount of academic time may have also increased slightly in the past year from 13.8% nonclinical time in 2003 to 16.1% in 2004, where 1 day/week is considered 20% time (Table 6). The average anesthesia charge has increased only $1.16, or 1.6%, over the past year, where it had increased 19.5% between 2000 and 2003. This survey did not request any information regarding payer mix or collection rate. Because most payer reimbursements are unrelated to charges, these data should not be interpreted as significantly affecting department revenue.
The number of anesthesiology units billed per faculty may be only a crude measure of the ability of a faculty to generate professional fees sufficient to cover their expenses. The net income associated with that professional fee effort is to a much greater extent dependent on the payer mix of the patients cared for and the overhead associated with the practice. Neither of these crucial financial measures was within the scope of this follow-up survey. It has also been demonstrated that the number of anesthesiology units generated by a faculty member is not a good measure of faculty productivity (10–13). It is a better measure of faculty and OR utilization (10–13). That is, if the ORs to which a faculty is assigned are well utilized by the surgical staff, then that faculty anesthesiologist will be able to generate more units, especially if there are more cases of shorter duration (10–13). If faculty are assigned to out-of-OR locations, such as radiology, electrophysiology, and labor and delivery, then, although the faculty time is consumed, the ability to generate anesthesia professional fees is greatly reduced. Billable hours of anesthesia service may be a better measure of anesthesiologist productivity but that was also beyond the scope of this survey (12,13). Anesthesiology units/FTE/year also does not account for faculty time and fees generated in non-OR areas, such as critical care units and pain management centers. These anesthesia unit data are provided here to give a rough guide of the relative utilization of anesthesiology faculty for OR services.
Survey data, in general, may misrepresent reality because of a small response rate, a skewed response population, or errors in the respondents’ understanding of the survey questions. The 73% response rate of this current survey compares favorably with the 25%–31% response rate of the MGMA reports (7,8). The large response rate achieved in this survey is likely attributed to the fact that the respondent program directors were informed that they would receive the results of this survey at their national meeting and these results may be useful to them in managing their departments. In addition, because this is the fifth consecutive year of surveying the same population regarding a similar topic, it is likely that these data are at least consistent and potentially improved over the previous 4 years.
A critical number in this analysis is the faculty count, i.e., “employed FTE faculty anesthesiologist” (Appendix 1). This was meant to be the number of employed faculty anesthesiologists rather than their clinical commitment. If the individual filling out the survey misinterprets this question then all the subsequent data, which are normalized to the faculty FTE count, would be in error. The average number of faculty per department of 45.3 from this survey is similar to the figure of 43.2 from the 2004 SAAC survey, providing some confirmatory data. All the results of the survey, as with all surveys, are dependent upon the respondents understanding what is being asked.
We conclude from this fifth survey that the U.S. anesthesiology training programs still require substantial support to maintain financial viability. The average department is receiving nearly $82,000/faculty in institutional support after the expenses of CRNAs are removed. Despite this support, on average, the departments continue to have a negative margin. It also appears that the faculty shortage in academic departments may be easing slightly, possibly as a result of increased salaries and a small increase in academic time.
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