A 16 min case is 2 time units, right? I was just pointing out most cataracts end up being 2 time units. If it’s 1, then so be it.
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Cataract Surgery Anesthesia Models
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A 16 min case is 2 time units, right? I was just pointing out most cataracts end up being 2 time units. If it’s 1, then so be it.
See the patient ahead of time. After you drop last one off you see the patient after them and then go to the or where the patient is positioned, prepped and has monitors on.
If you didn't know, we don't make crazy professional fees. Medicare pays $544 / cataract on average. This includes all the postop care that has to be done (which has its own overhead) as well as the surgery itself. In addition to this, we actually have to find the patient and schedule them for surgery. Anesthesia just shows up. As some of you have described above, we have to give sedation for cataract surgery. We do quite well with oral sedation most of the time but not all of the time. However unlike LASIK, we don't have much opportunity to stop and give more oral sedation. Older patients can react unpredictably. We also do cases under block (retina, plastics, cornea, in addition to complex cataracts). Some older surgeons still do all cataracts under block. What happens if you have get brainstem anesthesia? Salary may be an option but we are not going to give an independent group additional money on top of what they can bill. The margin for cataract surgery is again not that great. We have an option with an out of network group but it just does not feel right and we try to do what's right.
Correct. We actually cannot do 12 cases before 12 out of 1 room. Some of us can do close to 20 cases but out of 2 rooms. Anesthesia runs ahead of surgeon (leaves room as surgeon is closing up) and the surgeon shows up to the next room with patient draped and sedated. It can be exhausting for anesthesia but guess what, it's exhausting for the surgeon too. It sounds like the numbers could work as some of you have described above but maybe it won't work for everybody. And that's okay. I just wanted to point out why CRNA works for our situation and MD doesn't. We really would love to have MDs whenever possible but it doesn't sound like that's possible given the compensation expectations. Again, direct subsidies are totally out of the question.
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deleted126335
IDK if this is an option....light IV sedation with a sedation RN + topical only. If they fail, reschedule to hospital with Anesthesia.
It is and I have done it. I've also done many patients topical only zero sedation. Some patients really don't like it. Clockwork orange kind of thing. The other thing is we actually do want to continue providing services such as retina, cornea, plastics, etc in the appropriate forum.
New group would have to accept medicare/medicaid but would bill all commercial as out of network.
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deleted126335
The Kobayashi Maru is a training exercise in the fictional Star Trek universe designed to test the character of Starfleet Academy cadets in a no-win scenario.
You’re in a pickle then….
You don’t want to pay, but you still want service.
I can understand your conflict, but I won’t sympathize.
Like you’ve pointed out, you can always get CRNAs to provide anesthesia. It is a cheaper solution (perhaps on paper), but isn’t the “best” solution, and comes with its own set of problem.
You don’t want to pay, but you still want service.
I can understand your conflict, but I won’t sympathize.
Like you’ve pointed out, you can always get CRNAs to provide anesthesia. It is a cheaper solution (perhaps on paper), but isn’t the “best” solution, and comes with its own set of problem.
You’re very much on the low end of what you think an Anesthesia MD would make in an 8 hour shift. That barely covers a Crna salary in my region.
You are also forgetting that cataracts provide the average anesthesiologist zero job satisfaction and you are truly practicing at the bottom of your license. It’s just not a job an MD will want to do for lower 20% salary.
Anesthesiologists and CRNAs for that matter are not needed for cataracts, period.
Learn to do your own IV sedation like the GI docs if oral isn’t good enough for you.
You are also forgetting that cataracts provide the average anesthesiologist zero job satisfaction and you are truly practicing at the bottom of your license. It’s just not a job an MD will want to do for lower 20% salary.
Anesthesiologists and CRNAs for that matter are not needed for cataracts, period.
Learn to do your own IV sedation like the GI docs if oral isn’t good enough for you.
No sympathy needed. I'm just trying to understand the economics of it all. I hear all the complaints about why CRNAs are being hired over MDs. We'd prefer MDs obviously but it sounds like you guys want to be paid more than medicare/insurance/most patients are willing to pay.
I think we want to be (should be) paid more than Medicare rates, but would gladly take current market private insurance rates. Anesthesia fares the worst with any CMS payor vs private compared to any other speciality…
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depends on contracts, we get paid time units in fractions of units most of the time as opposed to rounded up (16 units is 1.06 units, not 2 units).
It’s an open market.
You get what you pay for.
I want a Bentley, but the dealership won’t take the 10K that I have (do they even have a dealership for Bentley…..). I can choose not have a Bentley or get a Kia. Just choices and, like you said, the economics.
I also want to thank you for bring this anesthesia forum to spark this lively discussion.
Good luck!
How do you know what patients are willing to pay? I am more than happy to take what insurance/private pay patients are wiling to pay.
the problem with cataracts is that they are nearly all on Medicare patients and our reimbursement is terrible for those cases. Privately insured ones would be massively lucrative.
As noted above, the "problem" in the anesthesia world re: Medicare patients is that we only get paid about 20% of what we make on a privately insured patient as opposed to most surgical subspecialties that are making like 60-70% of their private rates.
In our market, some of the private payers recently proposed medicaid rates. This was promptly rejected and it sounds like they came back to the table with Medicare rates. To be determined what patients are willing to pay for but it sounds like they'll be charged ~5x what the Medicare rate is if we go forward with out of network. Hard to imagine patients being happy paying double for anesthesia compared to their surgeon fee and it not even apply to their deductible.
The economics are as follows. Money is tight and you have to make the numbers work. I get that. What you are overlooking is the "never event." All it takes is 1 peribulbar or retrobulbar block gone wrong or one laryngospasm or one bradycardia event that goes untreated in a timely fashion and you have a lawsuit catastrophe. You're the doc in the room. The effin captain of the ship. That 1 lawsuit naming you, the ASC, and the inferior anesthesia delivery service (CRNA) will undo years (decades?) of chump change saved by skimping on anesthesiologists to instead proceed with CRNAs. Not to mention the emotional burden of being penny wise and pound foolish.
I understand the financial predicament you are in. Don't forget about the "never event." It is more expensive in the long run.
Medicaid rates would be less than 100 dollars per case. No one is going to take on all the liability and get out of bed for that. Medicare rates are not much better. 5x medicare rates is typical for private insurance rate for in network. Sounds like your insurance companies are relying on the new bill that they wrote and not negotiating in good faith.
What you get for the case is irrelevant to what we should be reimbursed. Should I be mad that a spine surgeon makes 5x what I do for their case?
It's up to you whether it's worth risking your license and livelihood
State suspends local doctor's medical license after 18-year-old ends up in coma
GREENWOOD VILLAGE, Colo. — The FOX31 Problem Solvers have discovered the medical license for a Greenwood Village plastic surgeon has been suspended following the tragic case of Emmalyn Nguyen…
kdvr.com
I'm not jealous but I think the patients will notice and not be happy. My MIL recently had to have a epidural pain procedure done and as soon as she wad told anesthesia would be OON she went shopping for a new doctor. I'd love to give MD anesthesia a chance but it doesn't sound viable. I've never heard of an eye only asc subsidizing (paying a stipend) to anesthesia. "Thankfully" all the CRNAs I've ever worked with in eyes have not only been very talented and conscientious but also independently licensed, insured and on top of that we have a great malpractice cap. As a few of you mentioned above, it doesn't seem to bode well for the profession. If a PE group comes and tells us they'll do it without a subsidy, how can you expect us to not say yes?Medicaid rates would be less than 100 dollars per case. No one is going to take on all the liability and get out of bed for that. Medicare rates are not much better. 5x medicare rates is typical for private insurance rate for in network. Sounds like your insurance companies are relying on the new bill that they wrote and not negotiating in good faith.
What you get for the case is irrelevant to what we should be reimbursed. Should I be mad that a spine surgeon makes 5x what I do for their case?
It's up to you whether it's worth risking your license and livelihood
State suspends local doctor's medical license after 18-year-old ends up in coma
GREENWOOD VILLAGE, Colo. — The FOX31 Problem Solvers have discovered the medical license for a Greenwood Village plastic surgeon has been suspended following the tragic case of Emmalyn Nguyen…
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deleted126335
We get it. We don't like it. But we get it.
Another factor is that a lot of solo CRNAs truly relish their independence, so much so that they will throw themselves into work that most practitioners loathe. High volume cataract practices make that list.
Doing cataract cases every day would be a good way to lose skills in anesthesia. Might even forget how to intubate when **** hits the fan.
"The CRNA admitted that he had not performed an intubation in the five years preceding this case and that he never discussed the risks and complications of anesthesia with the patient because he did not want to scare him."
Co-Defendant CRNA Denies Responsibility for Failed Resuscitation – OMIC
As the practice of medicine and ophthalmology changes, OMIC assesses industry trends to meet the insurance needs of member-insureds by providing current, practical, ophthalmic-specific risk management information.
www.omic.com
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deleted87051
The market is different now with a shortage of both anesthesiologists and CRNAs so it may require unprecedented incentives to get coverage. Otherwise they’ll just work elsewhere with better pay and more interesting cases.
And PE groups can promise whatever they like but most of them are having recruiting problems now so they may have trouble fulfilling the promises they make to you. Regardless, they’ll lose money too on Medicare cataracts. They can’t collect more from Medicare than anybody else.
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This article is well known in the eye community. Interestingly enough, the malpractice conclusion was not that there should have been an MD anesthesiologist. It was wrong place at the wrong time.Doing cataract cases every day would be a good way to lose skills in anesthesia. Might even forget how to intubate when **** hits the fan.
"The CRNA admitted that he had not performed an intubation in the five years preceding this case and that he never discussed the risks and complications of anesthesia with the patient because he did not want to scare him."
Co-Defendant CRNA Denies Responsibility for Failed Resuscitation – OMIC
As the practice of medicine and ophthalmology changes, OMIC assesses industry trends to meet the insurance needs of member-insureds by providing current, practical, ophthalmic-specific risk management information.
Risk Management Principles
For the OMIC insured, this could be viewed as a case of being in the wrong place at the wrong time. The procedure was performed in a surgery center with a CRNA who allegedly did not properly intubate the patient leading to a prolonged period without oxygen and eventual death. There are several steps insureds can take to minimize the risk of an improper resuscitation in a surgery center. First, find out if there is a peer review process in place to review the competency of CRNAs and anesthesiologists. Inquire about the emergency response measures in place and whether there is anyone else available within the surgery center to assist with resuscitations. Lastly, call 911 immediately when a potentially life-threatening situation arises.
Agree. Shortage is real and it is everywhere. Even big academic places are significantly short on staff.
I wouldn't blame you for taking a PE offer. But it wouldn't be a long term solution. At best they would be there a couple years before it fell apart for one reason or another. Honestly if you're >95% medicare I doubt even PE would jump at the opportunity. In my opinion your best bet is hoping there's a MD only group around that would staff your center as part of other coverage. If you need to go CRNA only, go for it. It appears you've been happy with that in the past.
We can't tell you what you don't already know about out of network billing. It sucks and it isn't right for the patient. It's also likely you understand the limitations for staffing Medicare only cases for our field. Medicare sucks far worse for us than it does for others. If some CRNAs jump at the opportunity I don't blame you. They generally love practicing 'at the top of their license'.
Also, let's be honest. This is hand-holding anesthesia with topical doing the heavy lifting. Sprinkling in a little versed or fentanyl should be more than enough. I wouldn't declare that as not boding well for the profession, just like I wouldn't expect a fresh out of residency/fellowship board certfied ophthalmologist to do the absolute very basics of what an optometrist does, for the entirety of their career, for optometrist pay.
Anyway, good luck.
I wasn't singling out CRNAs specifically for not having intubation skills. i'm saying that doing cataract surgery cases every day (which from an anesthesia perspective is fairly mundane, and involve efficiency and a lot of hand holding) is almost certainly going to lead to skill atrophy. This is probably true no matter who it was at the anesthesia workstation. this was just the case that was memorable, and especially the part where the CRNA denied responsibility (which really ought to be the bigger point in the lawsuit).
This part too was quite troubling: "When the paramedics arrived, they determined that the CO2 monitor had not changed color indicating the tube was in the esophagus rather than the trachea. This prompted the CRNA to get into a shoving match with one of the paramedics. The paramedic re-intubated the patient and O2 saturations began to go up"
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Haha dude I don’t think you understood how poorly paying this crap is. We ran a financial study a while ago and we basically would lose money on cataracts even if the AAs/CRNAs were practicing independently. And that’s before the recent shortage.
No PE group is running to pick up an eye center period.
Anyways, this all a moot discussion. Soon enough these will all be done with conscious sedation or PO Valium.
It doesn't matter if the anesthesia is done by an MD, an independent CRNA or an employed provider. The number of units billed is the same and so is the unit value that comes from medicare. How do you think the PE group makes money? They take 20% off the top and bill outrageous out of network rates or use their market share to demand higher unit values.
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And they can’t OON bill Medicare patients so it’s the scant few <65yo commercial insurance patients who will get reamed. And the PE group will more than likely be headquartered out of state so they could care less about the reputation of the surgeons or the local anesthesiologists.
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I don't understand why your OON billing has to be so crazy as to drive patients away. Can't the anesthesiologist bill the patient for 100$ on top of the medicare rate of 100 and get +-300-500$/h? That's what i do...
basically thats the state the country/profession is in. reimbursements are low, and a lot of cases are money losers after salary unless done in very high volume, but that probably increase risk from 'cutting corners'.
here we do 1 cataract in about 1 hr to 1.5 hours including preop time and room turnover. We also place IVs ourselves. if not that requires even more staff to pay. no one speaks english. everyone is medicaid/medicare, so we lose a lot of money obvoiusly. hospital subsidizes.
all the people who say 0 minute turnover, then something is wrong here, if its just 1 MD going between room to room. a good preop takes time!!
And if anesthesiologist is LEAVING when the surgeon is closing, doesnt that mean the anesthesiologist is not billing for that time? is that even allowed?? its like if i just extubate during closing a gen surg case and walk out, is that patient abandonment? the procedure is technically not over
here we do 1 cataract in about 1 hr to 1.5 hours including preop time and room turnover. We also place IVs ourselves. if not that requires even more staff to pay. no one speaks english. everyone is medicaid/medicare, so we lose a lot of money obvoiusly. hospital subsidizes.
all the people who say 0 minute turnover, then something is wrong here, if its just 1 MD going between room to room. a good preop takes time!!
And if anesthesiologist is LEAVING when the surgeon is closing, doesnt that mean the anesthesiologist is not billing for that time? is that even allowed?? its like if i just extubate during closing a gen surg case and walk out, is that patient abandonment? the procedure is technically not over
Why do you need a good preop for a cataract? It's a cataract. Can you lay there for fifteen minutes without dying? Then you can get a cataract.
Why does it take an hour? It's a 10 minute procedure. And if there's an hour between cases why does the nurse not place the iv? Strange.
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deleted87051
You don’t really need a good preop for cataracts. Preop nurse will let you know if they’re not fasted. Basically mine is, review the preop questionnaire, confirm allergies, “you’ll be aware but relaxed, it’s important for you to look directly at the light and not move or reach up with your hands. If you’re not comfortable at any point, let us know and we’ll make things better.” Our turnovers (room out to room in) with cataracts are under 5min. Agree it takes more time if you need an interpreter or they’re HOH.
Can you not bill the patient directly for 200$?
Medicare medicaid or in network insurance, no. I don't underarand why anesthesia needs to bill a "crazy" amount. As mentioned, our proposed group wants to bill ~5x medicare which sounds like what the people on this thread believe it should be (Medicare apparently pays 20% for privately insured patient per this thread). The private insurances in this market play much closer to Medicare. Maybe we should offer as an option "premium" sedation/anesthesia services in our refractive services (technically illegal).
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deleted87051
Most of our surgeons say private insurance pays 110-130% of Medicare. But Medicare reimbursement is terrible for anesthesia. A typical cataract would be paid about $120-130/case by Medicare. 5x Medicare would be $600/case which is comparable to a self pay plastics case of similar duration. I think that’s reasonable but the only way you can do that is if you don’t take care of any other Medicare patients.
The “crazy amount” comes into the picture if you are a Medicare participating provider and you get a lineup where 10/12 patients are Medicare. Then you may OON bill the 2 commercial insurance patients a “crazy amount” to make up for the revenue lost on the Medicare patients.
its a ~50 min procedure here. the preop nurse does her paperwork for all the OR cases, not just the cataract, so she got no time for IV. all the cases with anesthesiologist are IV done by anes team.
we dont have a dedicated housekeeping team just for cataract. so it take time for them to come and mop. also need to wait for room to dry.
getting interpreter easily increases length of preop by 2-3x
a full day of cataract is ~6 cataract
I don't understand anything you're saying.
It's a cataract. What needs to dry? What do you need to wash? It's a cataract.
The preop goes from 30 seconds to 1 minute? It's a cataract.
A full day of cataracts is 12-20. Because it's a cataract.
It’s a cataract!
But that’s why @dantt can’t understand why we want to bill “crazy” amount for it. Because…… it’s a cataract.
My life is wasting in front of me, after I give a “good” dose of whatever we give…..
Until that one that just can’t stay still…. I am “freaking out”. “Why am I not out, I’d prefer to be out….” “He’s moving…..”
no ****ing ****. The patient is alive, head is 6 feet away from me, and you want him to walk out in 20 mins. I am good, not THAT good. And guess what? If the patient needs general, we can do that. If the patient needs general AND to be intubated. I can do that too…..
Just because the surgery is quick, easy and bloodless doesn't mean the anesthesia is.
From what I understand, anbuitachi has the FDA certified worst job in america
It's cool though, no SRNAs. Even though you get an SRNA salary.
What kind of free market USA capitalist bs is that?
Dont't tell me people are not taking cash from people on Medicare under the table because that's what happens here. Some university professors were notorious for not even looking at the patient if he wasn't coming in with a 5k€ enveloppe for their surgery.
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deleted941485
Lol they don’t have the balls to pull that off.
