1. Profitability to Sustain Not-for-profit Objectives of Healthcare Organizations

Healthcare organization is a unique corporate en-tity that is expected to deliver medical resources and  manage  illness  in  a  beneficial  way.  For  many  years,  the  pursuit  of  better  treatment  outcomes  and  wider  accessibility  of  medical  resources  has  remained  the  top  priority  among  healthcare  per-sonnel. Meanwhile, hospital administrators, either private or public, are requested by their stockhold-ers or higher management to maximize internally-generated profit (e.g., service reimbursement from National  Health  Insurance  [NHI])  and  external  re-sources  (e.g.,  government  or  non-government  or-ganization budget and public donation) to support research, teaching, and service activities. This ap-proach  is  distinct  from  profit-oriented  entities,  usually  known  as  enterprise,  whose  operation  is  primarily  designed  to  maximize  financial  return  to stockholders per se but not to the public in gen-eral.  With  the  not-for-profit  objective  underlying  corporate strategies and managerial skills, the di-lemma  of  healthcare  organizations  to  choose  be-tween commercial or beneficial schemes has raised global  concerns  over  time.¹  One  of  the  most  de-batable issues is the conflict between nurse anes-thetists  and  anesthesiologists.²  There  have  been  extensive  discussions  from  academic,  administra-tive, financial and medicolegal perspectives.³ In this issue, we publish a national survey on nurse anes-thetist human resources by Dai (a former president of  the  Association  of  Taiwan  Nurse  Anesthetists),  Chen  (a  former  president  of  the  Taiwan  Society  of  Anesthesiologists) and  colleagues. This is the first national survey to compare  objective indices, i.e., annual  anesthetic  service  provision  from  2002  to 2005, and the manpower ratio between anesthesi-ologists  and  nurse  anesthetists,  to  help  illustrate  the ecosystem in Taiwan.⁴

2. Friend or Foe: A Rollercoaster Relationship

To help elucidate the interdependent relationship among all players involved, the value net model by Brandenburger and Nalebuff⁵ was introduced. There are   four   main   groups   that   currently   influence   anesthesiologists: customers, payers, competitors, and complementors. The first and most important step is to design the value net, whereby the vari-ous roles of the players can be depicted (Figure 1). In  our  proposed  ecosystem,  nurse  anesthetists  could  be  considered  as  the  competitor  and  com-plementor  at  the  same  time.  This  critical  finding  makes  it  clear  that  the  same  participant  can  oc-cupy  two  roles  simultaneously  while  his/her  role  can dramatically switch between a rival and part-ner depending on how he/she is rewarded.

Anesthesiologists,  though  authorized  by  the  Medical Practice Act, lack the bargaining power or position  when  exponential  demand  for  the  anes-thetic service keeps outweighing the steady supply of board certified anesthesiologists, as has  occurred over  recent  decades.  Since  1958,  nurse  anesthet-ists in Taiwan have played an indispensable role in every  step  of  clinical  anesthesia,  from  induction  to recovery of anesthesia. The  discrepant supply-demand  status  was  even  more    entrenched  when  healthcare in Taiwan went through a drastic move to  NHI  with  a  nationwide  coverage  rate  greater  than  99%  in  1995.  As  a    result,  a  unique  environ-ment  consisting  of  interdependent    relationships evolved  to  sustain  the  optimal  benefits  for  all stakeholders within the value net. In urban areas with  advanced  and  high-quality  medical  services,  nurse anesthetists are well accepted as complemen-tary  coworkers  of  anesthesiologists.⁶  However,  in  rural regions, some nurse anesthetists practice an-esthesia independent of anesthesiologists, but under the supervision of surgeons. The nurse anesthetists eventually  become  competitors  with  anesthesiolo-gists in the role of anesthesia administrator.

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Figure 1 Value net of anesthetic practice. NHI = National Health Insurance.

3. Meltdown of Anesthesiologists: From Monopoly to Competition

In  2007,  the  International  Federation  of  Nurse  Anesthetists  identified  107  countries  where  nurse  anesthetists are allowed to practice anesthesia and nine countries which only allow nurses to assist in administrating  anesthesia.⁷  The  worldwide  role  of  nurse anesthetists has been changing drastically as a  result  of  the  shifting  manpower  structure  over  the past decades.⁸ In 1942, the ratio of physicians to nurse anesthetists was 1:17, thus the delivery of anesthesia  was  mainly  a  nursing  function.⁹  In  the  United  States,  the  legislative  restriction  on  nurse  anesthetist  practice  varies  greatly  from  state  to  state. Nurse anesthetists practice under the state’s nursing practice acts, but not medical practice acts. In  2009,  Certified  Registered  Nurse  Anesthetists  (CRNAs) remained the highest remunerated among all  nursing  specialties  with  an  average  salary  of  $157,724 per year.¹⁰ This amount of payment, how-ever, is only 43% of that of certified anesthesiolo-gists ($366,640). The financial benefit represents a lucrative  cost-driver,  i.e.,  57%  less  on  the  annual  payroll, when institution payers (i.e., hospital ad-ministrators  and  insurance  companies)  choose  to  hire  nurse  anesthetists.  Despite  stringent  protests from the American Society of Anesthesiologists, the conflict of interest remains unsettled in the United States  whenever  there  is  a  marked  premium  for  nurse anesthetists and institution payers.

4. Complementor or Competitor, This is the Option for Anesthesiologists

Anesthesiologists  are  no  longer  monopolizing  the  supply  end  of  the  marketplace  both  domestically  and globally. Dai et al⁴ demonstrated in their arti-cle that the overall anesthetic manpower supply of both nurse and physician anesthetist has been crit-ically insufficient for the surgical demand in a na-tionwide scale. The supply-demand disequilibrium creates  a  win-loss  chasm  which  in  turn  leads  to  breach  of  loyalty  or  comradeship  in  consequence  of a profound conflict of interest. Institution pay-ers  could  tighten  their  bargaining  power  and  cut  the payment by firmly supporting the nurse anes-thetist  as  a  substitute  for  the  anesthesiologist.  Thus, as shown in the United States, the nurse an-esthetists  eventually  changed  from  subordinates  to  competitors.  Another  crisis  of  decision-making  is growing in Japan, where the Cabinet Office of the Government is starting to establish the CRNA system driven by the intense demand for extra anesthesi-ology  manpower.  However,  as  the  Bill  is  firmly  op-posed by the Japanese Society of Anesthesiologists, the Japanese government is shifting from the idea of  promoting  CRNAs  to  abolishing  the  system  of  certified  anesthesiologists  by  allowing  all  physi-cians to administer general anesthesia without any restriction.¹¹ According to the perfect competition model,  incorporation  leads  to  fierce  competition  and may result in zero profit for both competitors. 

In the long run, institution payers become the sole profiteer to set service standards and pay while all practicing  anesthetists of all rankings become the sufferers. All these are loss-loss outcomes to both patients and practicing anesthetists, either profes-sional or non-professional anesthesiologists, when the value net is entirely driven by profitability but not  through  the  adaptive  interaction  among  all  stakeholders.

To  reverse  the  unacceptable  trend,  anesthesi-ologists must distinguish themselves as fair and ra-tional  supervisors  with  good  leadership.  The  best  strategy is to firmly cooperate with nurse anesthet-ists by reducing the conflict of interest and enhanc-ing overall manpower supply to the institution payers. Win-win equilibrium is therefore achieved when all players  have  no  financial  incentive  to  change  the  status quo within the value net. Anesthesiologists in Taiwan  have  no  choice  but  to  accept  the  fact  that  we need the assistance of nurse anesthetists as we cannot  afford  to  turn  a  competent  assistant  into  a  powerful competitor. The relationship between the certified anesthesiologist and nurse anesthetist must be redefined with mutual respect, financial benefit and legislative protection.

Wei-Zen Sun, MD

Professor, Department of Anesthesiology,

National Taiwan University Hospital and

College of Medicine, National Taiwan University

Associate Editor, Acta Anaesthesiologica Taiwanica