Just got this in my email about California Opt-out

SDN Members don't see this ad. (About Ads)

http://www.anesthesiologynews.com//P...a+Opt-out+Case

Yeah, the field of anesthesiology is pretty much screwed.

When bidding wars between physician groups and CRNA groups for hospital contracts become more commonplace (and this will undoubtedly happen), the result will not be satisfactory for anesthesiologists. Think about it: the average RN with some experience likely earns approximately $75,000 per year. If you're an RN contemplating the possibility of more education to boost your career prospects, what financial threshold would justify the additional training? $30,000 more per year? $50,000? What if you could DOUBLE your income?

I would argue that the prospect of $150,000 annual salary is a huge incentive for nurses these days to pursue additional training. The vast majority of them would be on cloud nine if they earned a salary of $150,000 after two years of additional training (e.g., CRNA school).

Now, contrast this situation with medical school graduates. The average physician earns approximately $200,000 per year. The average anesthesiologist these days earns over $300,000 per year. I suspect that the vast majority of current anesthesiology residents are expecting a similar compensation down the road.

There is a big discrepancy in career expectations between CRNAs and anesthesiologists. This difference will be a huge problem for anesthesiologists. When CRNA groups and anesthesiology groups start to compete for exclusive hospital contracts, I imagine the compensation benchmark dropping significantly--I wouldn't be surprised if the salary guarantees drop to $150,000 per year, eliminating all hospital stipends for anesthesia services. Hell, even if it dropped to $125,000 per year, it's still a financial windfall for nurses who become CRNAs.

Who do you think would be happy making $150,000 per year: the college grad who quits a job that pays $75,000 in order to pursue a masters degree? Or the college grad who goes through 4 years of medical school, one year of internship, and 3 years of residency?

This field is truly f**ked. Anyone that thinks otherwise is either a moron or completely out of touch with the political agenda that the AANA is successfully pushing through state legislatures nationwide.

Welcome to the brave new world! The practice of anesthesia will be the practice of nursing, not medicine.

Originally Posted by EtherBunny

Yeah, the field of anesthesiology is pretty much screwed.

When bidding wars between physician groups and CRNA groups for hospital contracts become more commonplace (and this will undoubtedly happen), the result will not be satisfactory for anesthesiologists. Think about it: the average RN with some experience likely earns approximately $75,000 per year. If you're an RN contemplating the possibility of more education to boost your career prospects, what financial threshold would justify the additional training? $30,000 more per year? $50,000? What if you could DOUBLE your income?

I would argue that the prospect of $150,000 annual salary is a huge incentive for nurses these days to pursue additional training. The vast majority of them would be on cloud nine if they earned a salary of $150,000 after two years of additional training (e.g., CRNA school).

Now, contrast this situation with medical school graduates. The average physician earns approximately $200,000 per year. The average anesthesiologist these days earns over $300,000 per year. I suspect that the vast majority of current anesthesiology residents are expecting a similar compensation down the road.

There is a big discrepancy in career expectations between CRNAs and anesthesiologists. This difference will be a huge problem for anesthesiologists. When CRNA groups and anesthesiology groups start to compete for exclusive hospital contracts, I imagine the compensation benchmark dropping significantly--I wouldn't be surprised if the salary guarantees drop to $150,000 per year, eliminating all hospital stipends for anesthesia services. Hell, even if it dropped to $125,000 per year, it's still a financial windfall for nurses who become CRNAs.

Who do you think would be happy making $150,000 per year: the college grad who quits a job that pays $75,000 in order to pursue a masters degree? Or the college grad who goes through 4 years of medical school, one year of internship, and 3 years of residency?

This field is truly f**ked. Anyone that thinks otherwise is either a moron or completely out of touch with the political agenda that the AANA is successfully pushing through state legislatures nationwide.

Welcome to the brave new world! The practice of anesthesia will be the practice of nursing, not medicine.

Look nurses can lobby all they want, the politicians can legislate all they want but we as MDs do one one recourse and that is to: STOP TRAINING THEM! It's not too late, the sooner we realize this, the better off this specialty (and our patients) will be in the future.

Originally Posted by EtherBunny

Yeah, the field of anesthesiology is pretty much screwed.

When bidding wars between physician groups and CRNA groups for hospital contracts become more commonplace (and this will undoubtedly happen), the result will not be satisfactory for anesthesiologists. Think about it: the average RN with some experience likely earns approximately $75,000 per year. If you're an RN contemplating the possibility of more education to boost your career prospects, what financial threshold would justify the additional training? $30,000 more per year? $50,000? What if you could DOUBLE your income?

I would argue that the prospect of $150,000 annual salary is a huge incentive for nurses these days to pursue additional training. The vast majority of them would be on cloud nine if they earned a salary of $150,000 after two years of additional training (e.g., CRNA school).

Now, contrast this situation with medical school graduates. The average physician earns approximately $200,000 per year. The average anesthesiologist these days earns over $300,000 per year. I suspect that the vast majority of current anesthesiology residents are expecting a similar compensation down the road.

There is a big discrepancy in career expectations between CRNAs and anesthesiologists. This difference will be a huge problem for anesthesiologists. When CRNA groups and anesthesiology groups start to compete for exclusive hospital contracts, I imagine the compensation benchmark dropping significantly--I wouldn't be surprised if the salary guarantees drop to $150,000 per year, eliminating all hospital stipends for anesthesia services. Hell, even if it dropped to $125,000 per year, it's still a financial windfall for nurses who become CRNAs.

Who do you think would be happy making $150,000 per year: the college gronad who quits a job that pays $75,000 in order to pursue a masters degree? Or the college grad who goes through 4 years of medical school, year of internship, and 3 years of residency?

This field is truly f**ked. Anyone that thinks otherwise is either a moron or completely out of touch with the political agenda that the AANA is successfully pushing through state legislatures nationwide.

Welcome to the brave new world! The practice of anesthesia will be the practice of nursing, not medicine.

scMark weiss JD is a sharp dude. I consulted himm 10 years ago for my first contract out of residency. He knows a whole lot, and if he says were screwed. We're screwed!!
I like 8 minutes into it he states it used to be hospitals were all about bd certified anesthesiologists.. now they are reconsidering that stance. They are looking at crnas hard!!

"Mark weiss JD is a sharp dude. I consulted himm 10 years ago for my first contract out of residency. He knows a whole lot, and if he says were screwed. We're screwed!!"

Let me ask you this, do you think Mark Weiss will permit himself or his family member to be anesthetized by an unsupervised CRNA? ...I do not.

I think Weiss is wrong. I do not believe ultimately it will be found that Nursing Boards are the final arbiters of what is to be their scope of practice. IMHO it will be found that the Nursing Board imprimatur may be necessary, but it is not sufficient to determine the nurses scope of practice.

there will be a supervising anesthesiologist. Lets just say 1 for every 15 crna...
we're so f!@#$%^ed

the more interesting and telling bits (having not listened to the entire segment) are around six minutes, in which the discussant notes that these scope of practice issues will extend to other physician specialties, in that anesthesiologists are, to use their words, the canaries in the coal mines. i do believe this is true.

each of us has a responsibility to view the care that we provide as something more than a commodity. if the hospital administrators look at anesthesia service providers as equal from a quality standpoint, they will opt for providers with the lowest costs. the solution, then, from our perspective, must come from providing superior QUALITY and SERVICE in measurable ways--if not in a randomized trial, in palpable ways at the local level the everyone can see and feel. this means efficiency, quality, a responsibility to stay current with literature and to evaluate one's practice from a system-based approach, extension of service outside of the operating room (ICU, perioperative management). multiple state legislatures agree--we really can no longer sit on our stools to justify our compensation. the one thing nurses will never have that we should is professionalism and true dedication to our patients. it's what should set doctors apart from nurses (in general...there are certainly dedicated and professional nurses, but they all are used to punching in and punching out).


***edit: i see, after having listened to the rest of this, that mr. weiss goes into great detail on the topic of commoditization...

For the many hospitals that don't offer a subsidy, there should be little incentive to have solo crnas other than inability to recruit MDs.
It's important to support strong anti-kickback laws to avoid having hospitals and surgeons get income from anesthesia billing. That's the greatest threat to our specialty. That's where a bidding war would start that would **** us all. That should be a focus of the asapac and other hospital-based specialty pacs.

my question as someone interested in going into AA is this. Is there a correlation between the fact that is most of the Western states seems have opt-out policies and that these same states at the same time don't recognize AA?

Originally Posted by zoner

my question as someone interested in going into AA is this. Is there a correlation between the fact that is most of the Western states seems have opt-out policies and that these same states at the same time don't recognize AA?

the correlation is the power of the AANA lobby in those states. in theory, they should ALL approve AA practice when there is such a huge need for more providers in the state.

If MDs and CRNAs make the same amount of $$$, the hospital is going to choose the MD, so i dont think thats where the future of anesthesia is (disclosure -- I'm not an anesthesiologist).

The way I see it playing out is that MDs will NOT suddenly make 100k per year. Instead, what will happen is that hospitals wont hire MDs for "routine" anesthesia services anymore, they will hire them ONLY as leadership of the anesthesia group which is stocked 100% by CRNAs. So instead of hiring 10 MDs in a given 10 year period, they'll only hire 1. They'll have 3-4 MDs who rotate backup/supervision coverage for a fleet of CRNAs who actually provide the gas.

MDAs will still make 350k per year -- but the total number of jobs available to them is going to plummet.

Originally Posted by Socrates25

If MDs and CRNAs make the same amount of $$$, the hospital is going to choose the MD, so i dont think thats where the future of anesthesia is (disclosure -- I'm not an anesthesiologist).

The way I see it playing out is that MDs will NOT suddenly make 100k per year. Instead, what will happen is that hospitals wont hire MDs for "routine" anesthesia services anymore, they will hire them ONLY as leadership of the anesthesia group which is stocked 100% by CRNAs. So instead of hiring 10 MDs in a given 10 year period, they'll only hire 1. They'll have 3-4 MDs who rotate backup/supervision coverage for a fleet of CRNAs who actually provide the gas.

MDAs will still make 350k per year -- but the total number of jobs available to them is going to plummet.

Complex cases will increase the number of MDs somewhat, the rich and famous will also get MDs more often, but in general you are probably right.

Originally Posted by Socrates25

If MDs and CRNAs make the same amount of $$$, the hospital is going to choose the MD, so i dont think thats where the future of anesthesia is (disclosure -- I'm not an anesthesiologist).

The way I see it playing out is that MDs will NOT suddenly make 100k per year. Instead, what will happen is that hospitals wont hire MDs for "routine" anesthesia services anymore, they will hire them ONLY as leadership of the anesthesia group which is stocked 100% by CRNAs. So instead of hiring 10 MDs in a given 10 year period, they'll only hire 1. They'll have 3-4 MDs who rotate backup/supervision coverage for a fleet of CRNAs who actually provide the gas.

MDAs will still make 350k per year -- but the total number of jobs available to them is going to plummet.

Complex cases will increase the number of MDs somewhat, the rich and famous will also get MDs more often, but in general you are probably right.

The question is, what the hell are the extra MDs supposed to do? Hopefully the change will be gradual enough not to ruin everyone's lives/careers and the changing ratio will occur through retirement rather than unemployment. Ideally the change in MDs won't be so significant that there is an excess in practice, but it's hard to predict. Med students should really think twice about entering anesthesiology right now.

Originally Posted by Socrates25

If MDs and CRNAs make the same amount of $$$, the hospital is going to choose the MD, so i dont think thats where the future of anesthesia is (disclosure -- I'm not an anesthesiologist).

The way I see it playing out is that MDs will NOT suddenly make 100k per year. Instead, what will happen is that hospitals wont hire MDs for "routine" anesthesia services anymore, they will hire them ONLY as leadership of the anesthesia group which is stocked 100% by CRNAs. So instead of hiring 10 MDs in a given 10 year period, they'll only hire 1. They'll have 3-4 MDs who rotate backup/supervision coverage for a fleet of CRNAs who actually provide the gas.

MDAs will still make 350k per year -- but the total number of jobs available to them is going to plummet.

That doesn't make any sense. Increased competition among prospective employees for a particular job inevitably results in lower salary offers for that job. It's the basic economic principle of supply and demand. If suddenly 10 physicians are competing for one position as opposed to 2 physicians for the same spot, obviously the former scenario will result in a job with less pay. This is exactly why highly desirable cities such as San Francisco or San Diego, generally have terrible pay for doctors, when compared to other areas of the country (e.g., Kansas).

There are so many red flags right now that the economic future of anesthesiology is in dire straits: the increasing number of opt-out states despite the best efforts of the ASA to reverse the trend (e.g., the failed appeal in California); the fact that Medicare pays anesthesiologists roughly 1/3 to 1/2 the amount it pays to physicians in other specialties for the same amount of work; the gradual implementation of Obamacare, which will make the Medicare fee schedule more prevalent by insuring 40 million people and putting more pressure on private insurers to emulate Medicare; the lack of any compelling data as a counterpoint to the AANA narrative that "CRNAs and anesthesiologists are interchangeable"; the mounting emphasis on "cost-containment," especially among lawmakers and hospital administrators; the rising tide of accountable care organizations; the increasing power and market share of hospitals, as they systematically buy surrounding practices and hire doctors as employees; the of anesthesiology with the the simmering hatred on Main Street of "the 1%"; the fact that patients (and many doctors, for that matter) have no idea what an anesthesiologist actually does, and therefore the real value of anesthesiologists in patient care is elusive; the fact that anesthesiologist salaries are by and large SUBSIDIZED by hospitals that are struggling to cope with the trend of decreasing revenue... and the list goes on and on.

Fewer jobs, more competition, dramatically less pay, and less respect. That's the future, guys and gals. I hate to say it, but this field is in serious trouble. It may be a few years, maybe a decade, but there are some really bad things on the horizon.

Medical student here who can't really see myself doing any field outside of anesthesiology. I feel like I have been reading these "we are doomed" threads since I was an MS1 and there doesn't seem to be any concrete evidence to say that anything is actually happening. Any attending (yes I know they are in academics) I talk to says that for a qualified anesthesiologist who is willing to actually work for their money, jobs are there. I don't think the midlevel scare in anesthesia is anymore scary than that seen in many other fields where NPs are essentially running clinics. Will a fellowship trained anesthesiologist really have difficulty getting a job?

Originally Posted by Dawkter

Medical student here who can't really see myself doing any field outside of anesthesiology. I feel like I have been reading these "we are doomed" threads since I was an MS1 and there doesn't seem to be any concrete evidence to say that anything is actually happening. Any attending (yes I know they are in academics) I talk to says that for a qualified anesthesiologist who is willing to actually work for their money, jobs are there. I don't think the midlevel scare in anesthesia is anymore scary than that seen in many other fields where NPs are essentially running clinics. Will a fellowship trained anesthesiologist really have difficulty getting a job?

I'm starting my intern year in a month and I still feel confident at this point that a lot of the scare is mostly hype, especially if you're willing to work in the heartland or rural southeast. At the same time, I'm still hedging with the intention of doing a CCM fellowship after residency....

Originally Posted by Dawkter

I don't think the midlevel scare in anesthesia is anymore scary than that seen in many other fields where NPs are essentially running clinics. Will a fellowship trained anesthesiologist really have difficulty getting a job?

What you have to understand about NPs running primary care clinics is that in order to do so, they have to lay out a substantial investment (just like an MD does) in order to start that clinic. Thats why even with rules in some states saying that NPs can open their own clinics, very few choose to do so because its a very risky business venture. About 10 years ago New Mexico created a new state rule allowing NPs to operate clinics independently. Guess how many NP-run clinics there are now? Just one.

On the other hand, thats not needed for anesthesiology to the same degree. Its much easier for CRNAs to walk into an existing position at a hospital that was previously covered by an MD and take it from them, maybe not directly, but via attrition.

Originally Posted by Socrates25

What you have to understand about NPs running primary care clinics is that in order to do so, they have to lay out a substantial investment (just like an MD does) in order to start that clinic. Thats why even with rules in some states saying that NPs can open their own clinics, very few choose to do so because its a very risky business venture. About 10 years ago New Mexico created a new state rule allowing NPs to operate clinics independently. Guess how many NP-run clinics there are now? Just one.

On the other hand, thats not needed for anesthesiology to the same degree. Its much easier for CRNAs to walk into an existing position at a hospital that was previously covered by an MD and take it from them, maybe not directly, but via attrition.

A several years ago, I had a NP that told me that I needed to be treated for TB because of my skin test. If I didn't seek a MD advice, I would probably have been on that damn treatment for a year!

I will never go to NP again!

Originally Posted by Dawkter

Will a fellowship trained anesthesiologist really have difficulty getting a job?

This is a shame that you even have to ask this question. If your field is to the point where a fellowship is required just to get an "entry level" position in that field, then you have a problem.

Originally Posted by vector2

At the same time, I'm still hedging with the intention of doing a CCM fellowship after residency....

I take it you've heard that an MD at the Vanderbilt CCM fellowship program has just recently proposed starting a new "fellowship" for NPs/CRNAs for critical care medicine?

Apparently not even the fellowship fields are safe now. Its particularly outrageous that one of your own is the one who is spearheading this program.

Originally Posted by Socrates25

This is a shame that you even have to ask this question. If your field is to the point where a fellowship is required just to get an "entry level" position in that field, then you have a problem.

Isn't that what radiology has been for years now?

Of all the economic worries I obsess over, my employability circa 2025 isn't really one of them.

Originally Posted by Dawkter

Medical student here who can't really see myself doing any field outside of anesthesiology. I feel like I have been reading these "we are doomed" threads since I was an MS1 and there doesn't seem to be any concrete evidence to say that anything is actually happening. Any attending (yes I know they are in academics) I talk to says that for a qualified anesthesiologist who is willing to actually work for their money, jobs are there. I don't think the midlevel scare in anesthesia is anymore scary than that seen in many other fields where NPs are essentially running clinics. Will a fellowship trained anesthesiologist really have difficulty getting a job?

This.

Best advice one can get: don't go into a field of medicine for the money,etc... go into it because that is what you really want to do. POD, JPP, etc exemplify this attribute. Does that mean that one should just blindly go about their business, unaware of what's happening politically? No. I am a member of the ASA and I donate to the ASAPAC... I plan on fighting the good fight, but I'm not going to let the idea of falling wages "scare" me off from what I want to do.

But I'm just a naive (2nd) year med student... so take my views with a grain of salt...

</rant>

Originally Posted by Socrates25

I take it you've heard that an MD at the Vanderbilt CCM fellowship program has just recently proposed starting a new "fellowship" for NPs/CRNAs for critical care medicine?

Apparently not even the fellowship fields are safe now. Its particularly outrageous that one of your own is the one who is spearheading this program.

Even still, CCM has quite a ways to go before reaching the degree of midlevel competition that's currently facing OR anesthesia.

It just sucks to see this happening.

I loved anesthesiology like nothing else on rotations - got there early, stayed late, loved doing it. Tons of fun. Didn't even care that there was so much talk of salaries going down in the future - I'd be doing something I enjoyed. Then it became obvious that the chances of landing a job as an anesthesiologist in the future seemed to be declining. I don't need big money, but I do need a job. I realized that I liked some IM subspecialties almost as much and, well...I'm most likely going IM at this point.

Still, it sucks to see an essential and important specialty get decimated like this.

Seriously guys, the sky is not falling... even after all these years how MDs are actually being replaced by nurses in these opt out states?? The MDs in California will step up their game and unfortunately yes do so with less compensation in the future. But when the cost pressures become negligible MDs will always >>> nurses, as we are a superior product and our patients (when educated) will demand it. We will be ok.

Join the ASA, state chapter, donate to the ASAPAC, hire AAs, and STOP TRAINING NURSES!

For the "doom and gloom" people on this forum have you worked with new CRNA graduates...and if not go find one to work with, it will make you feel better. Will every state likely become an opt-out state...I think so. Will every state pass AA licensure laws...I think so. Will we be supervising more midlevels...yes. If you look at the new surgical procedures that are developed every year the vast majority are less invasive and this trend will continue to increase the need for sedations or non-complex anesthetics which we will have to likely supervise. But any hospital with any kind of complexity to its surgical volume will continue to require anesthesiologist. Like I have stated several times on this forum, I live in a opt-out state and have not noticed a decrease in job quality. New anesthesiologist grads are still making great money and all have found a job.

Hire AA's...they function the same way a CRNA does in a ACT practice and they don't bring all the annoying baggage with them

Yawn.... same old, same old.

The solution is soo simple. But most anesthesiologists are just too lazy to give a damn.

Just look at the ASA-PAC donor list for your state. Bet you can count the number of your attendings/colleagues on one hand. As for residents who donate the minimum $20 a year, is that what your specialty is worth to you??

Let's all just continue to bitch and moan on the internet while the CRNAs you supervise plot behind your back.

Originally Posted by Robert Loblaw

superior QUALITY and SERVICE in measurable ways--if not in a randomized trial, in palpable ways

Perform fellatio on the gay hospital administrator. Not only is that a measurable demonstration of one's worth it is also PALPABLE.

Originally Posted by vector2

I'm starting my intern year in a month and I still feel confident at this point that a lot of the scare is mostly hype, especially if you're willing to work in the heartland or rural southeast. At the same time, I'm still hedging with the intention of doing a CCM fellowship after residency....

Continue to think this way!!! stick your head further in the sand. And do a fellowship in something that we do almost none of that will insulate you from the problem

Or pull your head out of the sand and take a look at the change going on around you and attempt evolve your or your groups practice as needed

Originally Posted by Stank811

Or pull your head out of the sand and take a look at the change going on around you and attempt evolve your or your groups practice as needed

how are you guys ever going to change it? just by pushing for AA? what about all the CRNAS that are already there and continuously being mass produced in ever abundance? What is the system going to do with them?

Use them in an ACT capacity like they are currently used

Originally Posted by Stank811

Use them in an ACT capacity like they are currently used

if that's the case, what's the use of AA or are you guys really not concerned about AA after all?

I am not concerned about either group but options are never a bad thing to have

Originally Posted by Stank811

I am not concerned about either group but options are never a bad thing to have

so does that mean that for you, AA is just another option to use against CRNA and not for any ethical or superior quality concern?

Originally Posted by zoner

so does that mean that for you, AA is just another option to use against CRNA and not for any ethical or superior quality concern?

for someone considering becoming an AA you seem to use a lot of the nurses arguments against it.

an RT is EASILY just as qualified as an ICU nurse to get a masters in gas and deliver a simple anesthetic

the reason ANYONE outside of MDs deliver anesthesia is there is nowhere near enough providers to deliver anesthetics at the clip patients require it.

Originally Posted by darby11

Continue to think this way!!! stick your head further in the sand. And do a fellowship in something that we do almost none of that will insulate you from the problem

The fact that "we do almost none of" is exactly why I would put down money on my thinking being less shortsighted than yours. I've rotated in places where experienced CRNAs are sitting in hearts and peds rooms. I'm not particularly interested in pain even though they might have a burgeoning mid-level problem. CCM (I guess like pain) is in the infancy of being encroached by midlevel 'fellows', but it is also the field that will be key to whatever perioperative surgical home concept takes off in the future when reimbursement modalities change.

How should one be hedging against the future? Just throw more money at ASA and ASAPAC?

My hospital is private but does support an anesthesiology resdency. We do have CRNAs. There are a couple of things that make me not terribly concerned.
MOST of our anesthesiologists are not chair sitters. We have a active and respected acute pain service. We have a very busy peripheral nerve block service, including lots of catheters, that our surgeons LOVE. We assist in the patient's management well beyond the time of surgery.

We have a busy, almost exclusively procedural pain clinic.

Our CRNAs don't take part in any of these services. Some are a little bitter about it, but they know things are not going to change.
Our surgeons would NOT allow CRNA only anesthesia service. There is a huge difference between anesthesia robots (MDs OR CRNAs) who put people to sleep, wake them up, and go home, and DOCTORs of anesthesiology who provide full service peri-operative, (as well as non-surgical) patient management. Make yourself valuable. If your job is: induce-intubate-emerge-go home, then you definitely ARE replaceable.