CRNAs are trying to get rid of Anesthesiologist in Oklahoma. Write your senator.

[Mr.S]

Supervision v. collaboration: Bill on anesthetist-doctor relationship passes committee
My take on this is as follows:

IF they change the word supervision from collaboration it would allow for independence of CRNAs which decreases patient safety.

Everyone who works in Oklahoma should be writing their state senators.

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[Consigliere]

Nice try, Mr. S. I applaud your efforts...however, this is basically a done deal.

 

[Gastrapathy]

So the anesthesiologist in the article is arguing that the surgeon is supervising the CRNA? Seems like defacto independent practice already.

 

[Lecithin5]

So the anesthesiologist in the article is arguing that the surgeon is supervising the CRNA? Seems like defacto independent practice already.

Yes, ideally the supervising physician ideally is an anesthesiologist. But nonetheless, it is still physician supervision. A surgeon may not know the specific anesthetic details, but having any physician involved can be invaluable.

 

[Neopolymath]

So the anesthesiologist in the article is arguing that the surgeon is supervising the CRNA? Seems like defacto independent practice already.

You forget that everyone else beside whoever is administering anesthesia in the room already knows everything about anesthesia from the proceduralist to the guy moping the floor. Someone is always critiquing and supervising the anesthetic.

 

[deleted171991]

So the anesthesiologist in the article is arguing that the surgeon is supervising the CRNA? Seems like defacto independent practice already.

It may be de facto, but it's not de jure. Meaning, that, in the end, the CRNA has to do whatever the surgeon says. Also that the surgeon has liability, i.e. skin in the game, so the CRNA cannot just do whatever s/he wants. It adds another layer of control (and safety).

 

[Mr.S]

So the anesthesiologist in the article is arguing that the surgeon is supervising the CRNA? Seems like defacto independent practice already.

Look, as far as Im concerned we sold the specialty "a while ago" when we had language to change the way the medicare conditions of participation law(s) were written. As current, an anesthesiologist is NOT required at all for anesthesia to go on. ALl that is required is a PHYSICIAN(not dentist). It used to say "anesthesiologist" were the only ones who could supervise the conduct of an anesthetic but it was changed. I am not sure when or why but it was. That was the beginning of the end for us. Now 17 states are free of even the "physician supervision" language. And OK wants to change the said "supervision" to "collaboration". More absolute clownery. To make this even more ass backwards is Oklahoma is not even an opt out state.
If i was a med student or a resident I would be seeing absolute "red" over the fact that these things are even a point of contention

 

[deleted171991]

If i was a med student or a resident I would be seeing absolute "red" over the fact that these things are even a point of contention

This generation is so dumb you should be surprised they don't riot because it's not politically correct that RNs don't have independent practice.

Btw, the death blow to this specialty when the Medicare pass-through rules for "critical access" hospitals were approved. That has virtually guaranteed that no anesthesiologist gets to practice in rural hospitals, hence CRNAs can claim "independent" practice.

And here's why the AANA is fighting against anesthesiologists being subsidized in rural areas, too, especially if they were paid to supervise CRNAs: https://www.aana.com/docs/default-s...ya2017-05--1pager-rural-anesthesia-030717.pdf

"Upon reintroduction, oppose the Medicare Access to Rural Anesthesiology Act. This legislation offers additional funding to anesthesiologists serving in rural areas and risks cost growth without expanding access to care or improving patient safety. Since anesthesiologists cost about three times what CRNAs do for providing the same anesthesia services, such legislation if enacted would increase Medicare costs without expanding patient access to anesthesia care. This legislation also allows hospitals to seek reimbursement for anesthesiologists not providing direct anesthesia care."

 

[narcotics999]

Which one is worse: Work under our licenses and claim as equal VS work on their own licenses and take the liability?

 

[Gastrapathy]

It may be de facto, but it's not de jure. Meaning, that, in the end, the CRNA has to do whatever the surgeon says. Also that the surgeon has liability, i.e. skin in the game, so the CRNA cannot just do whatever s/he wants. It adds another layer of control (and safety).

I’m surprised you think surgeon supervision of CRNAs adds safety.

 

[narcotics999]

It may be de facto, but it's not de jure. Meaning, that, in the end, the CRNA has to do whatever the surgeon says. Also that the surgeon has liability, i.e. skin in the game, so the CRNA cannot just do whatever s/he wants. It adds another layer of control (and safety).

Oh yes, surgeons (gi proceduralists) will add another layer of safety.

 

[<(^_^)>]

This generation is so dumb you should be surprised they don't riot because it's not politically correct that RNs don't have independent practice.

Btw, the death blow to this specialty when the Medicare pass-through rules for "critical access" hospitals were approved. That has virtually guaranteed that no anesthesiologist gets to practice in rural hospitals, hence CRNAs can claim "independent" practice.

And here's why the AANA is fighting against anesthesiologists being subsidized in rural areas, too, especially if they were paid to supervise CRNAs: https://www.aana.com/docs/default-s...ya2017-05--1pager-rural-anesthesia-030717.pdf

"Upon reintroduction, oppose the Medicare Access to Rural Anesthesiology Act. This legislation offers additional funding to anesthesiologists serving in rural areas and risks cost growth without expanding access to care or improving patient safety. Since anesthesiologists cost about three times what CRNAs do for providing the same anesthesia services, such legislation if enacted would increase Medicare costs without expanding patient access to anesthesia care. This legislation also allows hospitals to seek reimbursement for anesthesiologists not providing direct anesthesia care."

“This generation” hadn’t graduated high school when Medicare opt out was passed under the old guard’s watch (2001).

Just sayin’.

 

[Lecithin5]

I’m surprised you think surgeon supervision of CRNAs adds safety.

Because a physician is a physician at the end of the day. That in and of itself adds (tremendous) value

 

[Gastrapathy]

Ok. I guess I never understood that this passed as supervision. Feels like independent practice with shared liability to me. Surprised surgeons go for that.

 

[GravelRider]

I’m surprised you think surgeon supervision of CRNAs adds safety.

It’s not safety for the patients, but rather safety for the specialty. The surgeon/proceduralist adds a nice liability buffer in cases where they are the “supervisor” of the CRNA.

 

[anbuitachi]

if a surgeon supervises the crna, does that mean the surgeon has the final say whether to proceed or not from both the surgery and anesthesia stand point? so if CRNA wants to cancel an elective knee replacement cause patient had a NSTEMI yesterday.. and orthopedic surgeon supervising the CRNA says screw that, we are proceeding, the case goes i guess?

 

[Lecithin5]

Ok. I guess I never understood that this passed as supervision. Feels like independent practice with shared liability to me. Surprised surgeons go for that.

Which is why ideally the supervisor is an anesthesiologist

 

[Gastrapathy]

Which is why ideally the supervisor is an anesthesiologist

Totally agree, I guess where I'm surprised is that from an anesthesiologists perspective surgeon "supervision" is preferable to letting CRNAs hang out on the their own. To me it seems like the bridge that really matters has already been crossed at that point.

 

[DrOwnage]

The surgeon and proceduralist cant even figure out what moderate sedation vs. deep sedation vs. general anesthesia means. Great call.

 

[deleted171991]

“This generation” hadn’t graduated high school when Medicare opt out was passed under the old guard’s watch (2001).

Just sayin’.

The old guard was greedy and corrupt. The new one is socialist and egalitarian. I don't know which one is worse.

 

[deleted171991]

Oh yes, surgeons (gi proceduralists) will add another layer of safety.

They have a strong financial incentive to avoid bad outcomes. The same cannot be said when the CRNAs "collaborate".

 

[deleted126335]

The old guard was greedy and corrupt. The new one is socialist and egalitarian. I don't know which one is worse.

they are both the same. It was in the best interest of the old guard to be greedy and corrupt. It is in the interest of the new guard to be socialist and egalitarian. If they were switched at birth and time there would be no difference. Everybody rises or falls to the level of their incentives.

 

[2Fast2Des]

The surgeon and proceduralist cant even figure out what moderate sedation vs. deep sedation vs. general anesthesia means. Great call.

GA level propofol infusion with nasal cannula = MAC/sedation.

GA level propofol infusion with LMA\tube = GA

 

[deleted126335]

GA level propofol infusion with nasal cannula = MAC/sedation.

GA level propofol infusion with LMA\tube = GA

What is propofol infusion with chin lift/jaw thrust with spontaneous ventilation. +/- oral or nasal airway?

 

[Mr.S]

They have a strong financial incentive to avoid bad outcomes. The same cannot be said when the CRNAs "collaborate".

Their bad outcomes(surgical), not anesthetic.
I am not sure even if you get a megaphone and spell out all the complication(s) that can happen in anesthesia will surgeons appreciate it. They simply do not view it as a real thing. They care about bowel leaks, common duct injuries, compartment syndrome, tonsillar bleeds. Surgical Screw ups. As far as anesthesia is concerned, if they are not moving, perfect anesthetic. By and large, thats true.
Do you know how many times I have asked the surgeons to write down all the patient's medications for me preop? They simply will not do it.

 

[aneftp]

Most independent crnas in rural areas make 300k plus working 30 hours a week. Total cases those hospitals do in the Or generally is 4-8 PER DAY between 3-4 crnas. Lots of waiting around.

We are talking total of 30-40 cases total a week between 3-4 “providers” in the OR. Of course they can try to pad those stats by adding back in 2-3 gi procedures they do to fluff up the numbers.

But $300k plus for very little work is a lot of money.

Or aana can say those independent hospitals case crna make only 220k a year in rural areas. So crnas are “cheaper” while providing access! Sure. But guess what. That’s 220k a year working 26 weeks a year! It’s a damn good deal for very little work.

We focus so much on salary. But we need to break down the amount of hours physically working divided by the pay.

An anesthesiologist working 55 hours for 375k-400k with 7-8 weeks off is making roughly the same as independent crna in rural area. Crnas are not cheaper.

 

[deleted126335]

Except you can’t get the docs to take the rural jobs for that money.

 

[Mman]

So the anesthesiologist in the article is arguing that the surgeon is supervising the CRNA? Seems like defacto independent practice already.

there are quite a few states that require physician supervision of CRNAs. Hospitals in those states still have anesthesiologists supervising the CRNAs. It's mostly just a loophole that teeny little places will use to get around it. Legal liability ensures that we will still be working in any real hospital in those states.

 

[aneftp]

Except you can’t get the docs to take the rural jobs for that money.

Depends if if small town doc wanting to move closer back home.

A friend of mine moved back to rural north Carolina. He likes it in rural areas .

Those types of 26 week a year rural jobs would appeal to a very select few anesthesiologists . Mainly ones with kids out of the house who like to travel but from small towns . They do exist .

 

[chocomorsel]

Except you can’t get the docs to take the rural jobs for that money.

For what money? 300k? That goes a long way in the country.
Problem is skill atrophy. And passthru legislation.

 

[psychbender]

For what money? 300k? That goes a long way in the country.
Problem is skill atrophy. And passthru legislation.

300k is better than a lot of academic jobs I've seen, for far less work.

Allowing physicians access to pass through funds wouldn't increase costs to the government or taxpayers. All it would do is potentially give the same dollars that are currently going to subsidize CRNAs to a physician. The fact that the AANA fights this so viciously, along with fighting AA expansion, should plainly demonstrate their greed to everyone involved.

 

[Mman]

The fact that the AANA fights this so viciously, along with fighting AA expansion, should plainly demonstrate their greed to everyone involved.

I always chuckle at the AANA's insinuation that CRNAs are just as good as anesthesiologists but god forbid you try to argue that AAs are just as good as CRNAs.


The majority of CRNAs are good decent people that are not trying to put anesthesiologists out of work. The majority of them actually like having a doc around to help keep them out of trouble and help when things go south. Their national organization, however, is insane.

 

[Man o War]

I live in an opt out state. And I have for the better part of my career.
Disclaimer: I don’t agree with these states letting nurses practice without supervision.
However, the presence of independent CRNAs has never impacted me as a physician.
The metro hospitals where most cases occur and all of the higher acuity cases occur have never wanted unsupervised nurses. In fact it’s a struggle to get them to even let nurses in the cardiac ORs at all....which is the right call.
These hospitals where they work by themselves is highly likely not a job they could get a doctor to take anyway.

 

[Man o War]

300k is better than a lot of academic jobs I've seen, for far less work.

Allowing physicians access to pass through funds wouldn't increase costs to the government or taxpayers. All it would do is potentially give the same dollars that are currently going to subsidize CRNAs to a physician. The fact that the AANA fights this so viciously, along with fighting AA expansion, should plainly demonstrate their greed to everyone involved.

They don’t want the competition, they know they will lose if they don’t get pass through money exclusively for themselves. That is if those hospitals can even get a doc to go out to those places.
300k isn’t worth it to me to take as much call as they do and to live where those hospitals are.

 

[<(^_^)>]

They don’t want the competition, they know they will lose if they don’t get pass through money exclusively for themselves. That is if those hospitals can even get a doc to go out to those places.
300k isn’t worth it to me to take as much call as they do and to live where those hospitals are.

My understanding (correct me if I’m wrong) is that current Medicare laws allow small rural hospitals to bill Medicare at a higher rate and use that money to attract CRNAs, but is prohibited to use that money to pay physicians. That honestly is insane to me.

Independent CRNAs cost an identical amount to Medicare as anesthesiologists. Treating the services as identical (despite the significant differences in training) is hard to defend, but treating physicians as inferior, and not eligible for this funding, is inexcusable.

 

[Man o War]

My understanding (correct me if I’m wrong) is that current Medicare laws allow small rural hospitals to bill Medicare at a higher rate and use that money to attract CRNAs, but is prohibited to use that money to pay physicians. That honestly is insane to me.

Pass through funds are only given for CRNAs in critical access hospitals, that is correct. These funds are not available for doctors. Yes, it is insane. These hospitals are already operating on razor thin margins, so they’ve essentially been forced to choose between money and patient safety.

 

[ugm12]

I'm a doctor in the UK (and daily reader of this active and engaging sub-forum!). After reading the "nurse anesthesiologist" thread, and now this, can someone please shed some light?
In England only the anaesthetist (a physician) is allowed to give a GA. We have physician assistants of anaesthesia who can do some nerve blocks and put lines in, but in the OR they are mainly a (very valued) assistant.
In the U.S. can a CRNA administer general anaesthesia completely independently? With no input or supervision of an anesthesiologist?

 

[Mr.S]

In the U.S. can a CRNA administer general anaesthesia completely independently? With no input or supervision of an anesthesiologist?

Yes.

 

[jw3600]

I'm a doctor in the UK (and daily reader of this active and engaging sub-forum!). After reading the "nurse anesthesiologist" thread, and now this, can someone please shed some light?
In England only the anaesthetist (a physician) is allowed to give a GA. We have physician assistants of anaesthesia who can do some nerve blocks and put lines in, but in the OR they are mainly a (very valued) assistant.
In the U.S. can a CRNA administer general anaesthesia completely independently? With no input or supervision of an anesthesiologist?

Yes. In America we no longer respect hard work and copious higher education.

 

[<(^_^)>]

I'm a doctor in the UK (and daily reader of this active and engaging sub-forum!). After reading the "nurse anesthesiologist" thread, and now this, can someone please shed some light?
In England only the anaesthetist (a physician) is allowed to give a GA. We have physician assistants of anaesthesia who can do some nerve blocks and put lines in, but in the OR they are mainly a (very valued) assistant.
In the U.S. can a CRNA administer general anaesthesia completely independently? With no input or supervision of an anesthesiologist?

In 17 states (or so) yes. Most of the time hospitals want CRNAs supervised regardless, and many CRNAs want to be supervised as they like safety net if things go wrong. For example California is an opt-out state but may have the most “MD-only” (as opposed to independent or supervised CRNA) anesthesia care models.

This is far from an anesthesiology-specific phenomenon in the US, nurse practitioners (some programs are mostly online and/or under 2 years in length) are producing nurses that can practice medicine independently in 23 states.

In both cases the profit of starting a CRNA or NP school is irresistible. The NP job market is already becoming saturated and only getting worse. The CRNA job market is set to become saturated in the next 3-4 years. Fortunately anesthesiology is set to remain in a “shortage” for what it’s worth.

The lobbying power of nursing organizations never fails to impress me. They managed to secure legislation that pays CRNAs more for rural cases, but not anesthesiologists. That should tell you everything you need to know about their political power vs ours. The American Society of Anesthesiologists (ASA) is pretty timid, but as far as I know there isn’t another group to donate to.

 

[ugm12]

Goodness....
Not to disrespect CRNAs capabilities or training. But I cannot imagine CRNA school is equivocal to the Royal College of Anaesthetists exams, or anesthesiology residency. So to ask the obvious question, why have anesthesiologists at all? Is it the health of the patient that determines if a CRNA can practice alone? (emergency/acute surgery vs elective?)

 

[Mr.S]

In 17 states (or so) yes..

In all states.

The conduct of Anesthesia does not need input from Anesthesiologist anywhere under state law in 50 states.
They need input and supervision from "A Physician." Does not matter who that said physician is. Now in 17 states, CRNAs can practice anywhere independently.

It is a painful reality.

 

[Mman]

Now in 17 states, CRNAs can practice anywhere independently.

It is a painful reality.

That is not true. Hospital privileges and credentials are a local decision. While opt out states have said CRNAs can provide anesthesia without a physician supervising them, individual hospitals are the ultimate arbiter of that. There are all kinds of hospitals in opt out states that do not allow CRNAs to practice independently.

 

[<(^_^)>]

Goodness....
Not to disrespect CRNAs capabilities or training. But I cannot imagine CRNA school is equivocal to the Royal College of Anaesthetists exams, or anesthesiology residency. So to ask the obvious question, why have anesthesiologists at all? Is it the health of the patient that determines if a CRNA can practice alone? (emergency/acute surgery vs elective?)

Well the main reason is they’re not equivalent and most people recognize this (including hospitals and many CRNAs). However from a legal standpoint they can function identically in those states.

In all states.

The conduct of Anesthesia does not need input from Anesthesiologist anywhere under state law in 50 states.
They need input and supervision from "A Physician." Does not matter who that said physician is. Now in 17 states, CRNAs can practice anywhere independently.

It is a painful reality.

This is true, but is a bit over the top. A surgeon can also provide anesthesia if they felt like it. An anesthesiologist could perform surgery if they felt like it. That doesn’t mean it happens often in practice, and there are issues of legal responsibility that make many surgeons uncomfortable with supervising CRNAs in non-opt out states. A surgeon is a much bigger fish for a malpractice lawyer to fry than a CRNA after all.

Again in California they are opt out but they are also probably the stronghold of MD-only anesthesia from what I understand.

 

[nimbus]

Again in California they are opt out but they are also probably the stronghold of MD-only anesthesia from what I understand.

This is largely true but even in my large metro coastal city there is one hospital and at least one surgicenter that is CRNA only. Granted the hospital has historically had problems recruiting and retaining anesthesiologists for all the usual reasons. The “Chief of surgical services/anesthesia” is a spine surgeon.

 

[deleted171991]

So to ask the obvious question, why have anesthesiologists at all?

That is a very good question that American hospital administrators tend to ask regularly.

The answer, for now, is because of liability.

 

[Mr.S]

That is not true. Hospital privileges and credentials are a local decision. While opt out states have said CRNAs can provide anesthesia without a physician supervising them, individual hospitals are the ultimate arbiter of that. There are all kinds of hospitals in opt out states that do not allow CRNAs to practice independently.

I meant legally speaking in the opt-out states CRNAs can function without ANY physician supervision by law. So if hospital administrators wanted to allow it and the medical executive committee was on-board that would be the way they would do it. We should have fought this tooth and nail way back when.

 

[BLADEMDA]

Well, I am no expert in malpractice law or insurance but many carriers will charge a lot more for a "collaborative" model than a supervisory one. I was specifically asked if I was going to be supervising CRNAs while doing my own cases at the same time. The Insurance company said "no". Either the CRNA is independent or I'm legally covering the cases, all of them, without being the only anesthesia provider on the chart (if 2 or more cases are underway).
I am not talking about Medical Direction vs Supervision as that is blurry line.

The worst of both worlds is the collaborative model. Let the surgeons deal with the consequences when a "medical" issue arises preop, intraop or postop.

My state requires, by law, that CRNAs be supervised by a Physician. Since I am the Anesthesiologist on site the surgeons and the insurance company assume that means me.

States That Allow CRNAs to Practice Independently

 

[MoMoGesiologist]

Their bad outcomes(surgical), not anesthetic.
I am not sure even if you get a megaphone and spell out all the complication(s) that can happen in anesthesia will surgeons appreciate it. They simply do not view it as a real thing. They care about bowel leaks, common duct injuries, compartment syndrome, tonsillar bleeds. Surgical Screw ups. As far as anesthesia is concerned, if they are not moving, perfect anesthetic. By and large, thats true.
Do you know how many times I have asked the surgeons to write down all the patient's medications for me preop? They simply will not do it.

Why the heck would the surgeon write down all the patient's meds for you preop?? Stop asking them to do that for you

 

[dhb]

Again in California they are opt out but they are also probably the stronghold of MD-only anesthesia from what I understand.

In all the boutique plastic surgery centers?