Dexter Franklin, Epstein Richard H
Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, IA 52242, USA.
Anesth Analg. 2008 Feb;106(2):544-53, table of contents. doi: 10.1213/ane.0b013e31815efb18.
Institutional support to anesthesia groups for clinical care is very common, particularly when compensation for certified registered nurse anesthetists and anesthesiology residents is considered. Poor contracts can reduce incentives for good operating room (OR) management. We show that two types of agreements for institutional support are rational, and that alternatives to those models increase profit for either the hospital or anesthesia group at the expense of the other. For both agreements, costs are based on survey data, not actual costs. Terms in equations are not recalculated regularly, thereby preventing undesirable incentives such as the anesthesia group profiting from reduced OR workload. Support is not based on hours worked late, because such an agreement would ignore the underutilized OR time sustained by the group. The support would create a disincentive to decision-making that would reduce overutilized OR time such as decreasing turnovers and starting add-on cases expeditiously. For groups with uncommonly low net collections, group profit is higher if the hospital provides support expected to assure a reasonable (fair) income for the group to recruit and retain members. For what is likely the majority of groups, with average net collections per anesthesia hour exceeding the hospital's compensation per scheduled hour, expected profit is higher if institutional support is payment at a reasonable rate (fair market value) for the expected incremental hours of underutilized OR time (i.e., nonbillable idle time) caused by the specialty-specific staffing (i.e., OR allocations). Such an agreement creates incentives whereby the hospital and anesthesia group both profit from increased OR workload and from more accurate specialty-specific staffing.
机构对麻醉团队临床护理的支持非常普遍，尤其是在考虑对注册护士麻醉师和麻醉学住院医师的薪酬时。糟糕的合同会降低对手术室良好管理的激励。我们表明，两种类型的机构支持协议是合理的，而这些模式的替代方案会以牺牲另一方为代价增加医院或麻醉团队的利润。对于这两种协议，成本基于调查数据，而非实际成本。方程式中的条款不会定期重新计算，从而防止出现不良激励，例如麻醉团队因手术室工作量减少而获利。支持并非基于加班时长，因为这样的协议会忽视该团队持续存在的手术室时间未充分利用的情况。这种支持会对决策产生抑制作用，从而减少手术室时间的过度利用，比如减少周转次数并迅速启动追加病例。对于净收款异常低的团队，如果医院提供支持以确保该团队有合理（公平）的收入来招募和留住成员，团队利润会更高。对于可能占大多数的团队，即每麻醉小时的平均净收款超过医院每预定小时的薪酬，若机构支持是以合理费率（公平市场价值）支付因特定专科人员配置（即手术室分配）导致的预期未充分利用的手术室时间（即不可计费的闲置时间）的增量小时数，则预期利润会更高。这样的协议会产生激励机制，使医院和麻醉团队都能从手术室工作量增加以及更准确的特定专科人员配置中获利。
