Brownman
I'll respond to your post, but first, a point or two. I believe you and I are in agreement on two fundamental points. First, that CRNA's should exist, and do perform a vital service in health care. Second, CRNA's are not overpaid. Your points about the market determining the value of services were exactly correct. If tomorrow somehow, the market were flooded with CRNA's, then CRNA salaries would decrease. I would not like it, but there would be little I could do about it. As you said, simple economics. I do appreciate your well thought out, intelligent posts.
On to your post. I've done a little editing for the sake of brevity, though I fear I have only succeeded in giving brevity a passing nod.
"Though by using the track that you and others have posted, I could get an anesthesiology assistant to also cover those cases. They are trained specifically in anesthetics and can be trained well enough to deliver anesthesia. Disregarding number of AA programs, or class size etc, you would have to concede using your own argument that AA's can deliver anesthesia in rural areas. Medicare has just not allowed independant reimbursement of these professionals yet. They might have to at the current rate of nursing shortage."
The AANA has come out strongly against AA's. I have not fully made up my mind, though the AANA makes some good points. The CRNA, before ever beginning school, has experience dealing with critically ill patients, since a minimum of one year's ICU experience is a prerequisite to all CRNA programs. The MDA, before ever beginning residency, must complete medical school. The AA is required to do neither. There is some justification, therefore, to saying that AA's have neither the experience nor education of CRNA's or MDA's.
But, you miss one other critical point. The license of the AA is dependent. In other words, the AA must practice under the supervision of an MDA. CRNA's, on the other hand, are independently licensed. In fact, all RN nursing licenses are independent. Any nurse can practice nursing, without the supervision of a physician. At the level of the bachelor's prepared RN, this has little consequence. Once the nurse is an advanced practitioner, however, the consequences of this independence are manifest. The AA, like all other PA's, has a dependent license. S/he must practice under the auspices of a physician. So, on that legal point, your argument fails.
"Well, it would both drive down the salaries of MDA's and limit the number of CRNA positions that are available, correct? If a physician is willing to take a lower salary, then is there an economic argument to having a CRNA? And it may no actually drive down the salary; only the salary in respect to hours of service performed. It would almost certainly reduce the need for additional anesthesia providers. So, in response, true but not completely."
Point taken. However, as I, you, and others have pointed out, the economic argument is spurious. CRNA's practicing independently bill at the same rate for their services as MDA's.
"Well, their path of entrance and movement and achievement is easier wouldn't you agree. I believe your achievements and accomplishments are the exception not the rule. So, I think it's understandable (maybe not logical but understandable) that people who are physicians would feel that getting to be a CRNA did not require as much effort as becoming a physician, and therefore should not be remediated as such. Is that logical? Probably not, but it's understandable I believe. Needless to say, if you saw an AA making more than a triage nurse...you might be mildly chagrined. I believe the analogy applies here as well."
Actually, I'm not the exception. All CRNA's attend master's level programs to become what they are, and most are very skilled and knowledgeble. Note, I did not say all, but then not all MDA's are highly skilled and knowledgeble, either, are they? It is also true that all of us, regardless of education, knowledge, or experience, is subject to the "brain fart." We are human, and can all make mistakes. I am a relatively new CRNA. For an MD to say s/he deserves more, from my viewpoint, IS understandable, but as you say, probably not logical. Each of us secretly believes we have done different things, have some innate ability or skill that makes us more than those around us. Most of us don't proclaim our secret belief, but at some level, it is there anyway. I won't say the path of entrance and achievement for a CRNA is easier than for an MD, but it is fundamentally different. I've highlighted some of those differences in earlier posts. Does that make the MDA better prepared to deliver an anesthetic than the CRNA? Each of us has our own opinions on that topic. Actually, AA's do make more than triage nurses (if I understand what you are referring to). The ER triage nurse is paid at the level of all other staff nurses, depending on experience. Where I live, that's between 30K and 50K a year. The last time I looked, a new graduate AA could expect to make about 70K right out of school. Of course, I last looked about three years ago. That may have gone up since then.
"I have friends who are paralegals for 20 years and honestly, know the law better than most anyone I've ever known. In life experience is the best teacher. But, the free market works by credential. Therefore all I can say is a CRNA can make whatever salary they want; it just shouldn't be higher than an MDA in the same market working the same hours. Reasonable, don't you think?"
You are correct, ours is a credential based society. Every profession, from auto mechanics, to physicians, has varying levels of professional certification. Each encourages the public to seek out the professional with the certification, and those with the certification earn higher salaries than those without. This is a simple fact of economics. To ask whether it is reasonable or not is like asking whether it is reasonable that the sky is blue. Reasonable or not, it is what it is. Whether the CRNA makes less, more, or the same as an MDA in the same market is equally a function of economics. As I pointed out earlier, an MDA fresh out of residency will often have difficulty breaking into a market that has been the domain of an all CRNA group. Surgeons, like all of us, are largely creatures of habit. The CRNA group is known to them, and they to the group. Preferences on both sides are well known. The new MDA has a very difficult time competing. Additionally, the new MDA generally does not have the experience of the CRNA group. Again, it is what it is. All that said, I agree with your fundamental premise, that a CRNA working in a market should not make more than an MDA in the same market, "all other things being equal."
"In the same sense, I believe a physician delivering a similar service to a CRNA should be able to bill more. Is that arrogant? I assume that's based on perception. But then it begs you to ask the question, why do you pay a lawyer from a top firm more per hour than the district attorney. Because there is that one time when you're really up S creek, and the trial lawyer is the only one with the paddle (or at least a paddle that can get you out of the mess). Like I said Kevin, I believe you are the exception not the rule. Not because other CRNA's can't be as good, but because they may not have the passion you do. All things being equal, you should pay more for the credential than that which does not have the credential, and that should be the system. And in relation to anesthesia, as all other fields of medicine it will be."
Again, arguing this point is like arguing the reason for the sky being blue. It is what it is. I have no qualm with MDA's being paid more than CRNA's when both are working in the same group. However, I differ on billing. Let's say that I and an MDA both perform an anesthetic for a patient undergoing a lumbar laminectomy. The outcome in both cases is the same, and both patients are well cared for (which I believe is true for the vast majority of anesthetics, whether delivered by an MDA or a CRNA). Why should I not be able to bill at the same rate? Your argument of paying lawyers is not applicable. Both lawyers have the same credential. You pay more to the top law firm because of a proven track record of winning cases, not for greater credential. Using this analogy, the anesthesia provider with the best track record, not the highest credential, should be highest paid. That's a true free market economy. However, payment for any medical service is capped by what medicare or the insurance company will pay. As I have said, I work for an anesthesia group owned and operated by anesthesiologists. In return for the anesthesia services I provide, I am paid a salary. That salary is lower than the income I generate through billing for the group, and less than the anesthesiologists that work in the same group. That's more simple economics. If I wanted, I could earn two to three times my current salary by leaving the urban area to work in a more rural community. I don't currently want to do that. In addition to my salary, my working for an anesthesia group relieves me of a large number of headaches. I don't have to worry about my malpractice insurance, my own health care coverage, or deal with the headaches of billing, among other things. And, as I have said, I am backed up by anesthesiologists with a ton of experience. But, the bottom line, where I work and how much I earn is, within limits, my choice. I want it to stay my choice.
"BUT, I BELIEVE A PHYSICIAN IS AROUND FOR THE EXTRAORDINARY NOT THE ORDINARY. Not because he's smarter, but because he is more well trained in the application." … "The reason is because, there is no premium placed on nurses having more theoretical knowledge of anesthetics and outcomes. They get paid to do procedures by and large. The nurses who have a passion for it, learn and study more and dedicate time to that knowledge. WHETHER A PHYSICIAN LIKES IT OR NOT, HE IS COMPELLED TO LEARN THEORY AS WELL AS PRACTICE, and that is what separates the two. I hope you see why that is, and I believe you do. I can't comment to the fairness of it; I can just tell you that it is my personal belief that regardless of whether the PA and a pathologist had the same amount of experience, I would want a pathologist reading my slides if I had the option or the choice. Not because of the 99 times that things go right, but for the one time something goes wrong, and only his theoretical knowledge can tell me why. Is that fair, or do you believe that argument is flawed? Because if you do, then you need to contact the AMA and tell them to shorten our residencies and let us get to the billable labor of private practice earlier. Because our additional knowledge serves us no benefit, and I believe you and I both agree that this is not the case."
If it is true that the physician is around for the extraordinary, not the ordinary, and that the training of the physician makes them more well versed in the application, why have residencies at all? Because med school gives the theoretical foundation for the practice of medicine. Unfortunately, the theoretical foundation is useless without experience. See my earlier example about the residents at the code. The AMA has discovered the best way to get that experience in a manner as safe as possible for both the physician and the patient is in the controlled environment of the residency. Knowledge must be tempered by experience. The CRNA, before ever beginning school, gets theoretical knowledge in nursing school, and experience working in the ICU. Once school is started, the CRNA student can expect a much more in depth, more difficult course of study in both theory and practice of anesthesia. Whatever your beliefs about me, the fact is I learned nearly all my theoretical knowledge in school. I firmly believe no one should perform an anesthetic without a foundation in the science that makes anesthesia work. So does the AANA, and that's why the requirements for what must be taught are so stringent.
Let me provide a simple example. In nearly every general anesthetic I do, I use a heat and moisture exchanger in the circuit. I know that it takes about 20 minutes for the HME to heat up and really provide for some conservation of heat, but it only takes about three breaths before it begins to conserve patient fluids. I am also fully aware that use of an HME involves a trade off. In exchange for the conservation of heat and humidity, I am increasing resistance in the breathing circuit, causing the patient to work harder to breathe. Resistance is one of the fundamental principles of physics that underlies breathing and mechanical ventilation. Knowing this, as we near the end of the case and I am trying to get the patient to breathe independently again, I often remove the HME from the circuit. I am particularly careful to do this with elderly patients or patients with COPD. They have a tough enough time as it is. I learned these theoretical principles in my CRNA master's program, not through self study. I have seen these theoretical principles at work in my practice. The point is that CRNA's are equally compelled to learn theory in school.
Your example of the PA versus the pathologist is not a good example. The PA does not have either the education or experience that a pathologist has. Let's make it a bit closer to home. Suppose you needed an aortic valve replacement. Who would you rather have perform the anesthetic, an MDA fresh out of residency, or a CRNA with 10 years of experience in open heart surgery? Personally, I'd take the CRNA. His/her experience is what has prepared him/her for the "zebra." While in school, I performed anesthetics for nearly 100 open heart procedures. I have had a large number of both residents and MDA's tell me that I gained far more experience with open heart patients than they did in their residency. Experience, even in the most complicated cases, is the real teacher. The AMA knows this, and this is why a residency is required.
Kevin McHugh, CRNA