AANA Journal — February 2014
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Cost of Education and Earning Potential for Non-Physician Anesthesia Providers
Philip MacIntyre, CRNA, MSN Bradley Stevens, CRNA, MSN Shawn Collins, CRNA, DNP, PhD Ian Hewer, CRNA, MA, MSN

Potential non-physician anesthesia students gauge many different aspects of a graduate program prior to applying, but cost of education and earning potential are typically high priorities for students. Our analysis evaluated the cost of tuition for all certified registered nurse anesthetist (CRNA) and anesthesiologist assistant (AA) programs in the United States, as well as earning potential for both professions. We collected educational cost data from school websites and salary data from the Medical Group Management Association's Physician Compensation and Production Survey: 2012 Report in order to compare the two groups. We found that the median cost of public CRNA programs is $40,195 and the median cost of private programs is $60,941, with an overall median of $51,720. Mean compensation for CRNAs in 2011 was $156,642. The median cost of public AA programs is $68,210 compared with $77,155 for private AA education, and an overall median cost of $76,037. Average compensation for AAs in 2011 was $123,328. Considering these factors, nurse anesthesia school is a better choice for candidates who already possess a nursing license; however, for those prospective students who are not nurses, AA school may be a more economical choice, depending on the type and location of practice desired.

Keywords: Anesthesiologist assistant, cost of anesthesia education, debt, nurse anesthetist, salary.

In the United States, there are two distinct pathways to obtaining a non–physician-based advanced degree in anesthesia. Certified registered nurse anesthetists (CRNAs) are advanced practice nurses who have earned a bachelor's degree–commonly in nursing– practiced at least 1 year as an acute care nurse, and have successfully completed a graduate-level nurse anesthesia program.1 Anesthesiologist assistants (AAs) earn a bachelor's degree in any field and then complete a graduatelevel anesthesia training program.2

Each type of anesthesia professional goes through a different pathway to obtain their credentials. Both types of students earn a degree in a fee-for-service educational system; this can be extremely expensive and often requires students to obtain loans in order to cover the cost of tuition and fees. In addition to the costs of tuition and fees, both AA and CRNA students are so immersed in the training that there is no time for work outside of the educational setting. This leads to the need for loans to cover living expenses as well as tuition. The cumulative effect of school debt can deter people from pursuing advanced degrees in uncertain economic times, unless the earning potential is substantial enough to overcome the debt load. Consequently, there is utility to quantifying the debt load and earning potential one can expect following completion of either AA or CRNA training.

History

Currently, there are approximately 30,000 practicing CRNAs and 1,023 AAs in the United States.3 CRNAs have been administering anesthesia since its inception in the late 1800s. The first nurse anesthesia training program began in 1909, whereas the first AA school opened in 1969– ostensibly in response to a shortage of nurse anesthetists. In general terms, the two professions have similar length of training and preparation for practice, and have previously been compared to each other.4 However, there are four main areas of difference between CRNAs and AAs: curriculum prerequisites, scope of practice, governing entities, and practice jurisdictions.

Curriculum prerequisites

Although nurse anesthesia programs do not all stipulate a bachelor's in nursing, there is a requirement that the candidate be a registered nurse with at least 1 year of acute care experience. It is possible for an applicant to have a bachelor's degree in a related field, but in order for them to practice as a nurse, they must have at least an associate's degree in nursing. AA programs do not specify required undergraduate majors; however, certain prerequisite science, math, and English undergraduate classes are required for admission.

Scope of practice

In terms of guidelines from their respective licensing bodies, the scope of practice of both professions is similar; however, significant differences exist between supervision requirements. AAs must always work under the supervision of an anesthesiologist, whereas CRNAs are not required to be under physician direction. However, although not required by professional scope of practice, in most states there is at least some form of legislative or billing requirement that stipulates supervision of a physician. The physician could be an anesthesiologist or a surgeon, and CRNAs are also permitted to work under the direction of certain other healthcare providers, such as dentists or podiatrists. Despite the use of the term supervision, it has been well established legally that when supervised by a non–anesthesia-trained physician, the CRNA is responsible for anesthetic-related negligence. 5 In addition, 17 states have chosen to "opt out" of a federal rule that stipulates physician supervision and allows independent practice of CRNAs.6

Governing entities

As advanced practice nurses, CRNAs fall under the jurisdiction of the Nursing Boards of the state of practice, whereas AAs are regulated by the Board of Medicine. Consequently, practice boundaries are defined by the respective nurse or physician practice acts of each individual state.

Practice jurisdiction

CRNAs can practice in any state in the US, though with slightly varying supervision requirements as indicated above. AAs face a much different employment market, with only 18 states currently permitting them to practice, and all requiring a supervising anesthesiologist.4

Review of the Literature

Surprisingly little research surrounding the cost of non– physician-based anesthesia education has been performed. Multiple healthcare, scientific, education, and other relevant resources were searched, including EBSCOhost, MEDLINE, CINAHL, PsycINFO, SPORTDiscus, ERIC, Academic and Business Search Complete, Google, and Google Scholar. Searches were conducted using keywords, phrases, and database-specific subject headings. Search words related to the topic of nurse anesthetists, anesthesiology assistants, and education costs were used, including variants of the terms: anesthetist, anaesthetist, or analgesia; nurse or assistant; education, training, school, or student; and cost, debt, or expense. Currently, the authors are unaware of any comparisons between cost of education and earning potential of CRNAs and AAs. Due to the limited research available, no search topics were excluded for this report.

Although there are no data comparing CRNAs and AAs, researchers have examined the total cost of educating CRNAs and physician anesthesiologists and concluded that the cost of anesthesia residency is substantially higher than nurse anesthetist training.1 However, although CRNAs are less costly to train, earning potential for anesthesiologists was shown to be substantially higher than for nurse anesthetists. The total estimated cost (in 2008 dollars) for CRNA education was $161,809 vs physician anesthesiologists at $1,083,795. These costs include direct and opportunity costs as well as the offset of estimated student/resident productivity. Undergraduate degree cost was included in this study, but was identical for both types of anesthesia providers. Importantly, it was also shown that anesthesia care was equally safe and effective for both CRNAs and physician anesthesiologists. The study was funded by the American Association of Nurse Anesthetists, but carried out by an independent research group.

More recently, analysis of the anesthesia labor market has demonstrated a continually increasing demand for all types of anesthesia providers over the past 10 years.3 This report also showed a steady increase of CRNAs and AAs graduating into the workforce over the same time period. In the early 2000s, there was a severe national shortage of both AAs and CRNAs. According to the authors, this was due to a low number of AAs entering the market, and retirement exceeding graduation of new CRNAs. By 2010, there were few regional shortages of CRNAs and a moderate national shortage of AAs (both AA and CRNA schools had substantial increases in enrollment during this time). Continuing this trend, a possible surplus of CRNAs was projected by the year 2020, which is likely to result in a drop in CRNA supply due to decreased interest in pursuing advanced practice degrees as fewer positions become available. The authors also suggest that CRNA training programs should limit their output of graduates until more definitive economic trends and healthcare reform data are available.

In a different approach, current and future demand for CRNAs was assessed by comparing the ratio of CRNAs to surgeries, rather than the number of vacant CRNA positions.7 The research identified an increased number of CRNAs entering the workforce, probably as a result of increased capacity in nurse anesthesia schools in response to the prior shortage. However, the authors suggested that the increasing supply of CRNAs would not outpace the market demand.7 This is due to multiple factors, including higher volume of surgery (2% per year) and increasing numbers of CRNAs moving into the non-surgical work environment, such as pain management and radiology.7

Accurate salary numbers are difficult to determine for CRNAs and AAs. The only source the authors could locate that had consistent data on both CRNA and AA salaries was the Physician Compensation and Production Survey published by the Medical Group Management Association (MGMA).8 Other sources list each occupation's salary data separately, and/or with varying ranges instead of a single mean or median salary, making comparison difficult.9-14

Methodology

The cost data collected were obtained from each school's respective website and consist of tuition and fees (see Tables 1-5). For the purposes of this study, tuition and fees refers to the cost of all credit hours needed to graduate, clinical site fees, equipment, and various other university-determined fees. We did not calculate cost of housing or travel, which is difficult to establish without surveying students in each program, and thus beyond the scope of this analysis. Books, licensing fees, and health insurance were also excluded from this report, as these fees are universal for all anesthesia programs and relatively small in the context of total educational costs, and therefore unlikely to influence the overall conclusions. The compared costs for public anesthesia programs are for in-state tuition only. The only exception to our webbased determination of costs was the Mayo Clinic College of Medicine Nurse Anesthesia Program, which was contacted by phone, as per instructions on their website.

The National Center for Education Statistics indicates an average undergraduate four-year degree costs $88,368.15 However, the total costs for undergraduate education were not considered in this research, since both CRNA and AA students must have a bachelor's degree prior to starting their respective master's or doctoral program. The focus of this research was on the differences between the advanced degrees earned by each profession. Since the cost of public and private institutions can vary dramatically, fees were separated into two categories. The total costs and length of each individual program are listed in Table 6. Similarly, the median length of program (in months) was determined for public and private schools separately. The overall median total cost and length of program were also determined for all CRNA and AA institutions, respectively.

The salary data for CRNAs were collected from the MGMA Physician Compensation and Production Survey: 2012 Report Based on 2011 Data8, and the numbers reported for CRNAs and AAs are for total compensation. Specifically, these totals include salaries, bonuses/incentives, and profit sharing, but not costs incurred funding health insurance, retirement plans, or any business/educational expense reimbursement.

Results

The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) lists 111 accredited nurse anesthesia educational programs.16 There is one nurse anesthesia program in Puerto Rico from which we were unable to obtain tuition information. Two other programs are military based and do not charge tuition in return for military service. These three programs have been excluded from this analysis.

Of the included nurse anesthesia programs, 60 are private schools and 48 are public institutions. The median cost of the public CRNA programs is $37,243 compared with a private program cost of $61,345. The median tuition and fees for all nurse anesthesia programs is $50,077, and the median program length is 28 months. Data for nurse anesthesia programs are current as of October 2012.

Average provider compensation for CRNAs in 2011, as reported by the MGMA Physician Compensation and Production Survey8, was $156,642. Median compensation was $158,092. The highest CRNA compensation was reported in the Midwest region of the United States (median $166,752). The lowest compensation was in the eastern region of the country (median $152,678).

The American Academy of Anesthesiologist Assistants (AAAA) lists eight AA programs in the United States.17 Seven of these eight schools are private institutions. The average cost of the seven private AA programs is $77,155. The one public AA program's tuition and fees is $68,210. This leads to an average cost of $76,037 to educate an anesthesiologist assistant. The average program length for AA education is 25.9 months. Data for AA programs are current as of October 2012.

Average provider compensation for AAs in 2011, as reported by the MGMA Physician Compensation and Production Survey8, was $123,328. Median compensation was $127,020. Geographic compensation data were not reported for AAs in the MGMA survey.

Limitations

There were several limitations noted when assessing the data. The cost and length of nurse anesthesia programs only offering a doctoral degree skews the educational cost data for CRNAs slightly higher than AA programs that only offer master's degree programs. When separated out, the mean cost for public CRNA programs only offering DNP education is $54,306 (n=5), whereas the private DNP program mean was $75,822 (n=5). However, the American Association of Colleges of Nursing (AACN) will require all CRNA programs to graduate doctoral-prepared anesthetists starting in the year 2025.18

The information obtained for the cost of education was reported by each respective school's website. Unfortunately, the fees stated by the programs are not standardized throughout anesthesia schools. Some costs were listed simply as "total estimated cost" instead of broken down into tuition, fees, books, and housing. This makes comparison difficult even among schools in the same anesthesia specialty. Also, we calculated costs of public school tuition based on in-state costs, but in all likelihood at least some students had to pay the higher out-of-state rate. This could be expected to increase overall expense for both programs, but possibly CRNAs to a greater degree since there is a higher ratio of public:private schools.

Another limitation in the data relates to compensation of AAs. The MGMA Physician Compensation Survey only had four medical practices consisting of a total of 33 anesthesiologist assistant providers reporting data on AAs.8 This is compared to 80 medical practices reporting compensation data on 1,901 CRNAs. According to the AAAA, when AAs are employed in the same department as CRNAs with similar expectations, salaries are typically identical.7 Since the MGMA data are not delineated by hospital, it is difficult to determine the accuracy of this statement. In addition, it is not known how many departments exist with CRNAs and AAs working concurrently. However, personal communication with one of the authors has verified concurrent employment with identical salaries in at least one department in Georgia. Thus, the authors believe if more AA compensation data were reported, the gap between the salaries could potentially be smaller, as AAAA claims.

Lastly, the authors acknowledge that there are several different options for obtaining a bachelor's degree in nursing other than the traditional 4-year route. These alternative programs were not considered for analysis in this study.

Discussion

There are many factors to consider when comparing educational routes to become a non-physician anesthesia provider. However, from an economic standpoint, our analysis indicates that whether a prospective student either has no undergraduate education or has already received a bachelor's degree in nursing, nurse anesthesia school is the better method. We found that the average cost of CRNA education is $24,317 less than AA education. Furthermore, while the additional cost of the DNP degree mandated for CRNAs effective in 2025 would decrease this difference, it would remain less costly to complete CRNA education in comparison to AA (net difference of $9,611). In addition, depending on the type of employment arrangement for a nurse anesthetist, there is a higher earning potential for CRNAs than AAs and no geographical practice restrictions in the United States.

However, if a prospective student has a bachelor's degree in any major other than nursing, anesthesiologist assistant school could be a more economical option. Our analysis shows the average cost of a second bachelor's degree plus nurse anesthesia school would be $140,088 (assuming all 4 years are needed to obtain the necessary bachelor's degree). This does not account for students who may be able to matriculate through an accelerated BSN program, or those who took an associate's degree; however, either route would still result in increased cost due to additional undergraduate education. While AA school is more expensive than CRNA school, our analysis suggests it is less costly (by $64,052) and faster than completing a second bachelor's degree in nursing and a nurse anesthesia program. Though alternate routes to a nursing licensure are less expensive, the net outcome– more costly education–is similar.

Summary

Overall, nurse anesthetists have better opportunities to attain a higher income due to fewer restrictions on practice, geographic mobility, and a wider distribution of available positions. Unless a prospective student is considering anesthesia with a bachelor's degree in a subject other than nursing, decreased cost of education, higher earning potential, wider scope of practice, and more job opportunities indicate becoming a CRNA is a more practical and economical choice.

REFERENCES

1. Hogan PF, Seifert RF, Moore CS, Simonson BE. Cost effectiveness analysis of anesthesia providers. Nurs Econ. 2010;28(3):159-169.

2. Facts about AAs. The American Academy of Anesthesiologist Assistants Website. http://www.anesthetist.org/factsaboutaas/. Accessed November 16, 2012.

3. Schubert A, Eckhout GV, Ngo AL, Tremper KK, Peterson MD. Status of the anesthesia workforce in 2011: evolution during the last decade and future outlook. Anesth Analg. 2012;115(2):407-427.

4. Amburgey B, Fordham M, Payne B, Trebelhorn M. A Study of Anesthesiologist Assistants. Frankfort, Kentucky: Legislative Research Commission; 2007.

5. Blumenreich G. Another article on the surgeon's liability for negligence. AANA J. 2007;75(2):89-93.

6. Fields R. 17 states opting out of the physician supervision of anesthesia rule. Becker's ASC Review Website. http://www.beckersasc. com/anesthesia/17-states-opting-out-of-the-physician-supervisionof- anesthesia-rule.html. Published May 30, 2012. Accessed January 28, 2013.

7. Merwin E, Stern S, Jordan LM. Supply, demand, and equilibrium in the market for CRNAs. AANA J. 2006;74(4):287-293.

8. Medical Group Management Association. MGMA Physician Compensation and Production Survey: 2012 Report Based on 2011 Data. USA: Glacier Publishing Services, Inc.; 2012.

9. Abouleish AE, Stead SW, Cohen NA. Myth or fact? Nurse anesthetists cost less than anesthesiologists. ASA Newsl. 2010;74(12):30-34, 51.

10. Nurse anesthetist. ExploreHealthCareers.org. http://explorehealthcareers. org/en/Career/80/Nurse_Anesthetist. Accessed December 13, 2012.

11. Anesthesiologist assistants. ExploreHealthCareers.org. http://explore healthcareers.org/en/Career/135/Anesthesiologist_Assistants# Tab=Overview. Accessed December 13, 2012.

12. Decker F. Anesthesiologist assistant vs. anesthesiologist nurse. Chron. com. http://work.chron.com/anesthesiologist-assistant-vs-anesthe siologist-nurse-5973.html. Accessed December 13, 2012.

13. 2012 Compensation and Benefits Survey. American Association of Nurse Anesthetists. Park Ridge, IL: 2012.

14. Anesthesiologist assistant. Health Care Careers Directory. American Medical Association; 2009.

15. Fast facts. National Center for Education Statistics Website. http://www. nces.ed.gov/fastfacts/display.asp?id=76. Accessed February 18, 2013.

16. Accredited nurse anesthesia programs. Council of Accreditation Website. http://home.coa.us.com/accredited-programs/Pages/default.aspx. Accessed October 8, 2012.

17. Educational programs. The American Academy of Anesthesiologist Assistants Website http://anesthetist.org/education/. Accessed November 16, 2012.

18. American Association of Colleges of Nursing. AACN Position Statement on the Practice Doctorate in Nursing. http://www.aacn.nche. edu/publications/position/DNPpositionstatement.pdf. Published October 2004. Accessed November 16, 2012.

AUTHORS

Philip MacIntyre, CRNA, MSN, is a graduate of Western Carolina University's nurse anesthesia program in Asheville, North Carolina. He works for Asheville Anesthesia Associates as a staff anesthetist. Email: pcmacintyre@yahoo.com.

Bradley Stevens, CRNA, MSN, is a graduate of Western Carolina University's nurse anesthesia program in Asheville, North Carolina.

Shawn Collins, CRNA, DNP, PhD, is interim associate dean of the College of Health and Human Sciences and program director of Western Carolina University's Nurse Anesthesia Program, Asheville, North Carolina. Email: shawncollins@wcu.edu.

Ian Hewer, CRNA, MA, MSN, is an assistant professor at Western Carolina University, in Asheville, North Carolina. He works for Asheville Anesthesia Associates as a staff anesthetist.
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