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Why are CRNA services compensated at the same rate as Anesthesiologist

Discussion in 'Anesthesiology' started by orangele, Mar 7, 2010.

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  1. orangele

    orangele

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    Please correct me if I am wrong, but it is my understanding that CRNA services (NOT involving supervision or medical direction by an anesthesiologist) are compensated at nearly or exactly the same rate by insurance companies and the government as an anesthesiologist is compensated.

    Further it is my understanding that Medicare payments to physicians are based on resource-based relative value scale (RBRVS) which is calculated based on a variey of factors including the complexity of the duties, but also the number of years of education of the PHYSICIAN providing service.

    So my question is why does the government and insurance companies compensate CRNAs at the same rate which they pay for anesthesiologists? Even assuming CRNAs were physicians, based on the lower number of years of training alone they should be paid less.

    An analogous situation would be if a paralegal provides service vs. an attorney or a dental assistant provides service vs. a dentist. Even if they do exactly the same procedure, I would not expect to pay the same.
  2. rsgillmd

    rsgillmd

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    Orangele, I don't know enough details to answer your question, but I don't think the number of years of education of a physician has anything to do with it. If it did, then fellowship trained physicians would be in greater demand than they are now for the extra pay they would bring to the group.
  3. gasaddict54

    gasaddict54

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    i am just worried what we will be paid period in a couple of years.....we may all he hoping for CRNA pay w the communist sitting on high
  4. sevo85288

    sevo85288 Junior Member

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    Pediatric Pulomonolgoists/cardiologists make less than adult internists while having 3-4 yrs of more training. GEN peds make less than ICU nurses. Hospital administrators make more than surgeons. The issue here is not education but supply and demand. CRNAs are subsidized in most part by hospitals and groups; as are some MDs, trauma surgeons, etc.
  5. Dirtball

    Dirtball

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    Unsupervized CRNA paid 85% of MD rate by alot of carriers. Some pay same as our rate. Causes me GERD.
  6. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

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    The insurance companies, hospitals, and patients are all consumers who are buying a service or a product we are providing.
    Consumers will always go after the cheaper service or the cheaper product regardless of the quality.
    None of these consumers cares who actually makes the product or how educated they are.
    If we make anesthesia provided by an MD more expensive than anesthesia provided by a CRNA, then the only result will be that these consumers will stop paying for our product and buy the cheaper products even if they are less shiny.
  7. aredoubleyou

    aredoubleyou Senior Member

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    Wamart has proven this to be true. Price over quality.
  8. Southpaw

    Southpaw ASA Member

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    Right, just like patients have stop going to see NPs and PAs b/c they reimburse less than their physician counterparts. Wait, no they haven't. What's going on here!?!?!
  9. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

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    :confused:
    i am not sure what you are trying to say but in Anesthesia business our "customers" couldn't care less if the one who is giving the anesthetic is an MD, a CRNA or a Chimpanzee!
    They don't have the slightest understanding of what we do and it's going to take generations to educate them on the differences.
    If we are going to prove our role in this business the worst thing we could do is asking for more money because we are physicians, what we need to do is to take control on the political level.
    We need to make it a "standard of care" that an anesthesiologist should supervise or personally administer the anesthetic.
    We should never advertise or accept that a generic "physician" could assume the role of supervising anesthesia midlevels as the ASA had advertised in the past.
  10. badasshairday

    badasshairday Account on Hold

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    I'm a certified Chimpanzee anesthestist. I do hearts solo too!
  11. badasshairday

    badasshairday Account on Hold

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    I agree. This would have forced rural hospitals to get anesthesiologists on staff. Would have been better for patients.
  12. Southpaw

    Southpaw ASA Member

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    The issue I pointed out was a differential, or lack thereof, between physician and nurse reimburement. Nothing was discussed with regards to patients choosing their provider, nurse or physician.

    An anesthesiologist offers their services as a consultant physician, with 12-13 years of training depending on a year in fellowship. They have increased training in medical diagnosis/management which I do believe plays out in the perioperative period. As a consultant physician, they're better trained to assist in the postoperative period if an anesthetic/medical issue arises and physician input is needed.

    This is in comparison with a RN with 2.5-3 years of extra training after year in the ICU and nursing school. There's a huge difference, as there should be. This is meant to be no offense to CRNAs, as from my experience they provide good anesthesia for the most part, but they do miss things.

    Based on that, increased length of training, physician vs nurse, there should be a difference in reimbursement when a physician administers the anesthestic vs when a CRNA delivers it. I see no debatable point, as it isn't debated in every other field of medicine where there is in fact a difference in reimbursement, for the exact reasons I've listed above.

    Your other point, about having an anesthesiologist involved as the standard of care, is a point in which I completely agree.

    And your other point, about patients choosing physician vs nurse to deliver the anesthetic, I completely disagree. If the ASA did their part, and patients became more aware of the issues and differences in training, most well educated would choose to have a physician directly involved.
  13. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

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    You and I definitely agree that a physician has more education than a nurse.
    But that does not matter when it comes to consumers!
    Consumers (patients, insurance companies, hospitals...) don't care if you are more educated, they will pay the cheapest possible price for the service.
    This is how it works.
    In a perfect world things should not be this way but this is not a perfect world.
  14. gasaddict54

    gasaddict54

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    this for the same reason is why i disagree w so many on here about pushing more AA schools to open, more anesthesia providers etc.....bc as many of u point out, what is the big difference between a AA and a CRNA? Most of u point out control by a physician and overall a smaller pay scale. BUT my point is what difference does it make to the consumer if it is a AA, CRNA, or MD that is providing the anesthesia? They dont know and 99% of the time dont care! That is why so disagree w flooding the market w anesthesia providers of ANY kind. The more supply, the less demand etc and a decrease in $ for EVERYONE.....
  15. NotAMD

    NotAMD New Member

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    i dont agree that the public doesnt care that an MD is not providing their anesthetic. i think people want to meet an MD just for the comfort factor, i think the public wants the people putting them to sleep to be well paid, well trained people, and beyond that they dont really know or care anything - like how i would think about a pilot.

    no matter if its 2:1 or 6:1 we are always going to be at the end of that chain and the higher the supervision ratio, the more value we have, and so the midlevels have to be even higher quality, and we supervise more, and so on - and the demand for surg is growing so much that i dont think this will hurt us unless we are taken away from the end of the chain, and the surgeons or someone else with alterior motives left in charge of making the choice of CRNA vs MD trained. i think most people i know want the best when the go under
  16. aredoubleyou

    aredoubleyou Senior Member

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    I think some of the people here have their head in the sand. Unfortunately Plank is dead on with this one. A price point is determined by how the market values that product or service. If your product or service costs more than what the market is willing to pay you vanish, if the reverse is true you make a profit.

    To increase your price point you need to convince the market your service has greater value. One way to do this is differentiating your service from your "competetor." We as a specialty have FAILED MISERABLLY at differentiating our service from that of a nurse. Meanwhile the nurses have gone through great hurdles to show that their services are not different than that of an MD. The result of that is that there is no differentiation of serviced and a generic anesthesia price point has been set for all...as the nurses like to say..."anesthesia providers."

    The strategy of marketing an undifferentiated (or poorly differentiated) service for a higher price is sure to lose, especially in an environment were the cheapest alternative is preferred.

    The strategy of added value on the basis of education alone I think is not going to win. Turn back time and argue that a nurses services have less value, and therefore should be worth less, may have worked at one time, but those days are long gone. Our best strategy is to message to the market that unsupervised, or barely supervised, services are unsafe. Our marketing machine, however, is spineless, impotent, uneffective, weak, and lacks a cohesive message. The nurses PAC are the exact opposite, persistant, unrelenting, aggresive and with a simple message: there is no difference.
  17. Southpaw

    Southpaw ASA Member

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    Some don't know, and wouldn't care. I believe it's more along the lines of people just don't know, and don't know to care. This is why I believe the ASA, and the older generation of anesthesiologists, have failed us and failed patients. As a current resident, I see how things work on the most difficult of cases. I can assure you, my family will have a physician involved in their operative care. If more were aware, more would care.
  18. Southpaw

    Southpaw ASA Member

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    Your statement applies in a free market with capitalistic principles, where I do not believe health care currently lies. Also, I think we as a specialty have done quite well at differentiating the care we provide as physicians vs. others. We know it, and many in the hospital know it as well. It's only the public with a big fat question mark over their head. The fault lies with our representative organization, and past anesthesiologists.

    I correct people when I hear MDA, and when I'm referred to as an "anesthesia provider". If others are so apathetic that they don't care what others refer to them as, then they're part of the problem.
  19. aredoubleyou

    aredoubleyou Senior Member

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    Nothing I said relies on a free market..actually. In fact, there is no free market...but thats besides the point. Perhaps at your academic institution, your services have been deiferetiated, but I personally do not believe that it has been done well overall throughout the country. Just a disagreement on a subject impossible to prove.

    Your comments on the older gen of anesthesiologists, couldnt AGREE more, they sold us all up a river.
  20. bama357

    bama357

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    I am a member of a CRNA only group. I get paid to provide anesthesia care for the patient. At 0200 when the call comes in for an epidural I go in and provide it. Patient gets same relief from my epidural as from the MD group 40 miles down the road. difference is that I will provide epidural for medicaid, self pay,or insured. The MD group requires payment up front. No money up front, no epidural.
    Most of the cases we do have an basic value of 3-7. Patients get good anesthesia, good outcomes, post op pain management as required ( we do not charge extra for PCA or any form of post op epidural pain management). We are paid for the service we give, if the service is the same, the pay should be the same. Am I saying our education is equal, NO. You have skills in areas I do not have. Am I saying in the majority of cases does that matter? Usually it does not.
    I did my share of vascular anesthesia, neuro anesthesia and major trauma in my younger days. I would guess that I averaged 8 carotids and 4 aortic cases per week for about 10 years, with the Anesthesiologist signing the chart in the POHA and never setting foot in the room. Did his income bother me, not at all but it sure pissed off the surgeons! You guys can have those cases. Not that I am not qualified to do them, just do not need the ego boost, and I am quite happy with 200k income in rural America.
    The anesthesia world is big enough for all of us. If we do not work together and BOTH sides get over the pettiness, the Obama'a of the world are going to screw us both. I have seen poor excuses for anesthesia providers with MD, CRNA, and DO after their names. I have also seen excellent ones with all the above. I elected not to mention AA's because I have never worked with any and try not to judge groups based on other people's ideas.
    Last edited: Mar 25, 2010
  21. karizma098

    karizma098 Neon Tiger

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    refreshing to actually see a CRNA make comments that aren't militant.

    CRNA's and MD's are both here to stay in anesthesiology. neither one has to undermine the other, both have roles in respective settings. some CRNA's moan that MD's make too much and vice versa. The sooner certain CRNA's stop preaching to the public and MD's that they are the 'same thing' as an anesthesiologist - and as soon as the anesthesiologists accept the fact that they can't be the sole provider of anesthesia in this healthcare model, the better the field will be for both.

    i'm not even a resident yet, but i'm already growing tired of the battle between MD's and CRNA's. I love anesthesia, but the politics is such a headache compared to anything else in this field.

    while i'd like to think that i'll encounter more level headed crna's such as yourself in the future, my current experience in the OR ( though limited ) speaks otherwise. :-/

    as long as there are CRNA's out there claiming to be equivalent ( or better ) in training, skill and education to anesthesiologists, this fight will continue.

    something tells me this will be forever.
  22. cfdavid

    cfdavid Removed

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    Whether we want to hear this or not, this poster has a point.

    I've been on several surgical services where, in the ACT model, the MD hardly stepped into the room. Intubation and that was IT.

    Pissed off (rather envious) surgeons? I would think, under those circumstances!

    I've OFTEN reflected, when experiencing the above scenario which I know is not the "norm" necessarily, on how the CRNA is EARNING the respect of the surgical team.

    If we're going to advocate the ACT model, then we as a profession MUST step up to the plate and become more involved, PHYSICALLY, during cases. Doesn't matter if that ruffles the CRNA's feathers, but popping in more frequently, if for no other reason than showing your face, is important.

    My 2 cents.

    cf
  23. cfdavid

    cfdavid Removed

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    Karizma,

    I feel you. But, here's the key. For sustainability, we'll all just need to accept the fact that ADVOCACY at the political level is simply PART OF THE JOB.

    Putting it in that perspective is the most healthy for the individual. It's just business, and every major professional organization (especially those that SUCCEED) prioritizes PACs.

    ****People wonder how Wall Street got this sensational bailout with very little REAL repurcussions other than some minor grief from the public and some in Congress. Lip service.

    ****But, look at the CASH these firms throw at BOTH PARTIES. They will ALWAYS succeed with that level of "committment"....... Untouchable, virtually.

    Also, I've often railed against other PACs, which advocate politically. Well, their success is DIRECTLY related to that groups committment, money, letter writing, physical presence in DC etc. etc. This is what creates a positive outcome, inspite of what some suggest is not even in the best interests of the US (I'm making a point, not opening up this can of worms, so let's not get into this one, please).

    cf
  24. Stank811

    Stank811 Junior Member

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    When I first clicked on the title I thought it was going to be another trash thread but I was surprised to see some good discussion:

    I am not sure were most of you practice but in the midwest were I am training the "consumer" does care who is providing there anesthesia. In my limited experience the patients either do not know the title of the person providing their anesthesia or the patient is to afraid to ask and assumes that a MD/DO will eventually introduce themselves. And I do agree the hospital and the insurance companies could care less who delivers the care as long as they are sitting pretty in the end.

    So I agree with trying to educate our patients on the importance of MD/DO delivered anesthetics which I am sure will take a lot of resources and money but in the long run will be well worth the effort.

    Also why do we support ACT with 4:1 supervision? I don't see how that empowers our field. Is the model economically driven in that it allows us to make more money and have more time off? Or is it to spread doctors thin/wide and cover as many patients as possible with the limited resources we have? I feel that a hospital that promoted MD/DO only anesthesia would have an advantage over other hospitals in the area who have a ACT model if it was marketed correctly...and I am sure some one will say prove one model is inferior to the other...which I understand but from the business side of it I do think "patients/consumers" care and would preferentially have surgery at the MD/DO hospital if possible. Am I even close on this?
  25. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

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    I understand from your post that you are willing to provide your services for free or for little money and this would not bother you!
    Why is that?
    Why would anyone want to work for free?
    If you want to work for free there are many humanitarian agencies and charities that would be happy to recruit you.
    I have not yet seen a CRNA that wants to work for free, not even one hour, so you must be a special person, god bless you.
    If you believe that you are providing services that are equal in quality to physicians then why are you selling these services for less money or for free?
    This is how manufacturers of lower quality products compete with others in the market, they sell their product cheaper and advertise it better.
    There is nothing wrong with selling your services cheaper but it would be more honest not to claim that you are doing that because you are such a great human being and want to work for free.


  26. Stank811

    Stank811 Junior Member

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    When I first clicked on the title I thought it was going to be another trash thread but I was surprised to see some good discussion:

    I am not sure were most of you practice but in the midwest were I am training the "consumer" does care who is providing there anesthesia. In my limited experience the patients either do not know the title of the person providing their anesthesia or the patient is to afraid to ask and assumes that a MD/DO will eventually introduce themselves. And I do agree the hospital and the insurance companies could care less who delivers the care as long as they are sitting pretty in the end.

    So I agree with trying to educate our patients on the importance of MD/DO delivered anesthetics which I am sure will take a lot of resources and money but in the long run will be well worth the effort.

    Also why do we support ACT with 4:1 supervision? I don't see how that empowers our field. Is the model economically driven in that it allows us to make more money and have more time off? Or is it to spread doctors thin/wide and cover as many patients as possible with the limited resources we have? I feel that a hospital that promoted MD/DO only anesthesia would have an advantage over other hospitals in the area who have a ACT model if it was marketed correctly...and I am sure some one will say prove one model is inferior to the other...which I understand but from the business side of it I do think "patients/consumers" care and would preferentially have surgery at the MD/DO hospital if possible. Am I even close on this?
  27. pd4emergence

    pd4emergence Man or Muppet?

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    Reading through this thread and seeing the comments on consumer preference, I think that one point has been missed. The average lay person has no idea what we do, what happens in the OR, or how important it is to have good anesthesia care. To most it's like that "anesthesia on" commercial. Most people think that because their surgeon is in the room and in control that everything is gonna be ok. I agree with plank the ASA should put out a practice guideline that says that an anesthesiologist should be involved in every anesthetic. They are moving forward (read the care team statement that came out not too long ago). Knowing the work and politics in the ASA, this statement is a major victory to those of us who believe that CRNA's should be supervised at all times and SRNA's should never be in a room by themselves. I also wish the ASA would make a push for more patient education. I think if people really knew our role in the OR, we would not have to have this discussion.
  28. Haole

    Haole

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    Only if someone else is paying for it :)

    When my kid had surgery I was so happy/comforted to know a fellowship trained pediatric anesthesiologist was involved in the case, even if it was a "simple case"...I would pay extra, but I doubt this would be true for most of the general public who have no idea what our training entails.
  29. Code Brown

    Code Brown Low man on the totem pole

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    Just to add to the conversation here. Since surgeons often have a lot of say when it comes to who runs the anesthesia during their cases (and since they are often the ones bringing the big bucks to the hospital), these are people we need to influence to push for MD run anesthesia in any even remotely difficult cases. How many times have they bitched and complained, often while completely at fault, only to have the administration cave in to their demands? Money talks. And as residents, we can push these ideas onto our resident surgical colleagues while we're still in training. Plant the seeds if you will. We've all seen at least one or two CRNA anesthesia disasters that wouldn't have happened with even a first or second year MD resident at the helm. We need to capitalize on this to show that while we can potentially provide the same service for a routine colonoscopy on a healthy 50 year old, having a mid-level provider on a tough case or on a sick patient with lots of comorbidities is not the best idea. I thought I read somewhere that the average settlement for a "hypoxemic disaster" is somewhere in the neighborhood of $600,000. One way to add value to our superior service.
  30. gasaddict54

    gasaddict54

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    While I dont disagree with these thoughts in principle, the realistic possibility of the future involving MD only practice is not realistic not at the MDs current salary. The ACT model IMHO is the way of the present and future that is in the best interest of everyone involved as Comrade Obamas plans dont include paying a MD 400K a year to do lap choles vs AA/CRNAs 125-150 to do the same, no matter how many arguments we put forth. BUT the necessity of MDs w high level cases cant be questioned, the idea of each MD doing his own cases is untenable in the current economic times of healthcare.

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