In 2023, the Bexar County Hospital District Board of Managers, which provides governance and oversight for University Health, the public health and hospital system for Bexar County, Texas, directed University Health President/CEO Edward Banos to address the impact of the growing nationwide shortage of anesthesia providers. Their decision was based on a bold and innovative strategy of implementing a delegation of privileges (DOP) model for Certified Registered Nurse Anesthetists (CRNAs). University Health already employed CRNAs throughout their facilities through University Medicine Associates, its nonprofit primary care and multi-specialty provider group practice. The organization recognized this strategy would allow them to maximize cost savings and efficiency while using CRNAs to their full capabilities. The DOP model can enhance team efficiency and build provider capabilities through the authorization given to CRNAs by a specialist such as a surgeon or endoscopist instead of an anesthesiologist. This has had an immediate fiscal impact in two of their busiest areas, the Advanced Diagnostic Center at University Hospital and the ambulatory surgery center (ASC) University Health operates at the UT Health San Antonio Medical Arts and Research Center (MARC).
University Hospital is one of two adult Level I trauma centers in South Texas, and the only pediatric Level I trauma center in the region. It was recently named one of the nation’s 100 Top Hospitals, while the newly built University Health Women’s and Children’s Hospital is ranked a top national maternity hospital by Newsweek. University Health is expanding its health care footprint north and south across Bexar County by building two community hospitals while continuing to provide world class, fiscally responsible health care. If the current proposed budget cuts to Medicaid are passed every dollar spent on health care will need to provide increased value. University Medical Associates is leading the way in maximizing anesthesia dollars for outpatient surgery.
Until 2023, University Health’s ASC at the MARC used an anesthesia staffing model of 2 physicians and 6 CRNAs to staff four operating rooms and two GI suites (a 3:1 ratio). This older model followed the status quo for San Antonio with an anesthesiologist supervising 3 CRNAs. This was not only costly, it also did not translate to increased patient care, productivity or efficiency. The current DOP model utilizes a medical director performing anesthetic preoperative assessments up to 3 days before surgery and 8 CRNA’s practicing under delegation of privileges, staffing an increased caseload of ASA classification patients I-III. The medical director does not perform anesthesia—the CRNAs provide all anesthesia under the delegation of the surgeon or endoscopist. This model allows the medical director to focus on strategic goals while significantly decreasing cancellations through early identification of any issues which may cause a costly same day cancellation. CRNAs perform anesthetic preoperative evaluations (that were added or unable to be completed by the medical director), OR case management, and perform peripheral nerve blocks for select cases. All anesthetics for surgical and GI procedures are performed by CRNAs. The delegation of privileges model allows University Medicine Associates to deliver increased productivity at a lower cost. The cost savings of eliminating two supervising anesthesiologist salaries and adding two direct patient care CRNA salaries is substantial. Further review of productivity at the MARC for equivalent periods of time under the different models identified an increase of 13% over the last 2 quarters of 2023 and 2024. Some of the key components that led to the increase in productivity and revenue are the elimination of costly unnecessary anesthesiologist supervision, the utilization of CRNAs to their full legal practice authority and a culture of teamwork between surgeons, the medical director, the CRNAs, and ancillary staff. For example, a review of Post-anesthesia Care Unit (PACU) pain medication administration since February 2025 shows patients who received peripheral nerve blocks performed by the CRNAs for orthopedic surgeries, decreased to less than 10%. This translates to increased productivity, more patient throughput due to shorter PACU lengths of stay, additional and unrealized revenue from increased Exparel use, and higher patient and surgeon satisfaction as shown through internal surveys. The decreased turnovers and greater efficiency have led to positive survey feedback from orthopedic surgeons like, “I could have never done these cases as well and as fast anywhere else in the city.” All these factors contribute to an already strong team culture, and the CRNAs working in these areas feel utilized to their fullest potential. This in turn increases the desire of CRNAs nationwide to work for University Medicine Associates and helps University Health address the ongoing anesthesia shortage.
By focusing on direct anesthesia delivery by the delegation of privileges model, University Medicine Associates has increased productivity at a lower cost while providing the same world-class patient care it is known for. This novel-to-San Antonio anesthesia delivery model demonstrates how University Medical Associates and University Health will continue to lead San Antonio and Bexar County in health care.
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