17 states allow independent CRNA practice?

[Weinberg Angle]

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[aneftp]

Mid levels have nothing to lose. They are always lobbying for rights "to practice to the fullest of their ability". Whatever that means.

Surprised paralegals haven't lobbied to have laws changed so they can legally practice law. Oh wait. Lawyers primarily make the the laws.

But doctors can't make protect their own laws.

But what's ironic is these same legislators want MD care when they pass laws to expand mid level services even for "routine" surgery like colon resection. Trust me. I've seen very high ranking govt officials request MD only anesthesia for their loved ones. Lets just same it was a former number one ranked US govt official requesting MD only anesthesia for their family member.

 

[digitox]

"Reagan Myers is a nurse anesthesia resident who is training in Colorado, where a scope-of-practice fight will be reviewed by the state's Supreme Court.
Photo credit: Colorado Association of Nurse Anesthetists"

Ohhh god here we go we got nurse resident here

 

[Weinberg Angle]

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[Weinberg Angle]

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[jwk]

What is this New York Academy of Medicine? How come they only have 1 physician in their entire staff, Jo Ivey Boufford, MD? How can they call themselves the New York Academy of Medicine? Fraud.

http://www.nyam.org/about-us/management.html

They're just a think tank. They are most certainly not any type of medical or physician organization.

NYAM's Health Policy team works to improve public health by bringing together researchers, policymakers, community members, and key stakeholders to think about strategic and creative solutions to the root causes of poor health outcomes.
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[jwk]

Do you know of any pro-doctor lobby groups that we can donate to? Should we have a separate lobby for Anesthesiologists and IM docs?

Anesthesiologists have the ASA-PAC. Is there no similar organization for IM docs? The AMA certainly isn't doing anything worthwhile.

 

[flashgordon]

If you really get down to it, I know NP/PA's can do 99.9% of what a board certified IM doc can do. And apparently, the same can be said of CRNAs and Anesthesiologists.

99.9%? Really? So NP/PA/CRNA = MD? Can't believe we went through all this training for nothing...

 

[Weinberg Angle]

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[pgg]

I can only speak for general internal medicine. I don't think it applies to the surgical or subspecialty fields of medicine.

I think you don't give yourself enough credit.

In the military we have this odd phenomenon called a general medical officer ... a physician with just PGY1/intern training is sent out to spend 2 or 3 years doing primary care for the troops. We also make extensive use of midlevels, and in the Navy we have something called an independent duty corpman which is something akin to a NP minus the nursing degree. Even given the healthiest and best-screened patient population on the face of the earth (active duty military) there is a real gulf in the level of care between that care and that of a residency-trained physician. It works out well, mostly, but midlevels and even doctors with just a PGY1 year behind them are not 99% of a board cert/eligible physician.

 

[Consigliere]

It will be all 50 states within the next 5 years.

 

[Consigliere]

It will be all 50 states within the next 5 years.

 

[jeffblue]

It will be all 50 states within the next 5 years.

Oh snap! Are you serious?

 

[Surfer]

I think they can practice solo in all 50 states already. It's only for medicare reimbursement that The opt out applies.

 

[deleted126335]

Even if they get a national opt out, even if they get all 50 states to allow independent CRNA practice, they will still have to fight for the work at the local institutional level. The closer they get, the more bitter the opposition they will face. The CRNA personnel glut will keep a lots of mouths shut at the local level.

I think they can practice solo in all 50 states already. It's only for medicare reimbursement that The opt out applies.

 

[Stellar Clouds]

Is there a difference in the malpractice insurance that an independent CRNA needs vs. one that is supervised?

 

[Pooh & Annie]

We live in a capitalist society. If you really believe that a mid level can do 99% of what you do, than you have no right to get irritated when hospitals start using them instead of docs to save money. It wouldn't be fair to consumers to say you MUST go to this more expensive provider even though they don't add anything to your care.

I don't for a second believe that the average nurse can do anywhere NEAR 99% of what I do. If at some point there is compelling evidence that that isn't true, I don't think I would argue to hard about them getting equal practice rights. I don't really worry about that because I don't see it happening, and I don't for a second think it's true.

 

[aneftp]

We live in a capitalist society. If you really believe that a mid level can do 99% of what you do, than you have no right to get irritated when hospitals start using them instead of docs to save money. It wouldn't be fair to consumers to say you MUST go to this more expensive provider even though they don't add anything to your care.

I don't for a second believe that the average nurse can do anywhere NEAR 99% of what I do. If at some point there is compelling evidence that that isn't true, I don't think I would argue to hard about them getting equal practice rights. I don't really worry about that because I don't see it happening, and I don't for a second think it's true.

That's a misconception that CRNAs "save money".

Two ways to look at this and they both involve zero savings to the system

1. If CRNAs were to take a "full schedule including weekends call" working an average of around 52-55 hours a week they would need to be paid over $300k a year plus benefits and paid vacation.

You see the average crna salary of around $150-170k generally involves zero call and "shift work" usually day time and no weekends. I am friends with many CRNAs. They love their 3-4 day a week 7-5 or 7-7 jobs that involves no weekend.

But quickly change their schedule to weekends and nights the costs add up quickly. Those CRNAs in solo hospital practices earn well over 350k a year plus take 10 weeks off. I know a few in the South.

2. Insurance especially Medicare pay exactly the same whether the job is done by Crna or md. So saying hospitals "save money" is just incorrect. All they are doing if they are employing CRNAs is just pocketing the money.

It costs the health care system the exact same whether hospital bills for Md anesthesia or CRNA anesthesia.

 

[Pooh & Annie]

In the rural areas where CRNAs have their own full time job with overtime, and are making 350k, do you really think an anesthesiologist in that scenario would make less than 500k?

CRNA schools are churning out graduates like mills. I promise you that there would be significant changes in reimbursement levels if there were no need for anesthesiologists and these people could go anywhere they want to practice completely independently.

 

[jwk]

In the rural areas where CRNAs have their own full time job with overtime, and are making 350k, do you really think an anesthesiologist in that scenario would make less than 500k?

Ah, but you're not taking into consideration the rural-pass through available to CRNA's from Medicare Part A. Critical Access Hospitals have an incentive to use CRNA's because they can charge more to Medicare. That benefit is not available for hospitals to use to help compensate/retain anesthesiologists.

 

[Pooh & Annie]

That incentive will go away if CRNAs HAVE to go rural to find a job. And:

Legislation pending in the U.S. House (HR 1044, Jenkins, R-KS) would expand the Medicare Part A rural hospital reasonable cost passthrough program to also cover the services of anesthesiologists. Because the labor cost of an anesthesiologist is about three times that of a nurse anesthetist, enactment of such legislation could triple Medicare rural anesthesia costs in a hospital without expanding patient access to care or improving quality.

I doubt it'll pass.
Policy will change to accommodate the climate. An over abundance of providers that are deemed "equal" WILL result in a drop in reimbursement.
Once again, I am NOT arguing in favor of this. I STRONGLY believe this would be a collossal disservice to patients.

 

[aneftp]

That incentive will go away if CRNAs HAVE to go rural to find a job. And:
Legislation pending in the U.S. House (HR 1044, Jenkins, R-KS) would expand the Medicare Part A rural hospital reasonable cost passthrough program to also cover the services of anesthesiologists. Because the labor cost of an anesthesiologist is about three times that of a nurse anesthetist, enactment of such legislation could triple Medicare rural anesthesia costs in a hospital without expanding patient access to care or improving quality."

I doubt it'll pass.
Policy will change to accommodate the climate. An over abundance of providers that are deemed "equal" WILL result in a drop in reimbursement.
Once again, I am NOT arguing in favor of this. I STRONGLY believe this would be a collossal disservice to patients.

Seems like you are quoting an AANA piece of written paper in OPPOSITION for expansion of rural pass through for MDs

("enactment of such legislation could triple Medicare rural anesthesia costs in a hospital without expanding patient access to care or improving quality.")

http://www.aana.com/advocacy/federalgovernmentaffairs/Pages/Rural-Anesthesia-Access.aspx

Of course they would try to sensationalize that costs would triple when they don't as we MDs all know Medicare pays the same regardless.

And it's funny AANA claims they want to increase "access" to patient care but arguing against pass through payments for MDs. Seems very counterintuitive, don't you think.

I've called my CRNAs friends out of this and we all laugh cause we know its true.

As a side note. CRNAs harbor back to being RNs when it comes to anything they that benefits them. Like student loan repayment forgiveness for RNs that MDs don't have access to as well.

 

[Pooh & Annie]

I don't agree with the "triple costs" argument, but the whole point of the rural pass through legislation is to allow higher medicare payment in order to draw providers. (The wording sounds like they determine the payments based on what similar rural pracritioners are making). This is NOT the usual way of Medicare reimbursement. If, in general, rural anesthesiologists make more than anesthetists, then CMS would have to take that into account when deciding reimbursement. It may also mean that CMS decides that similar providers (mid-levels) get paid a certain amount, and you're providing similar services, so that's the same as you get. The wording of the legislation doesn't clarify that.

If I took that quote from an AANA document, that was unintended and dumb. But it might be right in that rural anesthesiologists MIGHT get reimbursed considerably more under the new legislation. Obviously (to most of us), anesthesiologists, especially those with further sub-specialty board certification, are worth considerably more to a hospital than a mid-level, and should be paid accordingly.

 

[jwk]

And it's funny AANA claims they want to increase "access" to patient care but arguing against pass through payments for MDs. Seems very counterintuitive, don't you think.

OMG - you're saying they're....hypocritical???? GASP!?!?!?

It's also perfectly acceptable for them to attempt to limit/prevent/banish AA practice, yet they scream bloody friggin murder when they're accused of practicing medicine.

 

[jwk]

And it's funny AANA claims they want to increase "access" to patient care but arguing against pass through payments for MDs. Seems very counterintuitive, don't you think.

OMG - you're saying they're....hypocritical???? GASP!?!?!?

It's also perfectly acceptable for them to attempt to limit/prevent/banish AA practice, yet they scream bloody friggin murder when they're accused of practicing medicine.

 

[deleted128562]

I fear some of your colleagues aren't helping your situation much. I'm an EM resident - the other day had an MDA refuse to let me intubate a teenager because "it might be a bit too complicated".... then he stepped aside and let the CRNA intubate. I can imagine the message she took home from that interaction.

But in any case, I've been saying it for years, there are only 2 possible truths in all this:
1) Attending MD/DO's are far more competent to practice the spectrum of medicine than PA/NP's, and midlevels should remain in an assistant role as they do not have the same knowledge and abilities.
2) PA/NP's are either at or like 99% at an equivalent level to MD/DO, in which case the medical school and residency system is an absolute racket and should be abolished immediately. If a new PA or NP grad is truly competent to practice medicine on their own, then it is an absolute TRAVESTY that med school grads are forced into years of indentured servitude under the guise that "it is necessary to become competent to practice medicine". To make anyone go through 4 years of med school and then several years of residency, when they could get the equivalent training in 2 years of midlevel school, would be absolutely inexcusable.

So which is it?

 

[dismorfik]

So which is it?

Maybe it's option 3) where, with on-the-job experience, the PA/NP/CRNA's of the world can competently perform 90% of a physician's duties; however, the 10% that distinguishes a physician from the rest is worth the many extra years of training and higher pay.

 

[IlDestriero]

Don't forget that an experienced CRNA has infinitely more airway experience than an EM resident. That example of yours is not the best. If I'm called to an airway emergency the non anesthesia attempts are over. The exception would be to defer to ENT if they are there and it is appropriate. One thing is clear in our emergency airway algorithm, the attending anesthesiologist assumes control of the airway and it's management.

 

[Random Anesthesiologist]

I fear some of your colleagues aren't helping your situation much. I'm an EM resident - the other day had an MDA refuse to let me intubate a teenager because "it might be a bit too complicated".... then he stepped aside and let the CRNA intubate.

Did you refer to him as such? That could have been your problem....

 

[deleted128562]

Did you refer to him as such? That could have been your problem....

No of course not, I called him Dr. ---

But maybe I will now. Heh heh.

 

[drmwvr]

Did you refer to him as such? That could have been your problem....

What's the difference between 'MDA' and 'physician anesthesiologist'? The ASA uses the latter in the "When Seconds Count" campaign.

 

[chmd]

MDA is too reminiscent of CRNA. We are anesthesiologists and they are nurses. Terminology matters, just ask the GOP. I shudder every time I hear "Democrat party." Regardless of one's political leanings, it's just a bastardization of the English language.

 

[D0ct0rDee]

We live in a capitalist society. If you really believe that a mid level can do 99% of what you do, than you have no right to get irritated when hospitals start using them instead of docs to save money. It wouldn't be fair to consumers to say you MUST go to this more expensive provider even though they don't add anything to your care.

I don't for a second believe that the average nurse can do anywhere NEAR 99% of what I do. If at some point there is compelling evidence that that isn't true, I don't think I would argue to hard about them getting equal practice rights. I don't really worry about that because I don't see it happening, and I don't for a second think it's true.

Ok, you're looking at the glass half empty. Do you have compelling evidence that nurse anesthetists are less competent than MD anasthesiologists? Or are you just biased and ignorant? CNA's been around for decades, yet there aren't any studies that show that they are less effective or less safe than MD anasthesiologists.
Come on now docs, show me the evidence!

 

[GoSpursGo]

I don't see any particular reason to revive a thread that has been dead for a year and a half to go over a topic that has been done to death. Closed.