CRNA billing

[echod]

Is it true that billing codes and reimbursements are the same for independent CRNAs and anesthesiologists? Does this mean that in states (ie. california) that allow independent CRNAs the nurse anesthetist and anesthesiologists would be reimbursed identically for the same procedure? So theoretically CRNAs could make the exact same as an anesthesiologist for the same job?

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[goosegas]

For the most part, yes. There may be some variation in what Medicare/caid may reimburse between the two, but most private insurance does not differentiate. However, if you are referring to Opt Out when you mention independent CRNA practice, that has nothing to do with a CRNA's ability to bill insurance or the amount that they are reimbursed. They can bill and get reimbursed in non Opt Out states just the same as they can in an Opt Out state.

 

[IlDestriero]

The myth of cheaper care is just that.
CRNAs working for a Hospital, management company, or specialty group may have a lower salary if employed, but the group doing the billing will be getting rich off of their labor. This is true for employed physicians as well.
The only thing really cheaper about CRNAs is the cost of their training.
It's also why a PP group with 4:1 coverage employing their own CRNAs is the way to clean up in this business.

Cheers!

 

[cchoukal]

They can bill and get reimbursed in non Opt Out states just the same as they can in an Opt Out state.

I'm not sure this is quite right. My understanding is that the opt-out refers specifically to this issue. That is, the opt-out is "opting out" of the requirement that a CRNA be directed by an anesthesiologist in order to bill Medicare.

In other words, as I understand it, the law has nothing to do with supervision from a practice perspective, it does nothing to change what's "allowed by law" in terms of supervision, and does not guide hospital by-laws about what kinds of practice are allowed within hospital walls. It only removes the requirement that CRNAs be directed by an anesthesiologist in order to bill Medicare.

 

[lushmd]

When a given state's governor opts out, they are opting out of the federal requirement for physician (note, not anesthesiologist; could well be the proceduralist) supervision of anesthesia for the purpose of Medicare billing (i.e. without an opt out, physician supervision of anesthesia is part of Medicare's conditions of participation). There is no statutory requirement for anesthesiologist supervision (although this may be part of individual hospital/health system bylaws).

Echod, to answer your question: Medicare and many private insurers will pay the same for anesthesia services regardless of anesthesiologist involvement. If you include rural pass through payments (via Medicare part A), independent CRNAs in certain settings (very limited) can actually be paid more than anesthesiologists for a given anesthetic at a given hospital (something of a moot point since anesthesiologists typically don't practice at these rural hospitals due, at least in part, to the financial dis-incentive).

 

[goosegas]

My understanding is that the opt-out refers specifically to this issue. That is, the opt-out is "opting out" of the requirement that a CRNA be directed by an anesthesiologist in order to bill Medicare.

No, this is incorrect. No state or federal rule/law requires a CRNA to be supervised or directed by an anesthesiologist as a practice or billing requirement. And CRNA's can bill Medicare or private insurers regardless of the states Opt Out status. HHS requires a CRNA to be supervised by a physician (doesn't have to be an anesthesiologist) as a condition of participation for hospitals. If a state chooses to Opt out, a hospital can still choose to have CRNA's supervised if they wish.

 

[Sublimazing]

No, this is incorrect. No state or federal rule/law requires a CRNA to be supervised or directed by an anesthesiologist as a practice or billing requirement. And CRNA's can bill Medicare or private insurers regardless of the states Opt Out status. HHS requires a CRNA to be supervised by a physician (doesn't have to be an anesthesiologist) as a condition of participation for hospitals. If a state chooses to Opt out, a hospital can still choose to have CRNA's supervised if they wish.

Just curious,

In the attached HHS it mentions in section 4 that the CRNA must be under the supervision of an anesthesiologist or "operating practitioner"

Later in C it states supervision as only by a "physician"

In compliant (non opt out) states can a non physician practitioner fully licensed in GA supervise?

 

[jwk]

Just curious,

In the attached HHS it mentions in section 4 that the CRNA must be under the supervision of an anesthesiologist or "operating practitioner"

Later in C it states supervision as only by a "physician"

In compliant (non opt out) states can a non physician practitioner fully licensed in GA supervise?

??? "Fully licensed in GA" Is that Georgia, or general anesthesia, or what?

A CRNA can't supervise anyone except perhaps a student, or other anesthetists in a management (non-clinical) capacity.

 

[saratoga733]

Regardless of the legal fine print... most surgeons I know have absolutely ZERO interest in being responsible for the anesthetic, i.e 'supervising' CRNAs. Heck they have their hands full and are barely interested in supervising their own residents/fellows! In fact most look forward to blaming the anesthesiologist should any go wrong... and I mean ANYTHING. How do they do that when they are 'directing' the anesthetic?? All the while leaving their wallets wide open should malpractice suits come their way...

 

[CVRN]

Regardless of the legal fine print... most surgeons I know have absolutely ZERO interest in being responsible for the anesthetic, i.e 'supervising' CRNAs. Heck they have their hands full and are barely interested in supervising their own residents/fellows! In fact most look forward to blaming the anesthesiologist should any go wrong... and I mean ANYTHING. How do they do that when they are 'directing' the anesthetic?? All the while leaving their wallets wide open should malpractice suits come their way...

It's my understanding that a "supervising" surgeon has no extra liability than when working with an anesthesiologist. In fact, if they do dictate any specifics of an anesthetic they and the crna would be opening themselves to more liability. Essentially they order "anesthesia as per crna" and that's that. Here is an article that explains it and provides some case law examples: http://lawmedconsultant.com/3226/supervision-of-crnas-does-not-create-liability-for-surgeons/ I couldn't really say how credible this article is but the author feels pretty strongly about it

 

[okayplayer]

It's my understanding that a "supervising" surgeon has no extra liability than when working with an anesthesiologist. In fact, if they do dictate any specifics of an anesthetic they and the crna would be opening themselves to more liability. Essentially they order "anesthesia as per crna" and that's that. Here is an article that explains it and provides some case law examples: http://lawmedconsultant.com/3226/supervision-of-crnas-does-not-create-liability-for-surgeons/ I couldn't really say how credible this article is but the author feels pretty strongly about it

"About the author: Greg Stocks has nearly 3 decades experience in health care including 20+ years as a nurse anesthetist. He holds an Executive Juris Doctor in Health Law.*"

Shocking, another bullsh*t article posted from Dr Murse CRNA ARNP RN BSN LPN. Clown question bro.

 

[BLADEMDA]

It's my understanding that a "supervising" surgeon has no extra liability than when working with an anesthesiologist. In fact, if they do dictate any specifics of an anesthetic they and the crna would be opening themselves to more liability. Essentially they order "anesthesia as per crna" and that's that. Here is an article that explains it and provides some case law examples: http://lawmedconsultant.com/3226/supervision-of-crnas-does-not-create-liability-for-surgeons/ I couldn't really say how credible this article is but the author feels pretty strongly about it

Where does "anesthesia issues" begin and Medical problems related to the surgery stop?
Who assumes responsibility for the preop, intraop and postop care of all the medical issues during the case? Will the surgeon get another medical doctor's opinion and expertise in the care of his/her patient when using a solo crna?

While it is factual the anesthesia portion of the case is solely the responsibility of the solo crna the fact remains surgeons are taking on more liability for every case they do with such an arrangement. Only a delusional midlevel provider can't grasp the concept of Nurse vs Physician in front of a jury consisting of plumbers, electricians, janitors and teachers.

Surgeons aren't getting one extra dollar for using a solo crna over a Physician Anesthesiologist/ACT so why in world would he/she prefer such an arrangement? The places where Solo CRNAs are utilized include ASCs where the surgeon/doctor owner reaps the benefits of supervising the midlevel provider or in rural hospitals where Anesthesiologists simply don't exist.

 

[BLADEMDA]

Regardless of the legal fine print... most surgeons I know have absolutely ZERO interest in being responsible for the anesthetic, i.e 'supervising' CRNAs. Heck they have their hands full and are barely interested in supervising their own residents/fellows! In fact most look forward to blaming the anesthesiologist should any go wrong... and I mean ANYTHING. How do they do that when they are 'directing' the anesthetic?? All the while leaving their wallets wide open should malpractice suits come their way...

You are correct. CRNAs blur the lines between anesthesia and medical related issues which they aren't trained to handle as a Nurse. CRNAs are ONLY responsible for the anesthesia and all other issues related to the care of the patient are the surgeon's responsibility including complications in the PACU.

There are also moral implications in taking care of patients:

For example, the Solo CRNA can't intubate the patient for a lap chole. He gave 50 mg IV of Rocuronium and is having trouble masking the patient. Glidecope and LMA attempts are unsuccessful. Saturation remains 50%.
CRNA is shaken and anxious with only 1 year of post CRNA school experience. Should the surgeon cut the neck? Who is going to get the airway here? What should the surgeon do next? If the surgeon now takes part in helping the CRNA secure the airway and the patient dies who is responsible? What if the surgeon does a Cric and the patient develops severe complications postop?

Case number 2: CRNA sees a patient in the holding area. CRNA misreads the EKG or doesn't recognize EKG changes. Who is responsible for the postop MI in the PACU? Was this anesthesia or a surgeon error?
Afterall, the surgeon ordered the EKG.

I can think of many more scenarios where the surgeon is taking on more responsibility ALONE for the care of his/her patient by utilizing a Solo CRNA.

In the end the jury will hear "I'm just a Nurse he is the Doctor."

 

[BLADEMDA]

"The vast majority of surgeons will complete their careers without ever experiencing an anesthesia mishap leading to a lawsuit in one of their patients."

http://lawmedconsultant.com/3226/supervision-of-crnas-does-not-create-liability-for-surgeons/


I took that quote from the legal article posted by a CRNA. Here in Florida that statement is FALSE for both Surgeons and Anesthesiologists.

The lawyers look at all "mishaps" in the operating room/pacu which led to a complication as joint responsibility between Anesthesia and Surgery. It must be perfectly clear that the complication was strictly surgery related like a postop total joint infection to completely absolve anesthesia. This is also true for anesthesia complications. We are a "team" in the OR and this means co-responsibility for patient care/outcomes.

Case 3: Patient presents with acute abdomen/bowel perforation for Expl. Lap. Surgeon does not order or place NG/OG tube. During the RSI the patient aspirates 100 mls of gastric content into her lungs. She develops ARDS, Renal Failure and dies on POD#26. Family sues. Who is responsible here? Who will the lawyer sue?

 

[BLADEMDA]

MIAMI, FL— August 10, 2011 - The family of an Ohio man who died when an apparent medical error occurred before he could undergo surgery at a Kissimmee hospital in 2006 filed a medical malpractice lawsuit against an anesthesiologist and his medical group. According to information provided by the Orlando Sentinel, although the anesthesiologist’s insurer has since settled with the family for $1 million, the doctor did not appear to believe that he deviated from the standard of care.

Reports indicated that in 2006, Harold Hicks, then 67, got sick during his yearly golfing trip to Orlando. According to Harold’s widow, Barbara, “He helped me learn to play golf so after retirement we could play a lot of golf together. We both worked hard and were looking forward to having a lot of free time… He didn't get much of it.”

Hicks reportedly became ill after going out to eat with friends and family members who were also on vacation. When his wife brought him to Osceola Regional Medical Center, where he discovered that he was suffering from a blocked intestine that would require him to undergo surgery.

The pending medical negligence lawsuit claims that although the surgeon directed Dr. Scott Wurm, an anesthesiologist at Osceola Regional Medical Center, to pump the sick patient’s stomach to relieve bloating prior to the operation, that never happened.

After Dr. Wurm instructed his nurse-anesthetist to intubate the sick patient, he immediately exited the operation room, the medical negligence suit claimed. Citing standards of practice and hospital procedures, the lawsuit contended Wurm should have been watching his nurse-anesthetist as she placed a breathing tube down Hicks’ throat.

According to the anesthetist’s insurer, Hicks suffered brain damage after he became nauseous and inhaled his own vomit. Hicks’ hospital death was ultimately attributed an infection that he sustained by breathing vomit into his lungs, a recognized medical complication associated with intubation. The insurer settled with the family on the basis that it agreed that the doctor should have been supervising the intubation procedure.

 

[BLADEMDA]

Failure to properly supervise

The following closed claim study is based on an actual malpractice claim from TMLT. This case illustrates how action or inaction on the part of physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician's defensibility. An attempt has been made to make the material less easy to identify. If you recognize your own claim, please be assured it is presented solely to emphasize the issues of the case.
Presentation

A one-year-old child was admitted to a community hospital on February 18 for an adenoidectomy and bilateral tympanostomy. The child's father signed the anesthesia consent form which stated, "I hereby consent to the anesthesia service checked above and authorize that it be administered by Dr. A or his/her associates, all of whom are credentialed to provide anesthesia services at this health facility."
Anesthesia was provided by a Certified Registered Nurse Anesthetist (CRNA) — an employee of Dr. A's professional association — and a student training as a CRNA under an agreement between Dr. A, the hospital, and the university where the student was enrolled.
Physician action

The student and CRNA commenced anesthesia at 7:20 a.m. and ended at 8:30 a.m. Intravenous fluids of 450 cc of D5LR were infused during the procedure. There was no fluid output recorded. At the conclusion of the procedure, the patient was extubated by the student under the direction of the CRNA. Upon extubation the child exhibited signs of laryngospasm and his oxygen saturation dropped into the 30s. The student applied a chin lift and gave oxygen by mask and the laryngospasm ceased within one minute; however, the child continued to show evidence of shallow respirations. The CRNA testified that the child's oxygen level remained high when oxygen was given, but would drop when the mask was removed.
The child arrived in the Post Anesthesia Care Unit (PACU) at 8:35 a.m. and was initially described as pink in color; however, quickly became dusky around the lips. He was reintubated at 8:40 a.m. An IV of Ringers Lactate was started for fluid management. PACU records indicated the child received 500 cc of D5LR intraoperatively and 125 cc of additional IV fluids and medications. Urine output in the PACU was 355 cc. A chest x-ray revealed diffuse density over both lung fields, consistent with volume overload or possible aspiration. Dr. A was paged and arrived in the PACU at 8:50 a.m. He ordered Lasix for diuresis to improve the child's pulmonary edema and immediately arranged for transfer to a children's hospital.
Arterial blood gases (ABGs) were drawn at 8:45 a.m. and 9:50 a.m., both showing critically low PO2 and low oxygen saturations in the 80s. A second chest x-ray, taken about 9:35 a.m. showed improvement, but with new right upper lobe and perihilar infiltrates. The child was admitted to the children's hospital, sedated, and placed on a ventilator. His pupils were 2 mm and reactive; however, all four extremities were hypotonic. A chest x-ray taken at 1 p.m. showed the lungs were clear.
The child self-extubated at 11 p.m. the same day, and the attending ICU medical residency fellow elected not to reintubate. During the night, his respiratory rate went from 36 at 12 a.m. to 95 at 8 a.m. At 8:25 a.m., the child experienced acute decompensation. He was reintubated, requiring sodium bicarbonate to correct a pH of 6.9 (normal 7.35-7.45) and a base deficit of 19 (normal ± 3 mEq/l). He subsequently developed a pneumothorax and pneumomediastinium requiring a chest tube and mediastinal tube. His oxygen saturations stabilized; however, he developed severe hypotension with poor perfusion.
A cardiology consult was obtained and revealed an enlarged right atrium and right ventricle, consistent with chronic pulmonary hypertension. On February 23, he developed seizure activity of two to three minutes duration that resolved spontaneously. CT scan of the head revealed diffuse cortical, subcortical and cerebellar edema, as well as infarctions of the posterior left frontal lobe, left parietal lobe, and occipital lobes. It was thought that these changes represented an injury either during the severe pulmonary hypertensive crisis or during the surgery.
An EEG performed on February 25 revealed severe injury to the brain with moderate voltage slow waves consistent with irreversible injury. An MRI was performed on February 28. It revealed cortical and subcortical cerebral edema, consistent with a generalized anoxic-ischemic insult. The child's neurological status slowly improved and he was extubated on March 1. He was discharged to a children's rehabilitation facility on March 14 where he remained for one month. At the time of discharge, neurological status included seizures, decreased vision, bilateral absence of visual evoked potentials (suggesting severe dysfunction along the visual pathways), and physical limitations resulting from moderate to severe encephalopathy.
Allegations


A lawsuit was filed against the anesthesiologist. The allegations were primarily focused on Dr. A's professional association and included:

• allowing a non-credentialed student to administer anesthesia without proper supervision;
• failure to obtain appropriate informed consent related to administration of anesthesia by a student; and
• vicarious liability for the actions of the CRNA and the student.

Legal implications

The legal concept of vicarious liability allows liability to be extended beyond the original defendant to persons or entities who have not committed a wrong, but on whose behalf the defendant acted. Vicarious liability is based on the historical legal doctrine of "respondeat superior" — let the master answer for the torts (civil wrongs) of his servants. The CRNA in this case was an employee of the PA and the anesthesiologist was vicariously liable for her actions or omissions.
Three defendant anesthesiology consultants were generally critical of fluid management by the CRNA and the student during surgery; however, they questioned whether the fluid overload was sufficient to cause pulmonary edema. The consultants were also critical of the delay in reintubating the child following the laryngospasm, and that Dr. A was not contacted for assistance when the laryngospasm occurred. All the consultants were critical that Dr. A was not in the operating room or in the operating suite during the procedure. Two of the consultants questioned whether the injury occurred at the community hospital or after the child self-extubated at the children's hospital.
Expert testimony in this case supported the general care and treatment given by the CRNA, the student, and Dr. A. However, it was difficult to obtain support for the informed consent issue since the non-credentialed student provided anesthesia under the supervision of a CRNA, without the presence of Dr. A, who was designated as the clinical instructor for the student. The plaintiffs retained credible experts who were critical of the medical care, as well as the informed consent process, specifically a student administering anesthesia.
During her deposition, the student testified that she provided 80% of the anesthesia under the supervision of the CRNA. She further testified that she did not consider herself one of Dr. A's associates and, in her opinion, the family should have been advised that a student would be providing the majority of the anesthesia.
Disposition

This is an unfortunate case, resulting in a neurologically impaired young child, including physical limitations on the right side and visual impairment. The child requires continued physical, occupational, and speech therapy. Past medical expenses, future life-care needs, and future loss of wage-earning capacity are significant. The claim was settled on behalf of Dr. A and his professional association.
Risk management considerations

More frequently, anesthesiologists are practicing within an anesthesia care team model, whereby anesthesia is administered by a non-physician provider under the supervision of an anesthesiologist. The American Society of Anesthesiologists (ASA) has developed recommendations for the scope of practice of nurse anesthetists. (1) In these situations, " . . . the anesthesiologist concurrently medically directs two, three or four nurse anesthetists and/or anesthesiologist assistants in the performance of the technical aspects of anesthesia care. Anesthesiologists engaged in medical direction are responsible for the pre-anesthetic medical evaluation of the patient, prescription and implementation of the anesthesia plan, personal participation in the most demanding procedures of the plan (including induction and emergence), following the course of anesthesia administration at frequent intervals, remaining physically available for the immediate treatment of emergencies and providing indicated postanesthesia care." (1)
"Although selected tasks of overall anesthesia care may be delegated to qualified members of the Anesthesia Care Team, overall responsibility for the Anesthesia Care Team and the patients' safety rests with the anesthesiologist." (2)
All consultants were critical of Dr. A. for his alleged failure to follow the ASA recommended scope of practice and for his failure to be physically available in the hospital or operating suite to provide immediate treatment during the emergence phase of anesthesia. Additionally, one might question whether the student was a "qualified member" of the anesthesia care team, as described in ASA Statement of the Anesthesia Care Team, and question whether the administration of anesthesia should have been delegated to her.
The Texas Occupations Code specifically states, " . . . a physician may delegate to a certified registered nurse anesthetist the ordering of drugs and devices necessary for the nurse anesthetist to administer an anesthetic or an anesthetic-related service ordered by the physician." (3) Therefore, Dr. A was in violation of the code by delegating the administration of anesthesia to a non-credentialed student, and/or allowing supervision by the CRNA.
The case illustrates the importance of the availability of anesthesiologists to non-physician personnel administering anesthesia under their supervision. With the integration of the anesthesia care team model into our health care system, it is important for anesthesiologists to adhere to ASA standards and Texas statutes regarding delegation of responsibility.

 

[BLADEMDA]

FACTS


Sharilynn Starcher was admitted to Gulf Coast Medical Center on September 18, 1988 for elective surgery to correct a ventral hernia which was to be performed by the defendant,

[ 687 So.2d 739 ]​

Dr. David Byrne. The surgery was unsuccessfully attempted the next evening. The regular anesthesiologist, Dr. Jack Coursey, was not present to begin the anesthesia process. In his stead was Nurse William Wright, a certified registered nurse anesthetist (CRNA) and an employee of Dr. Coursey. Testimony elicited at trial showed that: Dr. Byrne was not Wright's supervisor; Dr. Byrne had little, if any say over the anesthesia process and was not expected to inject himself into the anesthesia process; Dr. Byrne could not definitively tell Wright what to do and expect that Wright would obey those commands if Wright thought that Dr. Byrne was wrong; it is not at all unusual for a CRNA to perform the anesthesia for surgical procedures in the total absence of an anesthesiologist so long as a physician is available in case of an emergency, and CRNAs in this state are trained to do so.
At the beginning of the anesthesia induction process, Dr. Byrne received an emergency page concerning another surgery that he had completed earlier that day on another patient. He went into the hallway to answer that page while the anesthesia process was being completed. The hallway was, of course, outside the operating room, but was within the operating suite and only about thirty feet from the operating room door. The operating suite is the area consisting of all the operating rooms as well as the doctors' lounge and scrub room. It was the hospital policy at that time that the surgeon was not expected to be in the operating room, but only had to be in the operating suite at the time that the anesthesia process began. After completing the telephone call, Dr. Byrne returned to the operating room where he noticed that there was a problem with the anesthesia induction. Dr. Byrne and Nurse Wright determined that Sharilynn was suffering from a bronchospasm, which is a constriction of the muscles of the throat that makes the passage of air to and from the lungs very difficult. Based on their diagnosis, the operating team conducted emergency treatment for a bronchospasm. Due to the patient's condition, her heart rate began to fall rapidly. It is the testimony of all persons present that Dr. Byrne administered Epinephrine, a drug which raises the heart rate and relaxes muscles, to counteract both the constricted throat muscles and the falling heart rate, although no notation was made in the hospital records to that effect. Dr. Byrne successfully administered CPR to Sharilynn Starcher at which time she was stabilized. As a result of her inability to breathe and the failure of her heart to adequately pump blood to all regions of her body, specifically her brain for several minutes, Sharilynn suffered brain damage resulting in decreased intellectual and physical capacity. She remained comatose for several days following this incident.

 

[BLADEMDA]

The Surgeon in the case above was found not liable and the Justices felt that the Captain of the Ship doctrine did not apply here. They did point out that the Captain of the Ship Doctrine could apply in the right situation but not in this case. One Justice dissented:


McRAE, J., dissents with separate written opinion.
McRAE, Justice, dissenting:
Unlike the majority, I am not persuaded that the "captain of the ship" doctrine is inapplicable to the case sub judice. In most states, surgeons may be found liable for the failure to supervise a nurse-anesthetist or vicariously liable for a nurse-anesthetist's negligence. 8 Am.Jur. Proof of Facts 2d, Surgeon's Failure to Exercise Supervision and Control over Anesthetist § 1,6 (1976). Such liability is usually predicated upon the captain of the ship doctrine, consistent with the premise that "the obligation to provide anesthesia is not necessarily limited to one person." McCullough v. Bethany Medical Center,235 Kan. 732, 737, 683 P.2d 1258, 1262 (1984). That the surgeon is captain of the ship does not expose him to unfettered liability for the acts of all personnel in the operating room. Rather, at least one court has found that the "vital test" is whether the surgeon has the right to control the employee. Harris v. Miller,103 N.C. App. 312, 322, 407 S.E.2d 556, 562 (1991). In the case sub judice, the issue of whether Dr. Byrne had the right to control Nurse Wright was a proper matter for the jury to consider.

 

[BLADEMDA]

http://www.aana.com/newsandjournal/Documents/legal_briefs_0498_p107.pdf

I read all of these cases. My conclusion? Hire the best Anesthesiologist money can buy and fight like hell to keep the unqualified CRNA from practicing solo. It is dangerous out there and CRNAs have no business practicing solo.

I did NOT take away from any of these cases that Surgeons are better off with a Solo CRNA; on the contrary, this makes a Surgeon/Physician realize he/she needs the most competent, most qualified Anesthesiologist money can buy.

 

[BLADEMDA]

http://lawmedconsultant.com/3226/supervision-of-crnas-does-not-create-liability-for-surgeons/

Forgot the Bull**** commentary. Read the legal cases. I read most of them. My conclusion is far different than the author of this "editorial" and I could use most of these legal cases to scare the **** out of my surgical collegaues. Not a single one would want a Solo CRNA after reading these legal cases.

 

[CVRN]

I've offered no replies to any of the comments my post stirred up because I am 100% unqualified to agree or disagree. However, to my surprise, I stumbled across a rebuttal article:

http://lawmedconsultant.com/3689/su...vision-dont-ask-an-anesthesiologist/#comments

I'm simply the messenger here and I have no connection to lawmedconsultant whatsoever.

 

[Coastie]

I've offered no replies to any of the comments my post stirred up because I am 100% unqualified to agree or disagree. However, to my surprise, I stumbled across a rebuttal article:

http://lawmedconsultant.com/3689/su...vision-dont-ask-an-anesthesiologist/#comments

I'm simply the messenger here and I have no connection to lawmedconsultant whatsoever.

I agree, you are unqualified to comment on medical discussions regarding physician responsibility and patient care.

So, begs the question..Why did you comment at all?

It couldn't be to stir up trouble, right?

Patients don't want solo nurses. Surgeons don't want solo nurses, and any one of em worth their salt sure as heck don't want the responsibility to operate and medically take care of the patient. It's not just a legal matter, but anyone who took an oath to protect patients (as all physicians do), wouldn't stand for a solo nurse to even try to practice medicine without a license or training.

Why send in a nurse to perform a medical duty? It's disingenuous to the patient, fraudulent to bill nursing level care at medical rates, and patients generally don't stand for it.

So, if you wouldn't mind CVRN, please take your inflammatory and poorly researched commentary elsewhere.

 

[CVRN]

I agree, you are unqualified to comment on medical discussions regarding physician responsibility and patient care.

So, begs the question..Why did you comment at all?

It couldn't be to stir up trouble, right?

Patients don't want solo nurses. Surgeons don't want solo nurses, and any one of em worth their salt sure as heck don't want the responsibility to operate and medically take care of the patient. It's not just a legal matter, but anyone who took an oath to protect patients (as all physicians do), wouldn't stand for a solo nurse to even try to practice medicine without a license or training.

Why send in a nurse to perform a medical duty? It's disingenuous to the patient, fraudulent to bill nursing level care at medical rates, and patients generally don't stand for it.

So, if you wouldn't mind CVRN, please take your inflammatory and poorly researched commentary elsewhere.

I mentioned the article because it was relevant to the topic at hand and nothing that I have said could be considered inflammatory. I'm not a CRNA let alone a solo CRNA and I have not argued for or against it so I'm not sure what you're talking about. It was only a matter of time before someone else stumbled across this article that directly referenced this thread and they would have then posted it. If they were a physician, you would not accuse them of stirring up trouble. Really, I have nothing i care to argue about. My intentions: learn about anesthesia. That's it. I've been reading SDN for a few years now and only rarely will I post something. I don't plan on changing that either so don't worry.

 

[BLADEMDA]

I've offered no replies to any of the comments my post stirred up because I am 100% unqualified to agree or disagree. However, to my surprise, I stumbled across a rebuttal article:

http://lawmedconsultant.com/3689/su...vision-dont-ask-an-anesthesiologist/#comments

I'm simply the messenger here and I have no connection to lawmedconsultant whatsoever.

They love me over at murseanesthesia.com.

Surgeons aren't lawyers. That is a fact. Secondly, I didn't misrepresent the law at all; but, rather attempt (feebly I may add) to show that one CRNA's legal opinion isn't the entire authority on this subject. Like our Court system has shown legal opinions vary significantly from judge to judge.

Surgeons do incur increased liability by using Solo CRNAs in place of Anesthesiologists. They know it and the OR nurses know it. They do it because they have no Other option or they can profit off the anesthesia portion of the case. It's that simple. Of course, this is my opinion again just as it is my opinion you need a parachute when you jump out of a Plane at 5,000 feet. There are no solid studies for either but both are just as obvious to anyone willing to examine the facts. There are no free lunches. Anesthesia nurses have a limited scope of knowledge and a wide range of practice skills.
Most surgeons recognize this limit to midevel providers and are glad to have a second Physican in the perioperative setting to help deal with medical issuss

Why do solo CRNAs exist at ASCs and Gi centers? Is it because CRNAs save money? Really? Who exactly saves money? Does the patient get a choice to decide between advanced anesthesia nurse and Physician Anesthesiologist?

 

[BLADEMDA]

I mentioned the article because it was relevant to the topic at hand and nothing that I have said could be considered inflammatory. I'm not a CRNA let alone a solo CRNA and I have not argued for or against it so I'm not sure what you're talking about. It was only a matter of time before someone else stumbled across this article that directly referenced this thread and they would have then posted it. If they were a physician, you would not accuse them of stirring up trouble. Really, I have nothing i care to argue about. My intentions: learn about anesthesia. That's it. I've been reading SDN for a few years now and only rarely will I post something. I don't plan on changing that either so don't worry.

CRNA solo practice is an abomination of our Health care system. What other first world country allows anesthesia nurses to run wild on patients without physician oversight?
Why havent the socialized European nations embraced these cheaper solo nurses?
Anesthesiology is the practice of medicine- perioperative medicine. Anesthesia nurses are technicians with a limited knowledge base and quite frankly, inadequate training to care for our sickest patients.

 

[BLADEMDA]

One last thing: all the legal bull**** in the world doesn't change the fact that a CRNA is viewed as a second tier provider by the surgeon and OR staff. The surgeon and patient prefer the most qualified, skilled anesthesia provider money can buy. But, there aren't enough Anesthesiologists to go around so we settle for a CRNA/MD model as the next Best thing. Both CRNAs and Anesthesiologists have benefited for decades with this arrangement.

While a few militant CRNAs claim equality with Anesthesiologists the vast majority do not. In fact, those militant CRNAs seeking independent practice would serve their patients far better if they got an MD instead of a JD or PhD. But, that is just my opinion again.

 

[BLADEMDA]

I've offered no replies to any of the comments my post stirred up because I am 100% unqualified to agree or disagree. However, to my surprise, I stumbled across a rebuttal article:

http://lawmedconsultant.com/3689/su...vision-dont-ask-an-anesthesiologist/#comments

I'm simply the messenger here and I have no connection to lawmedconsultant whatsoever.

Read the legal cases and leave the propaganda based commentary with the AANA. Common sense shows we need the most qualified Anesthesia provider available at all times for patient care. To most surgeons the most qualified anesthesia provider in the USA isn't a nurse.


The way I see this argument is quite simple: You have no legal obligation to help the man bleeding to death in the street or is about to walk in front of the oncoming car. There is no legal requirement or increased risk of lawsuit if you simply ignore the situation. But, what about the moral implications of that decision? Using an inferior provider as the sole anesthesia provider has implications in the care of patients preop, intraop and postop. God help us all.

 

[jwk]

I mentioned the article because it was relevant to the topic at hand and nothing that I have said could be considered inflammatory. I'm not a CRNA let alone a solo CRNA and I have not argued for or against it so I'm not sure what you're talking about. It was only a matter of time before someone else stumbled across this article that directly referenced this thread and they would have then posted it. If they were a physician, you would not accuse them of stirring up trouble. Really, I have nothing i care to argue about. My intentions: learn about anesthesia. That's it. I've been reading SDN for a few years now and only rarely will I post something. I don't plan on changing that either so don't worry.

You must have missed this part - again...let me help you...

Law Med Consulting provides Medical Legal consulting services to attorneys, law firms, institutions and other professionals. Specialties include medical malpractice case investigation, specialized forensic medical record analysis, trial preparation assistance and Risk Management consulting. With 26 years of experience in Health Care, 19 in the advanced practice of anesthesia as a Certified Registered Nurse Anesthetist (CRNA), and a specialized Executive Juris Doctor (EJD) in Health Law, Greg Stocks provides a unique service to his clients.
​

Hardly an objective opinion.

 

[BLADEMDA]

You must have missed this part - again...let me help you...

Law Med Consulting provides Medical Legal consulting services to attorneys, law firms, institutions and other professionals. Specialties include medical malpractice case investigation, specialized forensic medical record analysis, trial preparation assistance and Risk Management consulting. With 26 years of experience in Health Care, 19 in the advanced practice of anesthesia as a Certified Registered Nurse Anesthetist (CRNA), and a specialized Executive Juris Doctor (EJD) in Health Law, Greg Stocks provides a unique service to his clients.
​

Hardly an objective opinion.

Objective and militant CRNA are oxymorons. These individuals want to practice like a Doctor without going to medical school. Part of that solo practice is to convince ignorant surgeons that solo CRNA is equivalent to a Physican Anesthesiologist in all aspects. Unfortunately, anesthesia nurses just don't grasp the concept that there is no clear line delineating anesthesia decisions and care from Medical related issues. I always look and consider the latter before deciding the former.

 

[CVRN]

You must have missed this part - again...let me help you...

Law Med Consulting provides Medical Legal consulting services to attorneys, law firms, institutions and other professionals. Specialties include medical malpractice case investigation, specialized forensic medical record analysis, trial preparation assistance and Risk Management consulting. With 26 years of experience in Health Care, 19 in the advanced practice of anesthesia as a Certified Registered Nurse Anesthetist (CRNA), and a specialized Executive Juris Doctor (EJD) in Health Law, Greg Stocks provides a unique service to his clients.
​

Hardly an objective opinion.

What are you helping me with? Where did I say it was objective? I posted the original article because it was relevant. You may feel that it's worthless and thus should not have been posted in the first place and that's fine. I posted the second article because it directly referenced this thread with quotes and all, not because I thought the rebuttal arguments were valid or not. If you want to comment on the rebuttal statements of the author go ahead, but I have nothing to debate about. I'm an SRNA here to learn and I will gladly go back to doing just that.

 

[Coastie]

What are you helping me with? Where did I say it was objective? I posted the original article because it was relevant. You may feel that it's worthless and thus should not have been posted in the first place and that's fine. I posted the second article because it directly referenced this thread with quotes and all, not because I thought the rebuttal arguments were valid or not. If you want to comment on the rebuttal statements of the author go ahead, but I have nothing to debate about. I'm an SRNA here to learn and I will gladly go back to doing just that.

How's the CRNA job market reported to SRNA's these days? My friends who are SRNAs and CRNAs say that it's pretty bad. Does this correlate with what you've been hearing in your neck of the woods?

 

[BLADEMDA]

What are you helping me with? Where did I say it was objective? I posted the original article because it was relevant. You may feel that it's worthless and thus should not have been posted in the first place and that's fine. I posted the second article because it directly referenced this thread with quotes and all, not because I thought the rebuttal arguments were valid or not. If you want to comment on the rebuttal statements of the author go ahead, but I have nothing to debate about. I'm an SRNA here to learn and I will gladly go back to doing just that.

Is common sense still permitted in CRNA school? Despite what you read on the militant website and at the evil AANA coNventions the facts on the ground do not support the wholesale use of CRNAs in an independent fashion. As some CRNAs will attest to in private the quality of many CRNAs do not warrant independent practice.

Since the AANA has no mechanism for separating the wheat from the chaff all CRNAs are treated exactly the same by the law. Nothing is more helpful to the Anesthesiologists' cause than that simple fact. Thank you AANA.

 

[AlmostJesus]

Problem: Shortage of anesthesia providers
Solution: Educate exponentially more quality MDAs which means creating more quality medical school and residency slots which is a very tedious process.
How many potentially great MDAs get turned away from medical schools every year? Many of these individuals may not have the perfect numbers for medical school but are still capable and willing to spend the time to become a MDA, thus they turn towards CRNA school as their back up plan.
OR
Educate more CRNAs or AAs in QUALITY programs and close down the online/for profit/low quality programs. The ones that will succeed are likely the ones that would have been turned away from medical school.
INSTEAD
What has happened now is the result of supply and demand. There aren't many MDAs because of the restrictions on the number of medical school slots in the US. The CRNA model came about due to this. There still was not enough anesthesia providers being put out, so along came the profiteers who opened the for-profit low quality CNRA schools. These are what ends up giving the profession a bad name.
The problem wouldnt have come about had the AMA not been so restrictive about the number of medical school slots in the US in order to keep the prestige of being a physician. This along with the restrictive number of residency positions led to a shortage of physicians, so the other professions started to step up to the plate and are now encroaching. Sounds to me like physicians shot themselves in the foot.
Maybe instead of arguing against CRNAs, you need to be lobbying for an increase in MD school slots.

 

[Coastie]

What's an MDA? What's an "anesthesia provider"?

Are you even on the correct forum?

Problem: Shortage of anesthesia providers
Solution: Educate exponentially more quality MDAs which means creating more quality medical school and residency slots which is a very tedious process.
How many potentially great MDAs get turned away from medical schools every year? Many of these individuals may not have the perfect numbers for medical school but are still capable and willing to spend the time to become a MDA, thus they turn towards CRNA school as their back up plan.
OR
Educate more CRNAs or AAs in QUALITY programs and close down the online/for profit/low quality programs. The ones that will succeed are likely the ones that would have been turned away from medical school.
INSTEAD
What has happened now is the result of supply and demand. There aren't many MDAs because of the restrictions on the number of medical school slots in the US. The CRNA model came about due to this. There still was not enough anesthesia providers being put out, so along came the profiteers who opened the for-profit low quality CNRA schools. These are what ends up giving the profession a bad name.
The problem wouldnt have come about had the AMA not been so restrictive about the number of medical school slots in the US in order to keep the prestige of being a physician. This along with the restrictive number of residency positions led to a shortage of physicians, so the other professions started to step up to the plate and are now encroaching. Sounds to me like physicians shot themselves in the foot.
Maybe instead of arguing against CRNAs, you need to be lobbying for an increase in MD school slots.

 

[jwk]

Problem: Shortage of anesthesia providers
Solution: Educate exponentially more quality MDAs which means creating more quality medical school and residency slots which is a very tedious process.
How many potentially great MDAs get turned away from medical schools every year? Many of these individuals may not have the perfect numbers for medical school but are still capable and willing to spend the time to become a MDA, thus they turn towards CRNA school as their back up plan.
OR
Educate more CRNAs or AAs in QUALITY programs and close down the online/for profit/low quality programs. The ones that will succeed are likely the ones that would have been turned away from medical school.
INSTEAD
What has happened now is the result of supply and demand. There aren't many MDAs because of the restrictions on the number of medical school slots in the US. The CRNA model came about due to this. There still was not enough anesthesia providers being put out, so along came the profiteers who opened the for-profit low quality CNRA schools. These are what ends up giving the profession a bad name.
The problem wouldnt have come about had the AMA not been so restrictive about the number of medical school slots in the US in order to keep the prestige of being a physician. This along with the restrictive number of residency positions led to a shortage of physicians, so the other professions started to step up to the plate and are now encroaching. Sounds to me like physicians shot themselves in the foot.
Maybe instead of arguing against CRNAs, you need to be lobbying for an increase in MD school slots.

I kinda think you're supportive of anesthesiologists, but it's a little hard to tell, since your rant turned into more of a condemnation of medical school admissions numbers.

So how far should medical schools decrease their admission requirements to get more students? I mean really - that's all that's required for numbers - oh, and of course more money for education. I wonder where that will come from?

 

[climbingak]

CRNAs did not come about because of a shortage of anesthesiologists. CRNAs are much older than that. I feel its the opposite. Although I wasn't around for the history of anesthesia, it seems like anesthesiologists came about because of the failure of solo CRNA practice. People were dying in large numbers from anesthesia. Physicians became involved and vast improvements in safety and technology were made.

The world being the way it is, we are coming full circle again. Anesthesia is so "safe" that some feel the solo nurse can again provide it without anesthesiologist oversight. If this happens widespread, we will see the other side of the circle, patient deaths. The field is deadly enough that physicians will always need to be leading the field. The unfortunate thing is the needless deaths that will happen before these same people realize they were wrong.

I worked with a CRNA who graduated from a for profit school personally performing less than 5 epidurals. His transcript read differently as he was allowed to count every epidural he observed his peers doing. This is not a consultant of anesthesia. I, for one, am not to concerned about my job security.

 

[IlDestriero]

I worked with a CRNA who graduated from a for profit school personally performing less than 5 epidurals. His transcript read differently as he was allowed to count every epidural he observed his peers doing.

That was common practice in the military as well when I was at one of their training hospitals. Watch another SRNA do a block/case, count it as yours. That didn't fly for the residents. There was one outside trained SRNA rotating through for OB (which fortunately was rare). He was about to graduate and could not properly place a labor epidural. He was very proficient in wet taps however, he had more in a day than I did in more than a decade. It was eye opening, and frightening. He had already completed his required OB rotations. I don't know what he did during that time, but it clearly was not OB anesthesia. The variability in CRNA training is frightening and, as Blade has pointed out, may be their undoing.
-
"The truth is incontrovertible, malice may attack it, ignorance may deride it, but in the end; there it is."