Comment to CMS about CRNAs doing pain

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painstop

Pain Attending
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This was buried in a few threads so I just wanted to make it its own thread to put it at the top. Here is the link to let CMS know your thoughts about the proposal to have CRNAs be reimbursed for performing interventional pain procedures. Protect your field!

http://www.regulations.gov/#!submitComment;D=CMS-2012-0083-0001

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I posted a comment:

As a physician and future interventional pain fellow, I think the proposed CMS rule, in which the fee schedules for CRNAs who perform interventional pain procedures are equivalent to the fee schedules for board certified pain physicians, is misguided and dangerous.

It represents yet another attempt by the AANA propaganda machine to minimize and distort profound differences between nurses and physicians with respect to overall scope and depth of training--differences that are absolutely pertinent to competency in the field of interventional pain medicine. A board certified pain physician completes 4 years of undergrad, 4 years of medical school, 1 year of internship, 2-3 years of residency, and 1 year of fellowship. The primary focus of a physician's education is to be an expert in the diagnosis and treatment of disease. In addition, a board certified pain physician must undergo a very rigorous certification process to PROVE competency, including approximately 52 hours worth of written and practical examinations (USMLE Step 1, USMLE Step 2 CK, USMLE Step 2 CS, USMLE Step 3, specialty board examination, and the pain board examination) and 2 oral examinations.

The required training and certification process for CRNAs who elect to do interventional pain procedures isn't even remotely comparable. The focus of the training is different (nurses don't receive extensive training in diagnosis and treatment of disease because they typically have a different role in patient care). The length of the training is different (12 years vs. 6 years). The certification process is different ( nurses only take the NCLEX and CRNA certification exams). There is no pain fellowship for CRNAs.

Given these obvious differences, it is ridiculous to think that a CRNA is as qualified as a board certified pain physician to practice interventional pain medicine. The fee schedules should reflect these obvious differences.
 
Nice comment. Here is the comment I sent. I focus more on the safety aspect of the procedures that we do since there are already a lot of PA/NPs that help out in the pain clinic and don't want to imply that no one but a physician can work in a pain clinic. The decision on the procedures and the procedures themselves should be performed by the physican.Even if a CRNA gets paid 10% of what an MD makes, it's still not SAFE (although I'm sure they will come out with some BS study to refute me).

I am commenting on the proposal to have CRNAs be reimbursed for interventional pain procedures. I strongly disagree with this proposal. Interventional Pain is the practice of Medicine and Surgery. The procedures themselves require an advanced level of knowledge regarding evaluating MRI images and other objective data and corresponding them to the patient examination. Even after becoming board certified in Anesthesiology, it was not until I completed a Pain Fellowship that I finally started to understand all the anatomical variations in the sacral/lumbar/thoracic/cervical spine. These procedures (particularly cervical procedures) are extremely risky and must only be performed after proper training because catastrophic events (stroke,paralysis,seizure,MI,death) have occured in these areas by even well-trained physicians...the risk to the population by less trained midlevels is unacceptable in my mind. I understand access to care is always a consideration but when it comes to these procedures, I do not feel the access issue justifies the risk. Part of my training was also understanding complications and the appropriate time to consult a back surgeon. I fear many unnecessary procedures will be performed, which will cost more money in the long run and put more patients at unnecessary risk. The level of complexity of this field has advanced greatly over the past 25 years. Even if CRNAs can perform labor epidurals in some states without physician supervision, the inference that CRNAs can therefore perform epidurals for chronic pain cannot be made. There are variations in the type of epidurals that we do based on the imaging that do not mimic a simple lumbar interlaminar epidural placed on a parturient. In addition, we perform neurolytic procedures in the neuraxis and in the periphery and surgeries on the spine which can have a lot of morbidity issues if improperly performed (dorsal column stimulator implants, intrathecal pump implants, vertebral augmentation).
 
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This crap is UNBELIEVABLE:

http://www.protectmypaincare.com/site/action



Ensure Patient Access to Pain Care
*
The American Association of Nurse Anesthetists represent over 44,000 Certified Registered Nurse Anesthetists (CRNAs) and student nurse anesthetists who deliver over 32 million anesthetics in the United States each year and who provide anesthesia and analgesia care in every setting, as well as pain management services. *CRNAs predominate in rural America, with 100 percent of anesthesia and pain care in many U.S. counties provided solely and safely by nurse anesthetists, and in our military and Veterans health systems. *
*
• A critical aspect of the anesthesia care continuum is pain management, and providing acute and chronic pain management services is within CRNA professional scope of practice. *A recent Institute of Medicine analysis of pain in the U.S. found that 116 million Americans suffer from chronic intractable pain at an annual healthcare and economic cost near two thirds of a trillion dollars, and that not nearly enough healthcare professionals are available to assess and care for those patients effectively.
*
• For well over a decade Medicare has reimbursed CRNAs directly for essential chronic pain management services, and referring physicians, especially in rural areas, rely on CRNA expertise in caring for their patients. *
*
• This longstanding payment policy came into question in 2011 when the Medicare agency let stand two Medicare Administrative Contractor (MAC) bulletins denying direct reimbursement of CRNA chronic pain services. These two decisions by the Noridian and WPS MACs have had significant impact on care for patients with chronic pain in rural and other medically-underserved areas of the upper Midwest and Rocky Mountain states where CRNAs are the primary providers of chronic pain care. *
*
• The Centers for Medicare & Medicaid Services (CMS) is reviewing the issues raised in the MAC bulletins and is expected to respond through rulemaking within the next few months. *
*
To ensure patient access to chronic pain care services, the AANA urges the CMS to resume direct reimbursement of CRNA chronic pain care services, reverse the inconsistencies created by the recent MAC bulletins, and remove barriers to CRNAs providing pain management services. The IOM made a similar recommendation: *"…the constraints of outdated policies, regulations, and cultural barriers, including those related to scope of practice, will have to be lifted, most notably for advanced practice registered nurses." *It would not be new payment policy, and it does not expand the scope of practice, but rather reflects CRNA scope determined by states.
*
Action for Congress: Write HHS and Medicare and urge the agency to protect patient access to pain care services and resume direct reimbursement of CRNA services, reflecting longstanding Medicare reimbursement policies in place for more than a decade. *
 
I agree with all the comments posted, particularly the part about pain mngmt. is more than "doing an interlaminar epidural", it is understanding pathology, correlating to MRI, interpreting MRI, planning THOUGHTFUL and appropriate procedures and recognizing serious exam findings and knowing when to refer out for surgery etc.

The question that begs then is where in the sam hell are CRNA's learning how to do pain procedures. They are nurses and their CRNA school is only 2 years long after nursing school and focuses on the delivery of anesthetics supervised by physicians.

Where do they land the necessary medical knowledge, physical exam skills and procedural base to do interventional and medical pain management?? It seems absolutely and completely absurd to me. Even if they have someone where does the clinical application (Seeing pain patients under a supervisor (like residency/fellowship) come in during their 2 year stint??

Someone has to be teaching them.....that is the root of the problem, cut that out and problem greatly fixed

I do outreach clinics several times a month in the midwest about 1-2 hours away from major metropolitan area, a couple of the places I go to have CRNA's doing lumbar interlaminar epidurals, they do consults, there is no PE findings or mention of MRI on the consults and if you only have a hammer everything starts to look like a nail right......all the patients I started seeing in these communities including most with axial back pain had 2-3 epidurals a pop before seeing me, it is complete BS and to me a money maker for hospital vs "making access a premium" like the statement above. My ultimatum was they stop playing doctor or I go. Working out fine so far.
 
I agree with all the comments posted, particularly the part about pain mngmt. is more than "doing an interlaminar epidural", it is understanding pathology, correlating to MRI, interpreting MRI, planning THOUGHTFUL and appropriate procedures and recognizing serious exam findings and knowing when to refer out for surgery etc.

The question that begs then is where in the sam hell are CRNA's learning how to do pain procedures. They are nurses and their CRNA school is only 2 years long after nursing school and focuses on the delivery of anesthetics supervised by physicians.

Where do they land the necessary medical knowledge, physical exam skills and procedural base to do interventional and medical pain management?? It seems absolutely and completely absurd to me. Even if they have someone where does the clinical application (Seeing pain patients under a supervisor (like residency/fellowship) come in during their 2 year stint??

Someone has to be teaching them.....that is the root of the problem, cut that out and problem greatly fixed

I do outreach clinics several times a month in the midwest about 1-2 hours away from major metropolitan area, a couple of the places I go to have CRNA's doing lumbar interlaminar epidurals, they do consults, there is no PE findings or mention of MRI on the consults and if you only have a hammer everything starts to look like a nail right......all the patients I started seeing in these communities including most with axial back pain had 2-3 epidurals a pop before seeing me, it is complete BS and to me a money maker for hospital vs "making access a premium" like the statement above. My ultimatum was they stop playing doctor or I go. Working out fine so far.

they learn it from working in places like this guy...
http://www.painmd.com/our-providers/john-kane-crna.html
 
"I do outreach clinics several times a month in the midwest about 1-2 hours away from major metropolitan area, a couple of the places I go to have CRNA's doing lumbar interlaminar epidurals, they do consults, there is no PE findings or mention of MRI on the consults and if you only have a hammer everything starts to look like a nail right......all the patients I started seeing in these communities including most with axial back pain had 2-3 epidurals a pop before seeing me, it is complete BS and to me a money maker for hospital vs "making access a premium" like the statement above. My ultimatum was they stop playing doctor or I go. Working out fine so far."

Except.....for example, tell people why the ILESI at L5-S1 that the CRNA block jock did wasn't going to help with your lateral disc herniation at L3-4.....simply amazing
 
beating a dead horse, but...

is there an official statement posted on the ASIPP site? i cant find any. are they going to do advocacy for interventional pain physicians? they do tout their advocacy in a case in Louisiana...
 
No official statement posted by ASIPP but I believe they are working on this problem... We all need to stay unified, continue to write CMS and explain how ludacrous and dangerous this is and for god sake stop training them at seminars and in our practices. We give them the power and wonder why were faced with this result.
 
gratuitous bump. we do need to keep pushing. im sure those who want CRNAs to perform procedures are doing the same.

and why nothing on ASIPP? not even in the Alert section.

is it because a lot of their members are CRNAs?
 
WE NEED TO ALL CALL AND WRITE LETTERS TO THIS GUY. HES THE CAUSE.
Michael J. O'Connell, MD, MHA, PainCare CEO (The CEO of the pain Care practice in NEW HAmpshire letting CRNA's to do implants, and vertebroplasty. Unbelievable. We do this to ourselves.

Unbelievable. What a greedy jackass. I hate physicians that screw over their profession just to make more money.
 
Unbelievable. What a greedy jackass. I hate physicians that screw over their profession just to make more money.

I think as doctors we need to unite and stand together. It is a cluster mess out there! No field out there is so completely screwed up as healthcare is. You have people with MDs and nursing degrees doing the same thing, techs getting paid more than some doctors, costs spiraling out of control, midlevels who are supposed to be closing the gap focusing on specialties, etc. Such a mess. In part it is because of too much inactivity on the part of physicians. We need clear set rules and guidelines and we need to make our voice heard people!!! Also greedy creeps who screw over the profession are a disgrace.
 
I think as doctors we need to unite and stand together. It is a cluster mess out there! No field out there is so completely screwed up as healthcare is. You have people with MDs and nursing degrees doing the same thing, techs getting paid more than some doctors, costs spiraling out of control, midlevels who are supposed to be closing the gap focusing on specialties, etc. Such a mess. In part it is because of too much inactivity on the part of physicians. We need clear set rules and guidelines and we need to make our voice heard people!!! Also greedy creeps who screw over the profession are a disgrace.

Dr Awesome-

valid statement. Unfortunately, I feel that as MDs we try to 'get through med school, rsidncy and fellowship'. We often times have to 'bury our heads in the books' and passively look the other way when during training we get talked down to by our attendings, RNs etc.

Then after all that training we 'surface' and just want to do our work, get home, spend time with our families and then there's this feeling that, 'we've made it, we feel sorry about the future MDs, but atleast we will be ok".

This is the stuff I've heard other physicians say that occurs and will admit sometimes I've felt myself. But , I think we really need to collaborate/unite/unionize and do something.

IF the AMA doesnt step up, which it clearly looks like it's not going to, why not form another society that is more political active? That's how societies pop up isnt it?

I recently went to a review course where most of the MDs in teh room felt the same way. But we just all 'complain' but none of us know who to cmplain to and what to do about it.

The way I see it, if another more politically active group was formed encompassing all physicians' interests (derm, IM, surg, pain, anesth,etc), those members on the board would have to be paid well as they would be leaving behind their practices and doing this full time. Which means we all would have to do donate a ton of $$ just like the CRNAs, RNs do to their respective organizations.

I'm wondering if this form (SDN) via it's Private Forms could be a step off for something like this? It would be a multi-disciplinary form that had MD representatives from each of the specialities,etc. This would take a lot of organizing,etc. But would be in everyone's interest.
 
Dr Awesome-

valid statement. Unfortunately, I feel that as MDs we try to 'get through med school, rsidncy and fellowship'. We often times have to 'bury our heads in the books' and passively look the other way when during training we get talked down to by our attendings, RNs etc.

Then after all that training we 'surface' and just want to do our work, get home, spend time with our families and then there's this feeling that, 'we've made it, we feel sorry about the future MDs, but atleast we will be ok".

This is the stuff I've heard other physicians say that occurs and will admit sometimes I've felt myself. But , I think we really need to collaborate/unite/unionize and do something.

IF the AMA doesnt step up, which it clearly looks like it's not going to, why not form another society that is more political active? That's how societies pop up isnt it?

I recently went to a review course where most of the MDs in teh room felt the same way. But we just all 'complain' but none of us know who to cmplain to and what to do about it.

The way I see it, if another more politically active group was formed encompassing all physicians' interests (derm, IM, surg, pain, anesth,etc), those members on the board would have to be paid well as they would be leaving behind their practices and doing this full time. Which means we all would have to do donate a ton of $$ just like the CRNAs, RNs do to their respective organizations.

I'm wondering if this form (SDN) via it's Private Forms could be a step off for something like this? It would be a multi-disciplinary form that had MD representatives from each of the specialities,etc. This would take a lot of organizing,etc. But would be in everyone's interest.

I absolutely agree with your statements. I think people complain and see all the horrors but they are like oh well, i'm still doing ok so hopefully someone else will take up the fight. I would like to get involved. I don't think personally I have much to lose in this whole situation but I would like to see healthcare become less of a mess, and would love for the next generation of physicians to actually be in the position they should.

How does one even get involved with the AMA? They ask for comments/suggestions, but is there any way where residents as in my case can get involved/be on the board? I find it hard to believe that the AMA would be so powerless, when other groups make such advances!! We seem to always be last on the table.
 
dont bother with the AMA. they have stopped being an advocacy agency for physicians long ago, and they are currently focused on making money through CPT codes.
 
dont bother with the AMA. they have stopped being an advocacy agency for physicians long ago, and they are currently focused on making money through CPT codes.

Ok. So then who? You guys in particular are being forced to train CRNAs to take your jobs in the future kinda. Who puts these rules in place? Who can/will advocate for doctors? Can we form a union then?
 
Ok. So then who? You guys in particular are being forced to train CRNAs to take your jobs in the future kinda. Who puts these rules in place? Who can/will advocate for doctors? Can we form a union then?

ive been looking at both ISIS and ASIPP. i am getting the feeling that ISIS is more invested in this. Im wondering what proportion of ASIPP membership -i.e. the associate membership - is actually NP/CRNA.
 
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