AA Supervision?

[BLADEMDA]

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Going forward the strict ACT model with Medical Direction may not be flexible enought for many groups. Does anyone think the ASA and the AAAA would support the change to Supervision or Medical Direction?

Currently, AAs must be under medical direction and strict TEFRA. It would be nice to have a choice in the utilization of AAs.

 

[MRW]

what separates the two models?

 

[BLADEMDA]

From the AANA website:

TEFRA are a set of conditions an anesthesiologist must meet if he is to bill Medicare for medical direction of a CRNA/AA and thereby claim 50% of the anesthetic fee. There are 7 of these "steps" that an anesthesiologist must follow if he wants to bill Medicare Part B for the anesthetic given by a CRNA/AA.

These 7 steps include:
1. Pre-op assessment
2. Prescribe the Plan of Care
3. Personally participate in induction/emergence
4. Ensure that everything else is done by pro-
fessionals
5. Monitor the patient at frequent intervals
6. Be readily available to help treat emergencies
7. Provide post operative care

 

[lushmd]

Isn't this part of the reason for the current CRNA mess? IMHO, it seems that the TEFRA rules are a reasonable set of minimum regulations for a physician anesthesiologist to meet in supervising a CRNA/AA.

 

[Josh L.Ac.]

Internets, how do "double-edged sword"?

 

[Josh L.Ac.]

Well, on the other hand, having AAs that can fill all the roles that the CRNA's can while still being under the board of medicine might be advantagous.


I could be wrong, but it seems like if you wanted to make sure that the AA on solo call meets certain criteria, you can make that happen at the state level. Or if you want to limit the level of ASA patients that a solo AA treats, you could do that through the board.




But I'm still quite suspicious of the idea - seems like a last-ditch effort.

 

[BLADEMDA]

Well, on the other hand, having AAs that can fill all the roles that the CRNA's can while still being under the board of medicine might be advantagous.


I could be wrong, but it seems like if you wanted to make sure that the AA on solo call meets certain criteria, you can make that happen at the state level. Or if you want to limit the level of ASA patients that a solo AA treats, you could do that through the board.




But I'm still quite suspicious of the idea - seems like a last-ditch effort.

If I am busy with my other 3 rooms and Josh (now an AA-C in this example) wants to extubate his ASA 1 patient I must be physically present in the operating room. That is strict TEFRA. If I fail to meet the "emergence" criteria set by Medicare/TEFRA I am guilty of fraud. Only AAs have to deal with the full impact of TEFRA. Many MDs don't feel comfortable with AAs due to TEFRA and the potential billing issues it entails. So, AAs are at a huge disadvantage in at least 1/3 or more of ACT private practices IMHO.

AAs need to be on an equal footing with CRNAs sans solo practice. Until this happens many MDs won't fully embrace the AA concept.

 

[BLADEMDA]

I understand that legally "emergence" can have a broader meaning in the O.R.
Legally, I can meet TEFRA by showing up in the room at some point before Josh (in this example) leaves the room. Still, the intent of TEFRA is to be present during the most demanding parts of the case. This is usually induction/intubation and extubation/emergence.

 

[BLADEMDA]

the anesthesiologists had to "satisfy seven requirements in each case [The Tax Equity and Fiscal Responsibility Act (TEFRA) requirements]. One of those requirements was personal participation in 'the most demanding procedures in the anesthesia plan, including induction and emergence."' The trial court had ruled that the anesthesiologists had satisfied this requirement even though MANA had produced witnesses that "emergence" occurred when the breathing tube was removed and the patient woke up. MANA also had evidence that there were many instances when breathing tubes were removed after anesthesiologists had left the hospital or when anesthesiologists only spoke to patients via telephone; sometimes when they were in the recovery room and sometimes hours or even days after their procedures. The defendants claimed that they were nonetheless "present for emergence" because emergence "goes on for days." The 8th Circuit Court of Appeals pointed to testimony by a former employee of HCFA who had participated in drafting the regulations. He testified "that the regulations were based on advice from the American Society of Anesthesiologists that emergence was a particularly demanding part of the anesthesia process and that it occurred at 'the end of the case when the surgical procedure has been completed and the patient was being prepared by the anesthesiologist to be turned over to a nonanesthesia provider."' The 8th Circuit Court of Appeals pointed out that the trial court should not have granted summary judgment when so much conflicting evidence had been offered by MANA.

 

[BLADEMDA]

It turns out that theAANA and the ASA don't even agree on the meaning of emeregence. Court cases show that the ASA thinks just being around/covering the PACU qualifies as "emergence" when an AA completes his/her case. Some CRNAs believe (and have been wistleblowers) that MD (A)s must show up in the room at extubation or shortly thereafter.

I guess there are lawyers to defend both positions.