gasnurse said:
you are correct....i believe the number opted out at this point is 12....my state, WA, is one of them. and about why my malpractice cost is lower i can't answer that. i just pay what i'm told. i agree it doesn't seem fair. that would be a question for the carriers.
I have my suspicions. They number three
1). Malpractice carriers are concerned with one thing and one think only - the loss experience of the class of insured providers. For one reason or another the "loss experience" for CRNA's is lower than that of MDA's. The question is this: in what way is it lower, and why? I think we can dismiss from the outset the notion that CRNA's have better "loss experience" than MDA's do when comparing the same group of patients. This would entail a showing (evident to the carriers, in any event) that outcomes are better when CRNA's administer anesthetics than when MDA's do. No studies (that I am aware of) have shown this. If anything, they show outcomes across a particular class of patients to be the same (see Pine study - which the AANA LOVES). And yet "loss experience" is lower. One way to explain this is to suggest that the "risk of loss" is lower across the patient population a CRNA typically sees versus that which an MDA sees. This suggests, then, that in the
aggregate the MDA will see more complicated cases where the risk of loss is greater than a CRNA will.
As you know, the Pine study was "risk adjusted", which I gathered meant that the nine (9) surgical procedures under review would commonly be done either by a CRNA alone, a CRNA and MDA or an MDA alone. It either excluded what the authors thought were "risky" procedures OR it included these "risky" procedures but
adjusted outcome data from these to have the greater mortality rates of these procedures not reflect poorly on the anesthesia provider involved. IF both CRNA's and MDA's were equally likely to have participated in these more "risky" procedures, there would have been no need to "risk adjust" the study because the "risk" associated with the procedures would have been equally fair to both groups.
2). The carriers insure against loss across the
entire spectrum of what an MDA (or DOA), and the spectrum is not merely limited to the "administration of anesthetics" but also the post-operative period. This point is emphasized by the CRNA industry group (AANA? I can't recall) in its response to the recent study comparing CRNA and MDA outcomes (the Silber study). The CRNA position was this:
However, a closer examination clearly reveals that the study:
---is not about anesthesia care provided by nurse anesthetists
---actually examines post-operative physician care.
AANA
ie., that the study was too broad in that it evaluated outcomes not only for the administration of anesthetics but also a significant(30 day?) post-operative plan. I think there might have been some suggestion that greater "rescue" performance by MDA's was not a good evaluation of CRNA performance because "rescue" was outside the scope of anesthetic administration. Whatever side you come down on regarding this issue, the basic premise of the CRNA industry group argument is sound - the administration of anesthetics is merely a subset of the scope of practice of an MDA, and because CRNA's engage ONLY in the administration of anesthetics (remember, this was the CRNA group position) it is only fair to compare them to MDA's in regards to outcomes only within this limited subset of what an MDA does - ie., only with respect to the administration of anesthetics. As I said, however, carriers insure an MDA against loss over the
entire spectrum of what an MDA does, and therefore because his scope is greater (post-operative care - some work as intesivists, ICU, SICU - trips to the ER for airway management, etc.) than that of a CRNA, his loss experience will necessarily be greater. Which is to say that although CRNA's are correct that they ONLY deal with the administration of anesthetics, the insurance carriers know that MDA's are responsible for quite a bot more (and presumably patients are interested in knowing that there IS somebody in the room who is responsible for this part of thier care).
3) despite the official line from the AANA: "Whether or not a surgeon or obstetrician will be held liable for the negligence of the anesthetist depends on the facts of the case, not on the nature of the license of the anesthesia provider" the reality is that even today - with BROAD practice autonomy of CRNA's,
most (not
all - don't come back with a bunch of crap about how
your program doesn't do it this way) major surgical centers STILL require an MDA to exercise a supervisory role over CRNA's in a sort of "provider team" orthodoxy. If not an MDA, the perhaps the surgeon. The point is this - this still prominent practice model (despite technical autonomy for CRNA's) means increased a exposure to the supervising physician and decreased exposore to the CRNA. In practice then, carriers will have less "loss experience" for CRNA's than they will for MDA because of "residual" supervision.
Anyway, just some guesses.
Judd
