CRNA total compensation rose 21.9 percent between 2021 and 2024. The care team ratio that made economic sense three years ago may not make sense today. Here is how to run the math on your specific case mix.
Key Takeaways
- CRNA total cash compensation rose 21.9 percent between 2021 and 2024, according to SullivanCotter. The ratio that was profitable at a 3:1 or 4:1 supervision model three years ago may not be profitable at today’s CRNA wages.
- The anesthesia care team model allows one anesthesiologist to medically direct up to four concurrent CRNA cases under TEFRA conditions. At a 1:4 ratio, the anesthesiologist and each CRNA each bill at 50 percent of the unit-based rate, so the combined revenue per case is roughly equal to one fully performed case.
- UnitedHealthcare announced a 15 percent payment reduction on QZ CRNA claims beginning October 2025, excluding eight states. Groups with significant QZ volume need to model the revenue impact before it hits.
- The economic sweet spot for a care team depends on your payer mix, case complexity, CRNA market wages in your region, and whether your hospital contract requires specific staffing levels. Model first, staff second.
The anesthesia care team model – one physician anesthesiologist directing two, three, or four CRNA cases simultaneously – has been the dominant delivery structure in U.S. hospital-based anesthesia for decades. It exists for good reasons: it allows a physician to apply specialist judgment across more procedures than any single provider could perform alone, and it creates an economic structure that can sustain 24-hour hospital coverage. But the economics of that model are not static. CRNA compensation has risen sharply: SullivanCotter’s 2024 Advanced Practice Provider Compensation Survey reported a 21.9 percent increase in CRNA total cash compensation between 2021 and 2024. An anesthesiologist-to-CRNA ratio that generated positive margin at 2021 wage levels may not generate it at today’s rates, particularly in markets where CRNA recruitment has driven sign-on bonuses and salary guarantees to levels that would have seemed implausible five years ago.
At the same time, payer behavior is shifting in ways that affect which staffing model makes financial sense. In mid-2025, UnitedHealthcare announced a 15 percent payment reduction on claims submitted with the QZ modifier – claims for CRNA services rendered without physician medical direction – effective October 2025, with an exclusion for eight states. That change alone requires any group with material QZ volume to rerun its staffing economics before the effective date. The question is not whether the care team model is the right model in principle. The question is what ratio your specific case mix, your payer contracts, and your local CRNA market support financially – and whether you have modeled it recently enough to know.
How the Payment Structure Works at Each Ratio
The foundation is the TEFRA regulatory framework at 42 CFR 415.110, which sets seven conditions an anesthesiologist must meet to bill for medically directed services. When all seven conditions are met for up to four concurrent CRNA cases, the anesthesiologist bills at 50 percent of the unit-based rate using modifier QK (two to four cases) or QY (one case), and the CRNA bills at 50 percent using modifier QX. The combined revenue per case totals 100 percent of the base-plus-time-unit calculation – the same as if the anesthesiologist had performed the case personally under modifier AA – but it is split between two providers.
At a 1:2 ratio, the anesthesiologist’s 50 percent collections from two cases equals one case worth of physician revenue, while paying two CRNAs. At 1:3, physician revenue equals 1.5 cases while covering three CRNA salaries. At 1:4, physician revenue equals two cases while covering four CRNAs. The ratio only becomes profitable when the incremental CRNA cost is less than the incremental revenue the additional case generates – and that breakeven point moves every time CRNA wages rise or payer rates shift.
The 1:4 care team model generates the revenue equivalent of two personally performed cases. Whether that justifies four CRNA salaries depends entirely on what those salaries cost in your market today.
The QZ Model: When It Works and When It Does Not
In states that have opted out of the federal physician supervision requirement for CRNAs – there are currently more than twenty such states – groups can bill QZ: CRNA services without physician medical direction, at 100 percent of the CRNA fee schedule rate. The QZ model has historically been attractive in rural and semi-rural markets where physician anesthesiologist recruitment is difficult and the economics of the care team model do not support a full-time physician presence.
The UnitedHealthcare rate reduction on QZ services announced for October 2025 is the first major commercial payer action to formally differentiate between medically directed and non-directed CRNA claims in terms of payment. Whether other large commercial payers follow is uncertain, but it is a signal groups should take seriously. Any group with a material share of QZ billing – and any group considering a transition toward a CRNA-led model in a supervision-optional state – needs a payer-by-payer revenue model that accounts for the possibility that QZ rates erode further.
Building the Staffing Model From Your Own Numbers
The analysis your group needs starts with four inputs, all of which you own:
- Case volume by service line. Total annual cases, broken out by specialty (general surgery, orthopedics, OB, cardiac, neuro). Case complexity varies by line, which affects average base units and time units per case, which drives revenue per case.
- Realized revenue per case by payer. Not contracted rates – actual collections net of adjustment and denial write-off, by payer class. Your commercial cases, your Medicare cases, and any Medicaid volume need to be modeled separately because their unit values differ.
- CRNA total compensation at current market rates. Salary, benefits, malpractice, and any recruitment costs, annualized. Use the rate at which you are currently hiring, not what your tenured CRNAs are paid, because the marginal cost of adding capacity is what determines whether expansion is profitable.
- Physician anesthesiologist opportunity cost at each ratio. An anesthesiologist directing four rooms cannot also be generating personally performed revenue in a fifth. The model needs to account for what the physician is not doing while directing.
Run the model at 1:2, 1:3, and 1:4 ratios using your actual case distribution and wage inputs. The ratio that produces the highest net revenue per physician FTE is your target structure for the case mix you currently have. That target may be different for different service lines – a high-volume, routine orthopedic schedule may support 1:4 comfortably, while a cardiac surgery line with long, complex cases may only support 1:2 without jeopardizing the conditions required for medical direction.
Transition Complexity and the Seven TEFRA Conditions
The TEFRA conditions at 42 CFR 415.110 are not aspirational – they are the legal predicate for billing at the medically directed rate. They require, among other things, that the anesthesiologist perform the pre-anesthetic examination, be present for induction and emergence, be immediately available to each directed case throughout, and not leave the facility or direct more than four cases simultaneously. Groups that operate at 1:4 ratios in facilities where case start times are unpredictable, where simultaneous inductions are common, or where the physician must also cover obstetric emergencies should audit their documentation against all seven conditions before the next payer audit does it for them. A single condition that cannot be documented across a case turns a 50 percent QK claim into a potential overpayment. The compliance exposure at scale is significant, and it is an area where counsel should review the billing policies and the documentation templates in use.
From the Field
A seven-anesthesiologist group in the Southeast had been operating at a standard 1:3 care team ratio across all service lines for several years. As CRNA wages increased, the group’s net physician distributions had compressed, and two partners were discussing whether to reduce to a 1:2 ratio to cut CRNA headcount. Before making that decision, our engagement modeled the contribution margin at each ratio using the group’s actual case mix and current CRNA compensation. The analysis showed the group’s high-volume general surgery and GI endoscopy lines supported 1:4 comfortably at current CRNA wages, while the cardiac and neurosurgery lines – which ran long and required closer supervision – were already straining the 1:3 model. The answer was not a single ratio change; it was a service-line-specific staffing schedule. The fractional COO worked with the group’s administrator and the OR scheduling team to build the new template, retrain the schedule coordinators on the assignment rules, and track contribution margin by line through the first two quarters. Physician distributions recovered without reducing CRNA headcount, and the group kept its full capacity for the cardiac program.
Advice Versus Execution in a Staffing Redesign
A staffing model is a spreadsheet. Any consultant with your data and a few hours can build it, and if your group has an administrator who can translate the output into a new scheduling protocol, that may be the right scope. Consulting in this situation is often the more economical choice, and there is no reason to pay for more engagement than the problem requires.
Where groups lose value is in implementation: the schedule template that reflects the model on paper but does not account for how the charge nurses actually assign rooms, the CRNA assignment policies that exist in the model but not in any written document the staff has seen, and the monthly review that was supposed to track contribution by service line but never got set up because the administrator was managing three other projects. A fractional executive builds the model and then sits with the scheduler and the administrator through the first two scheduling cycles, rebuilding the template in the system the OR actually uses, installing the tracking report, and running the first few monthly reviews until the group is confident the numbers are moving the right direction. Whether that level of engagement is worth the cost depends on how much the current ratio is costing you and how much bandwidth your administrator actually has. Both are questions worth answering before you commit to a structure.
Sources
- Stout, The Anesthesiologist and CRNA Staffing Market — https://www.stout.com/en/insights/industry-update/anesthesiologist-crna-staffing-market
- 42 CFR 415.110 – Conditions for payment: Medically directed anesthesia services (TEFRA rules) — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-415/subpart-C/section-415.110
- Coronis Health, Practice Economics in Anesthesiology: A Framework for Optimization (Fall 2025) — https://www.coronishealth.com/blog/communique-fall-25-practice-economics-anesthesiology
- CMS, CY 2026 Physician Fee Schedule Final Rule – Anesthesia Conversion Factor ($20.4976) — https://www.cms.gov/medicare/payment/fee-schedules/physician/anesthesiologists-center
More in the Anesthesiology Series
- Negotiating the Hospital Stipend with Data — how to build the cost-gap analysis that supports a defensible stipend request.
- Anesthesia Billing: Base Units, Time Units, and the Modifiers That Matter — the billing mechanics that determine whether your group collects what it earned.
- Anesthesia Payer Contracting and the No Surprises Act IDR Process — how to negotiate commercial rates and use the IDR process when payers refuse to move.
- Anesthesia Group Governance: Buy-In, Distributions, and Succession — the governance decisions that determine whether your group survives a partner transition intact.