CRNA's Win, CMS ruling passes in their favor

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Excerpt from CMS ruling. See if you can read without vomiting-


The benefit category for services furnished by a certified registered nurse anesthetist (CRNA) was added in section 1861(s)(11) of the Act by section 9320 of the Omnibus Budget Reconciliation Act (OBRA) of 1986. Since this benefit was implemented on January 1, 1989, CRNAs have been eligible to bill Medicare directly for services within this benefit category. Section 1861(bb)(2) of the Act defines a CRNA as "a certified registered nurse anesthetist licensed by the State who meets such education, training, and other requirements relating to anesthesia services and related care as the Secretary may prescribe. In prescribing such requirements the Secretary may use the same requirements as those established by a national organization for the certification of nurse anesthetists."
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Section 410.69(b) defines a CRNA as a registered nurse who: (1) is licensed as a registered professional nurse by the State in which the nurse practices; (2) meets any licensure requirements the State imposes with respect to nonphysician anesthetists; (3) has graduated from a nurse anesthesia educational program that meets the standards of the Council on Accreditation of Nurse Anesthesia Programs, or such other accreditation organization as may be designated by the Secretary; and (4) meets one of the following criteria: (i) has passed a certification examination of the Council on Certification of Nurse Anesthetists, the Council on Recertification of Nurse Anesthetists, or any other certification organization that may be designated by the Secretary; or (ii) is a graduate of a program described in paragraph (3) of this definition and within 24 months after that graduation meets the requirements of paragraph (4)(i) of this definition.
Section 1861(bb)(1) of the Act defines services of a CRNA as "anesthesia services and related care furnished by a certified registered nurse anesthetist (as defined in paragraph (2)) which the nurse anesthetist is legally authorized to perform as such by the State in which the services are furnished." CRNAs are paid at the same rate as physicians for furnishing such services to Medicare beneficiaries. Payment for services furnished by CRNAs only differs from physicians in that payment to CRNAs is made only on an assignment-related basis (§414.60) and supervision requirements apply in certain circumstances.
At the time that the Medicare benefit for CRNA services was established, anesthesia practice, for anesthesiologists and CRNAs, largely occurred in the surgical setting and services other than anesthesia (medical and surgical) were furnished in the immediate pre- and post- surgery timeframe. The scope of "anesthesia services and related care" as delineated in section 1861(bb)(1) of the Act reflected that practice. As anesthesiologists and CRNAs have moved into other practice settings, questions have arisen regarding what services are encompassed under the benefit category's characterization of "anesthesia and related care." As an example, some
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CRNAs now offer chronic pain management services that are separate and distinct from a surgical procedure. We recently received additional information about upcoming changes to CRNA curricula to include specific training regarding chronic pain management services. Such changes in CRNA practice have prompted questions as to whether these services fall within the scope of section 1861(bb)(1) of the Act.
As we noted in the CY 2013 proposed rule (77 FR 44788), Medicare Administrative Contractors (MACs) have reached different conclusions as to whether the statutory benefit category description of "anesthesia services and related care" encompasses the chronic pain management services furnished by CRNAs. The scope of the benefit category determines the scope of services for which a physician, practitioner, or supplier may receive Medicare payment. In order for the specific services to be paid by Medicare, the services must be reasonable and necessary for treatment of the patient's illness or injury.
To address what is included in the benefit category for CRNAs in the CY 2013 proposed rule, we assessed our current regulations and subregulatory guidance, and determined that the existing guidance does not specifically address whether chronic pain management is included in the CRNA benefit. In the Internet Only Manual (Pub 100-04, Ch 12, Sec 140.4.3), we discuss the medical or surgical services that fall under the "related care" language stating: "These may include the insertion of Swan Ganz catheters, central venous pressure lines, pain management, emergency intubation, and the pre-anesthetic examination and evaluation of a patient who does not undergo surgery." Some have interpreted the reference to "pain management" in this language as authorizing direct payment to CRNAs for chronic pain management services, while others have taken the view that the services highlighted in the manual language are services furnished in the perioperative setting and refer only to acute pain management associated with the surgical procedure.
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After assessing in the proposed rule (see 77 FR 44788) the information available to us, we concluded that chronic pain management was an evolving field, and we recognized that certain states have determined that the scope of practice for a CRNA should include chronic pain management to meet health care needs of their residents and ensure their health and safety. We also found that several states, including California, Colorado, Missouri, Nevada, South Carolina, and Virginia, were debating whether to include pain management in the CRNA scope of practice. After determining that the scope of practice for CRNAs was evolving and that there was not a clear answer on pain management specifically, we proposed to revise our regulations at §410.69(b) to define the statutory benefit for CRNA services with deference to state scope of practice laws. Specifically, we proposed to add the following language: "Anesthesia and related care includes medical and surgical services that are related to anesthesia and that a CRNA is legally authorized to perform by the state in which the services are furnished." We explained that this proposed definition would set a Medicare standard for the services that can be furnished and billed by CRNAs while allowing appropriate flexibility to meet the unique needs of each state. The proposal also dovetailed with the language in section 1861(bb)(1) of the Act requiring the state's legal authorization to furnish CRNA services as a key component of the CRNA benefit category. Finally, we stated that the proposed benefit category definition was also consistent with our policy to recognize state scope of practice as defining the services that can be furnished and billed by other NPPs.
The following is a summary of the comments we received regarding the proposal to revise our regulations at §410.69(b) to define the statutory description of CRNA services. We received a significant volume of comments from specialty groups, individual physicians, and practitioners, including CRNAs and Student Registered Nurse Anesthetists (SRNAs), educational program directors, and patients, who strongly supported defining the CRNA benefit broadly. There were also many commenters who strongly opposed this proposal, including
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specialty groups, individual physicians and practitioners, patients, educational program directors, and a patient advocacy group.
Comment: Among those supporting the concept of our proposal, we received several comments suggesting alternative regulatory definitions of the statutory benefit category phrase, "anesthesia and related care." Many commenters said that CMS should allow CRNAs to practice to the full extent of state law. Some commenters provided alternative definitions for anesthesia and related care. These included "medical and surgical services that are related to anesthesia or that a CRNA is legally authorized to perform by the State in which the services are furnished," "medical and surgical services that are related to anesthesia, including chronic pain management services unless specifically prohibited or outside the scope of the CRNA's license to practice," "medical services, surgical services, and chronic and acute pain management services that a CRNA is legally authorized to perform by the State in which the services are furnished," "medical and surgical services a CRNA is legally authorized to perform by the state in which services are furnished and which are done to provide surgical or obstetrical anesthesia or alleviate post-operative or chronic pain," and "medical and surgical services that are related to anesthesia, including chronic pain management, unless a CRNA is legally prohibited to perform by the State in which the services are furnished." One commenter made the point that Medicare should use a definition that included coverage of advanced practice registered nurse services that are within the scope of practice under applicable state law, just as physicians' services are now covered.
Other commenters referenced preamble text in our 1992 final rule, which states "we describe related care services as... pain management services, and other services not directly connected with the anesthesia service or associated with the surgical service" and noted that historically, related care services have been recognized as a different class of anesthesia services, which may or may not be related to anesthesia. One commenter requested that we define
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"related care" separately from anesthesia, as "medical and surgical services not directly related to anesthesia, including but not limited to the insertion of arterial lines, central venous pressure lines, and Swan Ganz catheters, acute and chronic pain management and emergency intubation, and that a CRNA is legally authorized to perform by the state in which the services are furnished."
Some commenters pointed to Medicare policies allowing other advanced practice nurses such as nurse practitioners or clinical nurse specialists to furnish and bill for physicians' services as support for recognizing a similar interpretation of the scope of CRNA practice. Commenters stated that CRNAs should be able to practice to the full extent of state law. Commenters cited the Institute of Medicine report [The Future of Nursing: Leading Change, Advancing Health, 11/17/10] that stated that nurses should be able to practice to the full extent of their education and training.
Our proposal to define related care as "related to anesthesia" resulted in various views as to whether this would include pain management and other services. Some stated that it restricted the benefit category, but others believed that it expanded it. The commenters further stated that there are no chronic, long-term, anesthesia related services that occur outside the operating room or recovery room where the practice of anesthesia is appropriate. Others stated that chronic pain management services are outside the scope of perioperative related care defined in the Act, and that chronic pain is not related to anesthesia.
Response: After reviewing comments regarding our proposed definition of "anesthesia and related care," we believe that the proposed regulation language stating that "Anesthesia and related care includes medical and surgical services that are related to anesthesia and that a CRNA is legally authorized to perform by the state in which the services are furnished" would not accomplish our goals. It would require updating as health care evolves and as CRNA practice changes. It also would continue Medicare's differentiation between CRNAs and other NPPs
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because the Medicare benefit for other NPPs relies more heavily on the NPPs' authority under state law. In addition, we agree with commenters that the primary responsibility for establishing the scope of services CRNAs are sufficiently trained and, thus, should be authorized to furnish, resides with the states. We agree with commenters that, as CRNA training and practice evolve, the state scope of practice laws for CRNAs serve as a reasonable proxy for what constitutes "anesthesia and related care." Therefore, we are revising §410.69(b) to define the statutory benefit category for CRNAs, which is specified as "anesthesia and related care," as "those services that a certified registered nurse anesthetist is legally authorized to perform in the state in which the services are furnished." By this action, we are defining the Medicare benefit category for CRNAs as including any services the CRNA is permitted to furnish under their state scope of practice. In addition, this action results in CRNAs being treated similarly to other advanced practice nurses for Medicare purposes. This policy is consistent with the Institute of Medicine's recommendation that Medicare cover services provided by advanced practice nurses to the full extent of their state scope of practice. CMS will continue to monitor state scope of practice laws for CRNAs to ensure that they do not expand beyond the appropriate bounds of "anesthesia and related care" for purposes of the Medicare program.
Comment: Some commenters suggested that the proposal expands the scope of practice of CRNAs into the practice of medicine, and that the proposal undermines medical education, the practice of medicine, and the pain medicine specialty by equating nurses with physicians. Commenters further stated that such proposals, which lead to privileging and reimbursement for nonphysician practitioners that are identical to that of physicians, decrease the incentives to complete the rigorous training involved in medical school. Others stated that the proposal would interfere with the authority of states to regulate scope of practice.
Response: We acknowledge the concerns of the physician community; however, the intent of the proposal is not to undermine medical education, the practice of medicine, or the pain
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medicine specialty, but to establish parity between the scope of the Medicare benefit category for CRNAs and the CRNA authority to practice under state law. This proposal does not address payment rates for anesthesiologists or CRNAs. The statutory provisions that establish payment rates for CRNAs at the same rate as anesthesiologists are relatively longstanding. Our proposal in no way is intended to interfere with the authority of individual states; rather, it largely defers to individual states to determine the scope of practice for CRNAs. We believe that using state scope of practice law as a proxy for services encompassed in the statutory benefit language "anesthesia and related care" is preferable to choosing among individual interpretations of whether particular services fall within the scope of "anesthesia and related care." Moreover, we believe states are in an ideal position to gauge the status of, and respond to changes in, CRNA training and practice over time that might warrant changes in the definition of the scope of "anesthesia services and related care" for purposes of the Medicare program. As such, we believe it is appropriate to look to state scope of practice law as a proxy for the scope of the CRNA benefit.
Comment: Many commenters addressed the extent to which the standards for nurse anesthesia curricula and the content of nurse anesthesia educational programs do or do not prepare CRNAs to practice outside the perioperative setting, and specifically, to furnish chronic pain services. We received detailed comments regarding the necessary components of chronic pain services and conflicting information about whether CRNAs are trained or licensed to furnish such services. We received thorough descriptions of the skills required to furnish chronic pain services and the necessity of medical education to prepare one to furnish such services. Commenters also provided information about the inherent dangers involved in chronic pain services, the manner in which technical skills in chronic pain procedures are obtained, and the ways in which chronic pain services are or are not similar to other procedures performed by CRNAs in the perioperative setting and for labor epidurals. We received many comments from
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the physician community with concerns about the possibility of the furnishing of procedures that are not indicated due to lack of medical knowledge required to screen out patients who are not appropriate candidates for procedures.
Some commenters pointed to the long period of time during which CRNAs have furnished chronic pain services with no documented differences in patient outcomes, while others expressed concern about negative outcomes observed from inadequately trained providers. Descriptions were also provided regarding lawsuits at the state level that have debated whether CRNAs are qualified to furnish chronic pain services, the importance of medical regulation in protecting patients who may not be able to differentiate between different types of providers, and the role of the medical education process in ensuring competency of physicians. Other commenters opined that it is the responsibility of the individual provider to assure his or her competency for any and all procedures furnished.
Response: We acknowledge the varying perspectives about the education and training of CRNAs to furnish chronic pain management services as well as differences of opinion regarding the safety of chronic pain management services furnished by CRNAs. We are unable, at this time, to assess the appropriateness of the CRNA training relating to specific procedures. We are also unaware of any data regarding the safety of chronic pain management services when furnished by different types of professionals. However, we expect that states take into account all appropriate practitioner training and certifications, as well as the safety of their citizens, when making decisions about the scope of services CRNAs are authorized to furnish and providing licenses to individual practitioners in their jurisdictions.
We note that we did not address the services that CRNAs are trained and qualified to furnish in our proposal or in this final rule with comment period. Our proposal and this final rule merely define what services are included in the scope of the Medicare benefit established in section 1861(bb)(1) of the Act. The definition that we are adopting uses the state scope of
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practice as a proxy for what the term "anesthesia and related care" in section 1861(bb)(1) of the Act means and thus leaves decisions about what services constitute anesthesia and related care to be resolved by the state. This appropriately recognizes the actions of state bodies formed specifically to address the issue of what constitutes the scope of practice for a CRNA. We believe that determining whether or not CRNAs are adequately trained and can safely furnish chronic pain management is an appropriate decision for state bodies. This proposal is consistent with the Institute of Medicine's report on advanced practice nursing, which recommends that Medicare should "include coverage of advanced practice registered nurse services that are within the scope of practice under applicable state law, just as physicians' services are now covered."
We agree with commenters that it also is the responsibility of individual practitioners (physicians and CRNAs) to ensure that they are adequately trained and qualified to furnish any and all procedures that they furnish.
Comment: We received comments about the cost of CRNA services relative to those furnished by anesthesiologists. Commenters stated that chronic pain management services are less costly than surgical interventions, and that the services of CRNAs are more cost-effective for the Medicare program. Others stated that allowing CRNAs to furnish these services could increase spending due to the provision of inappropriate services and the complications that could result from procedures furnished by CRNAs who are not adequately trained.
Response: We do not have sufficient evidence to determine that chronic pain management interventions reduce the need for surgical interventions, or that there would be increased provision of inappropriate services and complications under a definition of the Medicare benefit category that defines "anesthesia and related care" as services a CRNA is authorized to furnish in his or her state. Spending for services under Medicare is not a factor in determining whether the statutory benefit encompasses particular services. However, we would note that CRNAs are generally paid at the same rate as anesthesiologists so there are no direct
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cost savings when services are furnished by CRNAs.
Comment: We received comments regarding special concerns about access in rural areas.
Commenters stated that CRNAs help patients avoid traveling long distances and long waits for appointments by having local providers available. Furthermore, commenters noted that as the population ages, the demand for chronic pain management services will increase. Commenters stated that decreased access to chronic pain management services (which would result if CRNAs are not permitted to furnish and bill for these services) would result in more institutionalization, reduced quality of life, longer wait times, and increased costs. Others stated that chronic pain management services are not emergent care services; that chronic pain management is a specialty that should be furnished by those with a high degree of sub-specialty training, and that pain physicians can be spread out over large areas since only a small minority of patients need procedural care. Some commenters cited a shortage of pain management physicians qualified to treat chronic pain, others stated that there is no shortage of such providers, while still others stated that the proposal may increase access, but at the expense of having unqualified providers. Finally, some commenters stated that procedures furnished improperly pose a greater danger than a lack of available services.
Response: While assuring access for beneficiaries in rural areas is a priority for Medicare, we do not have sufficient data to evaluate the presence or degree of problems of access to chronic pain management services in rural areas. We also do not have evidence that CRNAs have furnished chronic pain management services in quantities sufficient to improve any access problems in rural areas. We further lack sufficient data to determine whether beneficiaries who lack access to a CRNA care are more likely to suffer the negative outcomes cited by commenters. This lack of information does not deter us taking action to define the statutory benefit as it is not necessary to conclude that beneficiaries will suffer negative consequences to prompt us to act. Rather we are issuing this regulation based upon the factors we described
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above.
Comment: We received comments regarding those services included in the definition of
anesthesia and related care, as well as services "related to anesthesia." Some commenters stated that chronic pain management services are not directly "related to anesthesia" but still constitute "related care". Other commenters stated that CMS has already acknowledged in early preamble language that CRNAs may furnish services not directly related to anesthesia. Still other commenters stated that chronic pain services are not related to anesthesia in any way. One commenter suggested that CMS has already differentiated between anesthesia related acute pain and interventional chronic pain based on the creation of different specialty codes for anesthesia and chronic pain. One commenter requested that CMS make a regulatory change to allow CRNAs to order diagnostic tests in order to effectively provide chronic pain management services.
Response: We believe that the statutory intent was to include services not directly related to the peri-anesthetic setting in the CRNA benefit category. We believe that relying on state scope of practice to define the services encompassed in anesthesia and related care is preferable to choosing among conflicting definitions of "anesthesia and related care" or listing the specific services that fall within that benefit category. Rather, we believe states are in a better position to gauge the status of, and respond to changes in, CRNA training and practice over time that might warrant changes in the definition of the scope of "anesthesia services and related care" for purposes of the Medicare program. As such, we believe it is appropriate to look to state scope of practice law as a proxy for the scope of the CRNA benefit.
Comment: Several commenters expressed concern with the wording of our proposal; specifically, that the term "related to anesthesia" was unclear and subject to interpretation. States do not typically define services "related to anesthesia" in their state scope of practice acts.
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Response: We agree with commenters that the wording of the proposal was unclear. In

response to these and other commenter concerns, we are adopting a modification of our proposal to rely on state scope of practice to define the services encompassed in "anesthesia and related care" under section 1861(bb)(1) of the Act.
Comment: One commenter requested that we provide clarification for the payment of CRNA services furnished; specifically, which medical and/or surgical CRNA services are eligible for cost-based reimbursement (for CRNA pass-through payments or Method II billing for Critical Access Hospitals).
Response: We will be modifying the Internet Only Manual to reflect the change we are making in this final rule with comment period. The request for the list of services that are eligible for cost-based reimbursement is beyond the scope of this rule, as it pertains to hospital billing. We anticipate this matter will be addressed separately in a forthcoming transmittal.
Comment: Commenters requested that CMS instruct Medicare contractors to review prior denials of claims for CRNA services prior to any final rule determination of the scope of the CRNA Medicare benefit category.
Response: This definition of the Medicare benefit for CRNAs will be effective for services furnished on or after January 1, 2013. It does not apply to services furnished prior to this point so we will not be instructing contractors to review prior denials of claims.
After consideration of all comments, we are finalizing our proposal with modification to revise our regulations at §410.69(b) to define "Anesthesia and related care" under the statutory benefit for CRNA services as follows: "Anesthesia and related care means those services that a certified registered nurse anesthetist is legally authorized to perform in the state in which the services are furnished." We will continue to monitor the state scope of practice laws for CRNAs in order to insure that the use of state scope of practice as a proxy to define "anesthesia services and related care" is consistent with the goals and needs of Medicare program.
 
Holy f#cking ****..... this is insane. First thing to do is file suits at the state level. This is going to come down to decisions like Lousianna's several years ago. Make them justify the practice of medicine at the state level, good luck with that one.
 
yup, its confirmed, check ASA Website for rebuke statement.
 
Unbelievable.

Nurses: you are profoundly ill trained and ill equipped to be Interventional Pain Management specialists, and I will jump at the first chance I can to testify against you in court the first few times you paralyse and/or kill a patient.
 
Unbelievable.

Nurses: you are profoundly ill trained and ill equipped to be Interventional Pain Management specialists, and I will jump at the first chance I can to testify against you in court the first few times you paralyse and/or kill a patient.

+1 million
 
I just don't understand.

Nurses with no training now being paid by the government to do my job which took 13 years of training.

Obama destroying the future of physicians and my business.

Do you see a trend here to drive physicians out of existence? Replace us and make us broke.

Why did I go into this job to get replaced by nurses and driven out of business by my own government?

Fcku you Obama supporters. Fcku you physicians who voted for this socialist who will destroy YOUR career just as surely as mine.
 
I just don't understand.

Nurses with no training now being paid by the government to do my job which took 13 years of training.

Obama destroying the future of physicians and my business.

Do you see a trend here to drive physicians out of existence? Replace us and make us broke.

Why did I go into this job to get replaced by nurses and driven out of business by my own government?

Fcku you Obama supporters. Fcku you physicians who voted for this socialist who will destroy YOUR career just as surely as mine.

I don't buy that this was Obama. We did this to ourselves by allowing them to work alongside us and training them. If I personally ever meet anyone training a CRNA in chronic pain I am going to ruin them.
 
I just don't understand.

Nurses with no training now being paid by the government to do my job which took 13 years of training.

Obama destroying the future of physicians and my business.

Do you see a trend here to drive physicians out of existence? Replace us and make us broke.

Why did I go into this job to get replaced by nurses and driven out of business by my own government?

Fcku you Obama supporters. Fcku you physicians who voted for this socialist who will destroy YOUR career just as surely as mine.

Agree
 
I am in utter disbelief...... unbelievable
 
Yes, we have done some of this to ourselves but don't think Obama is not a part of this. Kathleen Sebelius (who Obama appointed) is a huge advocate of CRNA's. Don't think that she is not involved with CMS. This is a huge loss for our specialty. I have posted this on the anesthesia forum. I certainly hope that no academic centers allow CRNA students to start rotating there. I will quit my job before I train a CRNA to do pain. I am totally not kidding.
 
f*@k Obama, Obama supporters, CRNAs and all the 'Pain physicians' who didn't do jack sh#t to protect the profession. THANKS A LOT!! I am going to make as much money as possible while it lasts(3-5 years tops) and than I am going into management or something else more stable than being a pain physician.
 
I will quit my job before I train a CRNA to do pain. I am totally not kidding.
I'd be happy to train a CRNA to do pain. I just need tuition for 4 years of school, 4 years of residency, and 1 year of fellowship. Now the CRNA is capable of treating pain independently.
 
Well in case there was any question before if this was an election year move....the timing says it all

CMS is not entirely dumb, they know what they are doing here,

step 1: approve CRNAs to do pain
step 2: slash the **** out of pain $, implement aco's
Step 3: now the CRNAs are still willing to do pain (b/c 150K a year snds ok to them) as the docs return to there primary specialty (Gas, pmr, neuro)
step 4: doc's subjugated, ?money saved?
 
Atlas is starting to shrug folks
 
Okay, so CRNAs can bill CMS for pain procedures, but what is the role of individual states in this?

Don't states have to okay the independent practice of CRNAs individually, still?

What good is it to them if an individual state doesn't let them practice independently?
 
It unfortunately seems as through the CRNAs are more respected by the government regulators, hospital administrators etc than are the MDs. MDs in general are also woefully unaware of what is going on in the world around them and tend to adopt the "it will never happen" attitude that has destroyed anesthesiology as a profession.

Does anyone recall an instance where the ASAPAC has won a battle? It seems as though it is a completely ineffective organization.

I am ACGME Pain fellowship trained and ABMS Pain boarded, but my primary specialty is not anesthesia, so allow me some ignorance on the subject. I promise I'm not asking this to stir the pot, and don't get me wrong I am completely against nurses practicing as physicians without going to medical school, but....

Have CRNAs really destroyed the specialty of anesthesia?

I'm not an anesthesiologist, so I can honestly say I really couldn't answer the question myself.
 
Let me guess, they can't prescribe narcs either!!!! What a f@*#& joke!
 
I am so pissed and dumbfounded it is not even funny. CMS just using the old "let the states decide" BS to ruin my profession. Read this section:


Comment: Many commenters addressed the extent to which the standards for nurse

anesthesia curricula and the content of nurse anesthesia educational programs do or do not

prepare CRNAs to practice outside the perioperative setting, and specifically, to furnish chronic

pain services. We received detailed comments regarding the necessary components of chronic

pain services and conflicting information about whether CRNAs are trained or licensed to

furnish such services. We received thorough descriptions of the skills required to furnish chronic

pain services and the necessity of medical education to prepare one to furnish such services.

Commenters also provided information about the inherent dangers involved in chronic pain

services, the manner in which technical skills in chronic pain procedures are obtained, and the

ways in which chronic pain services are or are not similar to other procedures performed by

CRNAs in the perioperative setting and for labor epidurals. We received many comments from

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the physician community with concerns about the possibility of the furnishing of procedures that

are not indicated due to lack of medical knowledge required to screen out patients who are not

appropriate candidates for procedures.

Some commenters pointed to the long period of time during which CRNAs have

furnished chronic pain services with no documented differences in patient outcomes, while

others expressed concern about negative outcomes observed from inadequately trained providers.

Descriptions were also provided regarding lawsuits at the state level that have debated whether

CRNAs are qualified to furnish chronic pain services, the importance of medical regulation in

protecting patients who may not be able to differentiate between different types of providers, and

the role of the medical education process in ensuring competency of physicians. Other

commenters opined that it is the responsibility of the individual provider to assure his or her

competency for any and all procedures furnished.

Response: We acknowledge the varying perspectives about the education and training of

CRNAs to furnish chronic pain management services as well as differences of opinion regarding

the safety of chronic pain management services furnished by CRNAs. We are unable, at this

time, to assess the appropriateness of the CRNA training relating to specific procedures. We are

also unaware of any data regarding the safety of chronic pain management services when

furnished by different types of professionals. However, we expect that states take into account

all appropriate practitioner training and certifications, as well as the safety of their citizens, when

making decisions about the scope of services CRNAs are authorized to furnish and providing

licenses to individual practitioners in their jurisdictions.

We note that we did not address the services that CRNAs are trained and qualified to

furnish in our proposal or in this final rule with comment period. Our proposal and this final rule

merely define what services are included in the scope of the Medicare benefit established in

section 1861(bb)(1) of the Act. The definition that we are adopting uses the state scope of

377

practice as a proxy for what the term "anesthesia and related care" in section 1861(bb)(1) of the

Act means and thus leaves decisions about what services constitute anesthesia and related care to

be resolved by the state. This appropriately recognizes the actions of state bodies formed

specifically to address the issue of what constitutes the scope of practice for a CRNA. We

believe that determining whether or not CRNAs are adequately trained and can safely furnish

chronic pain management is an appropriate decision for state bodies. This proposal is consistent

with the Institute of Medicine's report on advanced practice nursing, which recommends that

Medicare should "include coverage of advanced practice registered nurse services that are within

the scope of practice under applicable state law, just as physicians' services are now covered."

We agree with commenters that it also is the responsibility of individual practitioners

(physicians and CRNAs) to ensure that they are adequately trained and qualified to furnish any

and all procedures that they furnish.
 
Now we have the uneducated inferiorly trained nurses practicing a surgical specialty. It is a sad day when "patient access" issues will propel our society into the acceptance of incompetent fools that simply want to expand their role in healthcare without doing any of the preparatory training or formal standard education. On the bright side, I look forward to my days of retirement from clinical practice serving as an expert in pain medicine scrutinizing charts and testifying against these charlatans. I should be able to make quite an income from the upcoming onslaught of injuries. Bring it on!
 
I just don't understand.

Nurses with no training now being paid by the government to do my job which took 13 years of training.

Obama destroying the future of physicians and my business.

Do you see a trend here to drive physicians out of existence? Replace us and make us broke.

Why did I go into this job to get replaced by nurses and driven out of business by my own government?

Fcku you Obama supporters. Fcku you physicians who voted for this socialist who will destroy YOUR career just as surely as mine.

Hope you are not really as ignorant as your statement
 
f*@k Obama, Obama supporters, CRNAs and all the 'Pain physicians' who didn't do jack sh#t to protect the profession. THANKS A LOT!! I am going to make as much money as possible while it lasts(3-5 years tops) and than I am going into management or something else more stable than being a pain physician.

Yes Obama is responsible for your anger issues...I am sure it was part of his Grand plan to destroy physicians and Favor CRNA's and "socialize" this country.
 
Well in case there was any question before if this was an election year move....the timing says it all

CMS is not entirely dumb, they know what they are doing here,

step 1: approve CRNAs to do pain
step 2: slash the **** out of pain $, implement aco's
Step 3: now the CRNAs are still willing to do pain (b/c 150K a year snds ok to them) as the docs return to there primary specialty (Gas, pmr, neuro)
step 4: doc's subjugated, ?money saved?

My question is-for one, how will this save any $? Are they slashing the rates for reimbursement? And if they don't want doctors in anesthesia, why not just stop funding anesthesia residencies? This is stupid.

I think striking and walkouts, protests are in order. If they don't want physicians, they should start shutting down medical schools.
 
This is not a personal slight. But I think it's very ignorant to believe obama isn't trying destroy physician autonomy and physician incomes.

he's trying to decrease health care costs and increase coverage.

decreased reimbursements and autonomy are a side-effect of the fact we have let insurance companies and hospitals railroad us b/c they have more money and stronger lobbies. if there is a bigger evil, its insurance companies and big pharma.

saying "F&CK obama, its all his fault" is very short-sighted.

not that i love the ACA, but you got a better way to do this, bedrock, im all ears.
 
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This is not a personal slight. But I think it's very ignorant to believe obama isn't trying destroy physician autonomy and physician incomes.

The ruling will allow more proceduralists and they bill at the same rate as us.

That won't save cost... And in the end, he doesn't care who gets the money.
 
Sample note I quickly drafted to send to your local senator and assemblyman:

"I am a Pain physician, and wI live in your district. The ruling from CMS has allowed CRNAs to bill for interventional pain.

I would like your assistance to oppose allowing any changes to the state mandates with regards to allowing CRNAs to practice independently and start performing injections. They receive no training in these challenging procedures, and they will be a new group of individuals that will start prescribing opiates, worsening our opioid problem.

We also do not have a pain physician shortage, which is the major reason CMS approved this change.

Our state does not need people who don't know what they are doing on pain patients.

Please call me or email me any time."
 
Sample note I quickly drafted to send to your local senator and assemblyman:

"I am a Pain physician, and wI live in your district. The ruling from CMS has allowed CRNAs to bill for interventional pain.

I would like your assistance to oppose allowing any changes to the state mandates with regards to allowing CRNAs to practice independently and start performing injections. They receive no training in these challenging procedures, and they will be a new group of individuals that will start prescribing opiates, worsening our opioid problem.

We also do not have a pain physician shortage, which is the major reason CMS approved this change.

Our state does not need people who don't know what they are doing on pain patients.

Please call me or email me any time."

This would cover half the competition in my state. Blind ESI, series of 3 everything, multiple short actings.

I like the idea of CRNA practicing independently. I can testify for the plaintiff without feeling guilty. I can tell patients who weer injected by the CRNA to go back to them for meds as I will not see them. I can tell my family and friends to see MD/DO only, no PA, NP, CRNA. It will improve the caliber of patient I see because someone who knows less, is ridiculously less trained and unqualified, can make their money off the unknowing, innocent, and less fortunate.
 
This would cover half the competition in my state. Blind ESI, series of 3 everything, multiple short actings.

I like the idea of CRNA practicing independently. I can testify for the plaintiff without feeling guilty. I can tell patients who weer injected by the CRNA to go back to them for meds as I will not see them. I can tell my family and friends to see MD/DO only, no PA, NP, CRNA. It will improve the caliber of patient I see because someone who knows less, is ridiculously less trained and unqualified, can make their money off the unknowing, innocent, and less fortunate.

Care to explain how this lowers cost overall? And realistically who would go to a CRNA vs an MD/DO if they BILL THE SAME and therefore cost the same?! It seems ******ed. If there is no cost savings what is the point of this?
 
I don't buy that this was Obama. We did this to ourselves by allowing them to work alongside us and training them. If I personally ever meet anyone training a CRNA in chronic pain I am going to ruin them.

Here you go! http://www.painmd.com/about-us/michael-oconnell-paincare-ceo.html

This is the devil who is putting our profession under! Why doesn't someone sue him or at the least put him in the spot light for training these uneducated greedy CRNA's. Read the CRNA bios in the website and how their special interests include spinal cord stimulators, kyphoplasty etc. Not just bread and butter procedures. So dangerous! This guy and others we should be attacking full force. Lets not make the same mistake as in anesthesia and continue to let these greedy doctors get away with training these midlevels and bringing down our profession!
 
Care to explain how this lowers cost overall? And realistically who would go to a CRNA vs an MD/DO if they BILL THE SAME and therefore cost the same?! It seems ******ed. If there is no cost savings what is the point of this?

It increases costs. What does this have to do with lowering costs. I will increase utilization and have chiros all over the place racing to add a CRNA to do all the procedures their FP flunkies could not perform. Most of the places are just trigger points, knee injections, and blind SIJ. Now they can screw the insurance for all they've got and try and dump them.

But this does not effect me directly for the foreseeable future. It should make me busier for RF, SCS, and evals to undue what has been done. No problem.
 
Perhaps we need a permanent thread "Stupid CRNA Tricks" that will give info about errant judgments, poor clinical decisionmaking, technical mistakes, with naming names and another section naming CRNAs involved in pain procedure disasters resulting in complaints and litigation. Could make for some interesting reading. Any takers for such on the private forum?

Regarding PainCare: from the NH Board Action Reports: Michael J. O'Connell, M.D. - License # 7690
1/5/12 - The Board of Medicine approved a Settlement Agreement for Michael J. O'Connell, M.D. Dr. O'Connell has agreed to a permanent voluntary surrender of his license to practice to avoid further delay and expense of proceedings arising out of the certain allegations regarding improper relationships with former patients.
 
Okay. Let's all take a deep breath.

I understand how this is intensely personal if you are an anesthesiologist, considering this battle has been going on for more than 20 years. And I agree, CRNAs are not physicians and absolutely should not be able to practice as such.

(Here's an interesting article about the same exact thing going back to 1988!http://www.scribd.com/doc/37932145/Anesthesia-Battle-Royale-Parade-Magazine-1988)

But the reality of the situation is this:

I you are highly trained with an MD/DO, fellowship trained and ABMS certified. If you are good at what you do. If you treat patients right and appropriately.

You'll be fine.

Although, most patients don't know the difference between boarded or not, "anesthesia-trained or not", acgme-fellowship or not, they do know the difference between a doctor and a nurse.

I agree, this ruling sucks, and it will have consequences, and I wrote my own letters/comments against it, but....


Most patients prefer a doctor.

And most patients want the doctor with as much training as possible.

Market yourself as such.

And you will be fine.


What it really comes down to is this:

Do you really think a CRNA can do as good a job as you?

If not, you'll be fine. There will be plenty of people in pain.

Will salaries go down? I don't know. Will jobs be harder to find? I don't know.

But what I'm sure of is, that there will be plenty of need for....


Doctors with way more training who can do it better.
 
Yes this is freaking crazy. The problem is that no one really understands what we do therefore its easier for groups like crnas to cloud the real issues when speaking to lay people. I think the problem with this from an economic standpoint is if orthos/neurosurgeons/primaries decide to hire a crna and do all their procedures in house. Right now thats cost prohibitive since a pain docs salary is too high, but if you don't care about quality of care and just want to skim money off injections...well a crna that you only have to 120k a year for sounds pretty good. Of course none of these people will actually get better and the rate of failed back/opiate addicted patients/utilization of pain management cpt codes will increase, but these are downstream effects that will occur long after Kathleen Sebelius has left office.
 
false. this would never have happened under repbulican control. Bill Clinton and Sabelius are CRNA loving wh-res....
 
bill clinton's mom was a CRNA.

I hope everyone grabs just ONE other person and gets them to join ASIPP. if everyone does that, we can actually have a strong organization. then we can start fighting. we haven't lost until all of us are making under 6 figures and CRNA's are our bosses.
 
What a f**king disaster.

It's crap like this that makes me wish I had stayed in surgery. When I was a surgeon I didn't have to worry about midlevels competing against me for jobs. I was miserable, but at least I had job security and the respect of being a physician. Now that I'm in anesthesiology and on the verge of starting a pain fellowship next year, I can't believe that I actually have to worry about midlevels taking my job. It's absolutely ridiculous.

What was the point of all my postgraduate education? Why did I endure the years of additional training, the countless nights on call, the seemingly endless barrage of examinations? Why would any rational person endure twice the hardship and sacrifice to achieve an "equivalent" endpoint? CRNAs literally have one half the formal postgraduate training of a fellowship trained pain management physician. Yet, according to the bureaucrats at CMS, the training of CRNAs and physicians in the field of pain management is "equivalent."

CMS reasoning in a nutshell:

Masters degree vs. a doctorate...Eh, that's pretty much the same thing.

6.5 years vs. 13 years...No big deal. CRNAs have ample experience as ICU nurses.

8 hours vs. 50+ hours of certification exams...Irrelevant, because CRNAs will know when they're practicing outside their "safe zone" and consult physician specialists accordingly.

OR anesthesia vs. diagnosing and treating diseases in clinic...It's the same damn thing!

Jesus, what a cluster f**k. Say goodbye to the specialty of anesthesiology and the subspecialty of pain management. Nurses are going to run the show from now on. God help us all.
 
Its like a dejavu for me, very similar to the U.K system. Wait till nurses become attendings with equal authority and challenge your every decission to feed their underlying twisted ego. What an utter disaster, no words to express.
What I dont understand is if every move is to bring this country's health system closer to the NHS system, then why is no one paying attention to bringing the same level of litigation/medicolegal status as UK. Guess lawyers have a bigger and powerful lobby!
 
I fail to see how Ayn Rand has anything to do with this CRNA bullsh@t

this excerpt from Atlas sums it up...

I quit when medicine was placed under State control, some years ago,” said Dr. Hendricks. “Do you know what it takes to perform a brain operation? Do you know the kind of skill it demands, and the years of passionate, merciless, excruciating devotion that go to acquire that skill? That was what I would not place at the disposal of men whose sole qualification to rule me was their capacity to spout the fraudulent generalities that got them elected to the privilege of enforcing their wishes at the point of a gun. I would not let them dictate the purpose for which my years of study had been spent, or the conditions of my work, or my choice of patients, or the amount of my reward. I observed that in all the discussions that preceded the enslavement of medicine, men discussed everything – except the desires of the doctors. Men considered only the ‘welfare’ of the patients, with no thought for those who were to provide it. That a doctor should have any right, desire or choice in the matter was regarded as irrelevant selfishness; his is not to choose, they said, only ‘to serve.’ That a man who’s willing to work under compulsion is too dangerous a brute to entrust with a job in the stockyards – never occurred to those who proposed to help the sick by making life impossible for the healthy. I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind – yet what is it that they expect to depend on, when they lie on an operating table under my hands? Their moral code has taught them to believe that it is safe to rely on the virtue of their victims. Well, that is the virtue I have withdrawn. Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of a man who resents it – and still less safe, if he is the sort who doesn’t.
 
well i def agree with everyone that this royally sucks ass and is basically crna friendly dems (sebelius) ramming her personal agenda through despite expert opinion. But there are still multiple hurdles that need to be overcome. First is at the state level which will I guess determine the actual scope of their practice. Second would be to convince other docs that its somehow better to send patients to a crna as opposed to a doc...which I dont think will ever really happen. Yea maybe a few crnas may start doing some procedures out in bumble but I think it will be exceedingly hard for them to gain a foothold in a competitive market. I think the scourge of midlevels has left a sour taste in every physicians mouth, and I sense more and more docs are starting to stick together a little bit. Third, I dont see too many hospitals giving crnas privileges to perform IP procedures. Hospitals are constantly worried they are going to get sued, and are not willing to take risks unless the reward can be very clearly defined....in other words they are very conservative. All the hospitals that we're on staff at state specifically in the by-laws (that we help to create btw) you have to be board certified from the ABA or equivalent ACGME recognized board for your medical specialty within 1 year of joining the staff, otherwise privileges get revoked. .
 
well i def agree with everyone that this royally sucks ass and is basically crna friendly dems (sebelius) ramming her personal agenda through despite expert opinion. But there are still multiple hurdles that need to be overcome. First is at the state level which will I guess determine the actual scope of their practice. Second would be to convince other docs that its somehow better to send patients to a crna as opposed to a doc...which I dont think will ever really happen. Yea maybe a few crnas may start doing some procedures out in bumble but I think it will be exceedingly hard for them to gain a foothold in a competitive market. I think the scourge of midlevels has left a sour taste in every physicians mouth, and I sense more and more docs are starting to stick together a little bit. Third, I dont see too many hospitals giving crnas privileges to perform IP procedures. Hospitals are constantly worried they are going to get sued, and are not willing to take risks unless the reward can be very clearly defined....in other words they are very conservative. All the hospitals that we're on staff at state specifically in the by-laws (that we help to create btw) you have to be board certified from the ABA or equivalent ACGME recognized board for your medical specialty within 1 year of joining the staff, otherwise privileges get revoked. .

I agree totally. Since most of what we do is referral based, can you honestly see your PHYSICIAN referrers sending their patients, not to a more highly trained specialist physician, but to a nurse with less training than them?

No.

Maybe Medicaid, self pay or ipiod dumps that have burned every other bridge in town.

Also, with hospitals obsessed with patient satisfaction, lawsuit avoidance and advertising board certification and credentials.....I don't think it's as big of a threat as we all think it is.
 
Perhaps we need a permanent thread "Stupid CRNA Tricks" that will give info about errant judgments, poor clinical decisionmaking, technical mistakes, with naming names and another section naming CRNAs involved in pain procedure disasters resulting in complaints and litigation. Could make for some interesting reading. Any takers for such on the private forum?

Regarding PainCare: from the NH Board Action Reports: Michael J. O’Connell, M.D. - License # 7690
1/5/12 - The Board of Medicine approved a Settlement Agreement for Michael J. O'Connell, M.D. Dr. O'Connell has agreed to a permanent voluntary surrender of his license to practice to avoid further delay and expense of proceedings arising out of the certain allegations regarding improper relationships with former patients.

You bring a good point up.

We should PUBLICLY bring these sorts of things up.

Organizations like the ASA and ASIPP are playing way too nice. I think it's time to just be blunt.

Have advertisements showing the disparity of education. Demonstrating the potential complications, "DEATH, PARALYSIS, MENINGITIS".

Then asking questions like do you want your unknowing grandmother (medicare recipient) getting injections from these inferiorly educated nurses versus a doctor with 13 years of medical education.

I say, stop trying to 'pass' these things through legislators, bring the issues directly to the CONSUMER (aka the patient). Make it a patient safety issue that patients must see.
 
You bring a good point up.

We should PUBLICLY bring these sorts of things up.

Organizations like the ASA and ASIPP are playing way too nice. I think it's time to just be blunt.

Have advertisements showing the disparity of education. Demonstrating the potential complications, "DEATH, PARALYSIS, MENINGITIS".

Then asking questions like do you want your unknowing grandmother (medicare recipient) getting injections from these inferiorly educated nurses versus a doctor with 13 years of medical education.

I say, stop trying to 'pass' these things through legislators, bring the issues directly to the CONSUMER (aka the patient). Make it a patient safety issue that patients must see.

Caveat emptor.
 
You bring a good point up.

We should PUBLICLY bring these sorts of things up.

Organizations like the ASA and ASIPP are playing way too nice. I think it's time to just be blunt.

Have advertisements showing the disparity of education. Demonstrating the potential complications, "DEATH, PARALYSIS, MENINGITIS".

Then asking questions like do you want your unknowing grandmother (medicare recipient) getting injections from these inferiorly educated nurses versus a doctor with 13 years of medical education.

I say, stop trying to 'pass' these things through legislators, bring the issues directly to the CONSUMER (aka the patient). Make it a patient safety issue that patients must see.

I agree strongly. Time to inform the public, even through commercials. This can also be done for OR anesthesia. Patients ask for a particular medicine that they saw on TV from their PCPs all the time. Why not have them ask for a physician to provide their care by educating them. Knowledge is power!!!
 
Yes I agree with that. Look at asipps website there's not even a mention of this. And the asa... forget about it, they sold pain management up the river a long time ago. Just this last year they failed to give any rvu recommendations in their latest guidelines. The guidelines use to be a good negotiating tool that interventional pain docs could use for leverage when negotiating with insurances including medicare but by giving them up they effectively steered attention away from operating room codes. We really have no 1 to lobby for us which sucks. Personally I've been calling my senator and have been speaking with his secretary of Health. It's not too late to get this stupid ass rule overturned if we all band together.
 
Yes I agree with that. Look at asipps website there's not even a mention of this. And the asa... forget about it, they sold pain management up the river a long time ago. Just this last year they failed to give any rvu recommendations in their latest guidelines. The guidelines use to be a good negotiating tool that interventional pain docs could use for leverage when negotiating with insurances including medicare but by giving them up they effectively steered attention away from operating room codes. We really have no 1 to lobby for us which sucks. Personally I've been calling my senator and have been speaking with his secretary of Health. It's not too late to get this stupid ass rule overturned if we all band together.


The question is how. We are all on the same page here on SDN. We know that this is soo wrong. We write about it . It's all to deaf ears.

IDeally our societies should be doing this for us. How do we ban together. Perhaps a private forum conversation. But perhaps TV ads, newspaper ads that we all collectively put together. Everyone pitches in a $1000 or so? How do we do it?
 
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