CRNA student with a Tefra question

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Jacads

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I know the current ratio is 1:4 but managing a typical CRNA/MDA practice how many CRNAs could an MDA manage 5, 6 or more? Or is 4 about the right number?

Thanks,

Jacads
 
Jacads said:
I know the current ratio is 1:4 but managing a typical CRNA/MDA practice how many CRNAs could an MDA manage 5, 6 or more? Or is 4 about the right number?

Thanks,

Jacads

With decent CRNAs, 4 is a good number. If they suck, then 2-3 will stress you out.
 
Jacads said:
I know the current ratio is 1:4 but managing a typical CRNA/MDA practice how many CRNAs could an MDA manage 5, 6 or more? Or is 4 about the right number?

Thanks,

Jacads

What is "Tefra"?

I googled and got some child aid thing in MN and evidently its the name of a "traditional english doom metal" band too; they are canceling gigs, very sad. But anyway, what's Tefra?
 
Depends if you medically direct them or supervise them.

Oh, and b/4 someone rips into you here. Drop the "MDA" term. I know it seems trivial but many of us MD's get a little peaved about this crna generated term. 👍
 
Jacads said:
I know the current ratio is 1:4 but managing a typical CRNA/MDA practice how many CRNAs could an MDA manage 5, 6 or more? Or is 4 about the right number?

Thanks,

Jacads

an MD (or DO) attending anesthesiologist can manage up to 4 crnas at one time and still fully bill for services. this is a medicare/medicaid billing issue. (there's no such thing as an MDA). where allowed, a crna practicing by him/herself can only do a case with another supervising physician (surgeon, etc.) on a 1:1 basis. the latter is a supremely ineffective anesthesia delivery model, especially since that supervising physician will still likely take a cut of that nurse anesthetists pay.

there is no "right" number. there is just a set limit at which full reimbursement can be received. depending on the practice, individual crnas can negotiate to get what they feel is their fair share of the billable units. most are typically paid a flat hourly rate regardless of what type of case they do.
 
TERFA - Tax Equalization and Fiscal Responsibility Act

1. Performs pre-anesthetic eval
2. Prescribes anesthetic plan
3. Participates in demanding portions of the case (induction / emergence)
4. Ensures anesthetic is performed by a qualified individual
5. Monitor the anesthetic at intervals
6. Remain physically present and available to assist with emergencies
7. Provides indicated PACU care
 
Are you serious MDA is a CRNA derived term? I didn't know that. If you have a medicare patient tht gets extubated and transferred to PACU because the anesthesiologist was busy with a code or someone crashing, can the anesthesiologist or hospital still receive payment for that patient? Is there a remedy in place for just a scenario under the Tefra guidelines?



Noyac said:
Depends if you medically direct them or supervise them.

Oh, and b/4 someone rips into you here. Drop the "MDA" term. I know it seems trivial but many of us MD's get a little peaved about this crna generated term. 👍
 
This is more than just a billing issue.

Most OR systems need an N+1 system at the very least, sometimes N+1 per 2-3 OR's depending on how rapid turnover is. It isn't just a safety issue; efficiency counts in private practice!
 
Noyac said:
Oh, and b/4 someone rips into you here. Drop the "MDA" term. I know it seems trivial but many of us MD's get a little peaved about this crna generated term. 👍

yeah - doesn't "anesthesiologist" do the job? 😀
 
rn29306 said:
TERFA - Tax Equalization and Fiscal Responsibility Act

Thanks.
 
CRNA'S do not by law have to be supervised by an "anesthesiologist" They can work independent of an anesthesiologist. They must be supervised by a "physician" according to medicare. The anesthesiologist making the $500k-750k range use the following practice structure: They bypass TEFRA altogether by having the CRNA sign over 50% of their billing to work in their group. They then bill unsupervised regardless if they lay eyes on that case, they are getting 50% of the reimbursement. In other words, where they reduce overhead. Say hospital A has 9 OR's to start @7:30am said group sends 9 CRNAs and 1 anesthesiologist vs billing supervised sending 3 anesthesiologist. The pie is bigger for the anesthesiologist. For the most part no hospital will give an all CRNA group privileges so just take advantage of what the law allows with their license. I know of several groups that use this practice shell. Those are the ologist's that drive the Ferrari vs the Lincoln. I have said this many times before in this forum.
 
Our MDs meet all TERFA requirements and stick to the 4:1 ratio.

$500K salary.
 
rn29306 said:
Our MDs meet all TERFA requirements and stick to the 4:1 ratio.

$500K salary.

Good boy! your making them alot of $money. They'd probably make $750k by ditching TEFRA and taking %50 of your billing.
 
50% of your billing? If he works in an ACT group the MD is getting all of his billing and in return paying the CRNA's salary.
 
BIS said:
50% of your billing? If he works in an ACT group the MD is getting all of his billing and in return paying the CRNA's salary.
with ACT I assume you mean billing supervised 1:4 and staying within TEFRA.
That's right 50%. You make the CRNA fee for service and don't pay them an hourly wage even at 50% they still make 200-250k if you are a moderatley busy group. Where the extra $money comes in for the ologist is this practice type requires less partners. Its true ask any MD who works this way! There may not be any in your area but they make a HUGH amount more than a 1:4 "they must be supervised"company man.
 
bestiller said:
Good boy! your making them alot of $money. They'd probably make $750 by ditching TEFRA and taking %50 of your billing.

And we thank you......
 
bestiller said:
Good boy! your making them alot of $money. They'd probably make $750k by ditching TEFRA and taking %50 of your billing.


I doubt they'd go for total unsupervision just to earn another buck.
We are a trauma level 1 teaching institution.

And you can drop the 'good boy' description. I realize I make those above me a certain amount of change. I also realize they bill for over 2 million dollars per senior class for running cases solo as students alone. It's just how things are done. I accept that. I appreciate the degree of freedom they allow me as a senior student to be placed daily in rooms without a CRNA, for an entire senior year, with exception of hearts and dissecting AAAs (read between the lines). It's just me and the MD. I'll be damned if someone on this board is going to call me a 'good boy' for my efforts thus far.
 
bestiller said:
CRNA'S do not by law have to be supervised by an "anesthesiologist" They can work independent of an anesthesiologist. They must be supervised by a "physician" according to medicare. The anesthesiologist making the $500k-750k range use the following practice structure: They bypass TEFRA altogether by having the CRNA sign over 50% of their billing to work in their group. They then bill unsupervised regardless if they lay eyes on that case, they are getting 50% of the reimbursement. In other words, where they reduce overhead. Say hospital A has 9 OR's to start @7:30am said group sends 9 CRNAs and 1 anesthesiologist vs billing supervised sending 3 anesthesiologist. The pie is bigger for the anesthesiologist. For the most part no hospital will give an all CRNA group privileges so just take advantage of what the law allows with their license. I know of several groups that use this practice shell. Those are the ologist's that drive the Ferrari vs the Lincoln. I have said this many times before in this forum.
Ah, after a long absence he returns...

Our docs go strictly by the TEFRA requirements in our very large group of MD's, CRNA's and AA's. They drive an assortment of vehicles from Vespa scooter to Ferrari and everything in between.
 
JWK , how are things in The People's Republic of Georgia ? Any AA jobs in La?
 
bestiller said:
JWK , how are things in The People's Republic of Georgia ? Any AA jobs in La?


Aren't we were now taking a hardline with trolls? This character screams just being here to antagonize others.
 
Why is everybody so concerned with the salary everyone else makes? A CRNAs income is well above that of a staff nurse with good reason. The same as an anesthesiologist salary is well above that of many other physician specialties. You're paid for the supply demand issue as well as the responsibility and knowledge base you bring with you into the OR. If you don't like your salary as a CRNA, you know how things work, quit moaning and go to med school if the bigger paycheck is your incentive for anesthesia.

I understand why some CRNAs percieve the current system to be unfair, but look at the bigger picture. The bottom line is we need the anesthesiologists as well as the anesthetists for a variety of reasons. One thing many people don't consider is that the anesthesiologist is not just there to "supervise" CRNAs, they are also there for lunch breaks, pee breaks, to bounce ideas off of in a case, to be that second set of hands in a case that goes bad unexpectedly, and plenty of other uses. Plus, the MDs manage the patients in recovery, so if we did have CRNAs delivering anesthesia solo, who would manage their patients in the recovery period? The surgeon? Give me a break. That's why the ACT- anesthesia care TEAM exists. No one can be everywhere doing everything at once. Patients get the best care when everyone works together and complements the roles of their co-workers.

Do your job the best you can, worry about yourself as an employee, and let everyone else do the same. We'd have a lot less moaning and groaning. I'm not saying don't be proactive about your profession, but save your energy for issues that really need to be fixed. JMO, but the current system of ACT benefits everybody.
 
The_Sensei said:
And we thank you......

These types of comments are what piss CRNAs off so bad. Don't act like you're the big mojo of anesthesia, regardless of what letters are behind your name. Someone who is truly secure with themselves and where they stand in their professional arena doesn't need to rub it in to others they percieve as being below them in the anesthesia food chain. Give me a smart, respectful anesthesiologist who works well with everyone any day over a brilliant jacka ss who can't go a day without telling everybody "I'm an anesthesiologist and you're not", or one who has that mindset so obviously from the way he interacts with his co-workers. We both (anesthetists and anesthesiologists) have to give a little to end this constant battle of the egos, but respect much be given equally on both sides. Respect me for the job I do and the time I've put in for my education, don't be quick to respect me less because I haven't taken the same path as you to work in the field of anesthesia.
 
SilverStreak said:
Why is everybody so concerned with the salary everyone else makes? A CRNAs income is well above that of a staff nurse with good reason. The same as an anesthesiologist salary is well above that of many other physician specialties. You're paid for the supply demand issue as well as the responsibility and knowledge base you bring with you into the OR. If you don't like your salary as a CRNA, you know how things work, quit moaning and go to med school if the bigger paycheck is your incentive for anesthesia.

I understand why some CRNAs percieve the current system to be unfair, but look at the bigger picture. The bottom line is we need the anesthesiologists as well as the anesthetists for a variety of reasons. One thing many people don't consider is that the anesthesiologist is not just there to "supervise" CRNAs, they are also there for lunch breaks, pee breaks, to bounce ideas off of in a case, to be that second set of hands in a case that goes bad unexpectedly, and plenty of other uses. Plus, the MDs manage the patients in recovery, so if we did have CRNAs delivering anesthesia solo, who would manage their patients in the recovery period? The surgeon? Give me a break. That's why the ACT- anesthesia care TEAM exists. No one can be everywhere doing everything at once. Patients get the best care when everyone works together and complements the roles of their co-workers.

Do your job the best you can, worry about yourself as an employee, and let everyone else do the same. We'd have a lot less moaning and groaning. I'm not saying don't be proactive about your profession, but save your energy for issues that really need to be fixed. JMO, but the current system of ACT benefits everybody.
Well said, but IMHO the ACT creates an evviroment for a very top heavy practice(more partners than necessary). When you say ACT I assume you mean adhering to TEFRA by the way. I do agree w/ you for the most part.
 
bestiller said:
Well said, but IMHO the ACT creates an evviroment for a very top heavy practice(more partners than necessary). When you say ACT I assume you mean adhering to TEFRA by the way. I do agree w/ you for the most part.

I guess I can see what you're saying, in part because at my hospital the ratio of CRNAs is roughly 50/50 to that of anesthesiologists. In theory, if we're using the ACT TEFRA then there would be a ratio of 75% CRNAs to 25% anesthesiologists (if we're assuming 3-4 CRNAs for 1 anesthesiologist). But, I don't think our OR cases are split that way (I work in the ICU right now, so only speaking from observation time in the OR and other areas of hospital). We have anesthesiologists running cases by themselves, covering for others, working in preop, PACU, SICU, so they are not just supervising the CRNAs with no other resposibilities. I'm not trying to say that's why you're implying that all they do is supervise, but I think that's why it's a little misleading to say they are top heavy in the ACT format, simply because they are active in the areas CRNAs aren't, so there would have to be a higher percentage of them simply for that reason to have availability in those areas as well as the OR.
 
SilverStreak said:
These types of comments are what piss CRNAs off so bad.

Relax, tough guy........

Did you see the belittling comment to which I was referring? If not, please re-read the post before offering your opinion. Oh, by the way.......I AM the big mojo of anesthesia where I am since I am the chief. 🙂
 
The_Sensei said:
Relax, tough guy........

Did you see the belittling comment to which I was referring? If not, please re-read the post before offering your opinion. Oh, by the way.......I AM the big mojo of anesthesia where I am since I am the chief. 🙂

Yes I did read the comment you responded to, and my interpretation was that you were making a smart reply to that comment thanking CRNAs for the hard work they do so you can make the big bucks. If that is not what you intended, then I freely apologize, but that's how it came across to me. Also, mojo, chief or not, the best of the best know they're good, they're humble and don't have to flaunt anything. I respect your position, you must be good to get where you are, but it doesn't matter to me who you are or what your title is if you don't use your power wisely with good decorum to others.
 
SilverStreak said:
Yes I did read the comment you responded to, and my interpretation was that you were making a smart reply to that comment thanking CRNAs for the hard work they do so you can make the big bucks. If that is not what you intended, then I freely apologize, but that's how it came across to me. Also, mojo, chief or not, the best of the best know they're good, they're humble and don't have to flaunt anything. I respect your position, you must be good to get where you are, but it doesn't matter to me who you are or what your title is if you don't use your power wisely with good decorum to others.

I do. Please PM me if you would like to speak with ANY of the CRNAs with whom I work. I know, without hesitation, that they will agree I exercise "good decorum" on a daily basis. Apology accepted.
 
The_Sensei said:
I do. Please PM me if you would like to speak with ANY of the CRNAs with whom I work. I know, without hesitation, that they will agree I exercise "good decorum" on a daily basis. Apology accepted.

Understood. I have no interest in being the polite police on this board. 🙂 I just get my hide rubbed a little raw when I feel that nurses are not being respected. I'm sure your CRNAs are very appreciative for your support as a leader.
 
when i happen to have a crna work with me if said crna does not toe the line.. or there is any passive aggression at all i do the case myself and never work with that crna again... these are my cases.. i am the one consulted.. the crnas have not been consulted because they are not consultants I prefer doing cases on my own.. much better.. less headache..
 
I think it is ridiculous that CRNAs and Anesthesiologist have to be so rude to eachother. It does take CRNAs atleast 6-7 years of education. A nurse's education is also completely with the patient (the whole education). The four years of premed preparation is not hands on with the patient and the first 2 years of medical school hardly is. Yes, MDs do have a broader background in the sciences. That is not an argument. Let's not forget that CRNAs provide 65% or more of the anesthesia provided. Also nurses were the first to provide anesthesia in history. Nothing is more disgusting to me than seeing a person who could care less about the patient and go into medical school for respect and authority reasons. Hint : Maybe if MDs would not be so arrogant- things wouldn't be going in the direction that it is. Bottom line, nurses and MDs are servants of the public. We are both here to provide care to the patient. Nurse Anesthetists are very smart and their education is very competitive and intense. We could not practice without eachother. So both sides should appreciate eachother and focus on the patients (this is why we both work in the medical fields anyway)- or atleast should be. So both sides get over it and get over yourselves.
 
This post is degenerating, quickly.
 
lax said:
Nurse Anesthetists are very smart and their education is very competitive and intense. .



Not really.
 
lax said:
. We could not practice without eachother. .

Physicians can practice without CRNAs, They do all the time at many groups. There are physicians who have never ever supervised crnas. When im consulted.. I do the cases by myself.. If there happens to be a crna who I enjoy working with I work with them and give them some money.. If there is any hint of passive aggression.. I dont work with them ever again and do it on my own... So I work without crnas all the time.. Maybe 95 percent of the time.. I think you need to go to allnursing.com and bash physicians.. I think other people would agree with me.. I think you are nitecap
 
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