East Coast States Haven't Opted Out.

[tima]

I was looking at the 16 states that have opted out. I don't see many East Coast states yet. I only see NH. Any explanations.

http://www.beckersasc.com/anesthesi...physician-supervision-of-anesthesia-rule.html

Thank you.

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[Monty Python]

I was looking at the 16 states that have opted out. I don't see many East Coast states yet. I only see NH. Any explanations.

http://www.beckersasc.com/anesthesi...physician-supervision-of-anesthesia-rule.html

Thank you.

Opting-out is a non-issue in the ~25 states which require physician supervision/direction of CRNA practice as legislated in their state nurse practice act.

 

[deleted126335]

I was looking at the 16 states that have opted out. I don't see many East Coast states yet. I only see NH. Any explanations.

http://www.beckersasc.com/anesthesi...physician-supervision-of-anesthesia-rule.html

Thank you.

Just a guess on my part. More docs per capita in the densely populated states. More MD Anesthesia. Relatively few rural areas on the east coast, the hallmark of solo CRNA practice... they don't get a foothold from which to build.

 

[BLADEMDA]

Opting-out is a non-issue in the ~25 states which require physician supervision/direction of CRNA practice as legislated in their state nurse practice act.

Some say there are only 12 states which specifically say supervision by a physician for CRNA practice is required per the state nurse practice act.

What's the truth?

 

[BLADEMDA]

Opting-out is a non-issue in the ~25 states which require physician supervision/direction of CRNA practice as legislated in their state nurse practice act.

I have so many sick patients requiring tough medical decisions preop and postop. The CRNA handles much of the intraop management but what about preop and postop? Who is there to help the Ortho, ENT, Urologist, Optho, neurosurgeon, etc with all the medical issues? Internists and Medical Intensivists rarely understand the issues surrounding anesthesia.

I don't see how a CRNA practices independently in a major medical center. I can see the "fireman" model for Anesthesiologists with the CRNA doing more in the OR but the necessity of a Board Certified Perioperative Physician still remains.

 

[Monty Python]

Some say there are only 12 states which specifically say supervision by a physician for CRNA practice is required per the state nurse practice act.

What's the truth?

Sorry for the lack of formatting, I couldn't get the page to cut and paste more neatly.

No Supervision or Direction Requirement (including hospital statutes/regulations)

The following 24 states, and the District of Columbia, have no supervision or direction requirement concerning nurse anesthetists in nurse practice acts, board of nursing rules/regulations, medical practice acts, board of medicine rules/regulations, hospital licensing statutes, hospital licensing rules/regulations, or their generic equivalents:

Alaska Nebraska
California New Hampshire
Colorado New Mexico
Delaware North Carolina
District of Columbia North Dakota
Hawaii Oregon
Idaho South Carolina
Illinois Tennessee
Iowa Texas
Maryland Vermont
Minnesota Washington
Mississippi Wisconsin
Montana

 

[Monty Python]

I don't see how a CRNA practices independently in a major medical center. I can see the "fireman" model for Anesthesiologists with the CRNA doing more in the OR but the necessity of a Board Certified Perioperative Physician still remains.

Two things drive that bus: (1) state law, and (2) hospital staff by-laws.

 

[tima]

That seems right, since "CRNAs are the only anesthesia providers in more than two-thirds of all rural hospitals in the U.S." There are less rural places on the east coast.

http://www.allnursingschools.com/nursing-careers/nurse-anesthetist/registered-nurse-anesthetist

Just a guess on my part. More docs per capita in the densely populated states. More MD Anesthesia. Relatively few rural areas on the east coast, the hallmark of solo CRNA practice... they don't get a foothold from which to build.

 

[tima]

Any idea on how hard it is for the gov't to change the nurse practice act to allow less CRNA supervision.

Opting-out is a non-issue in the ~25 states which require physician supervision/direction of CRNA practice as legislated in their state nurse practice act.

 

[tima]

If you look at city or suburban hospitals, do you think a ratio of 3-4 CRNAs to 1 MD is accurate? Please elaborate.

I have so many sick patients requiring tough medical decisions preop and postop. The CRNA handles much of the intraop management but what about preop and postop? Who is there to help the Ortho, ENT, Urologist, Optho, neurosurgeon, etc with all the medical issues? Internists and Medical Intensivists rarely understand the issues surrounding anesthesia.

I don't see how a CRNA practices independently in a major medical center. I can see the "fireman" model for Anesthesiologists with the CRNA doing more in the OR but the necessity of a Board Certified Perioperative Physician still remains.

 

[Monty Python]

Any idea on how hard it is for the gov't to change the nurse practice act to allow less CRNA supervision.

Just make sure you're not mixing apples and oranges with your question here.

1. Individual state nurse practice acts are an all-or-nothing thing, when talking about CRNA supervision requirement. If CRNA supervision is required by state law it's not quantified. Changing state law is pretty generic: it's a political battle with all that entails.

2. Medicare requires MD supervision of CRNAs for Medicare reimbursement purposes. Medicare limits the ratio of MD:CRNA supervision to 1:4 for billing purposes.

3. Opt-out allows Medicare reimbursement of CRNA independent practice, but only (a) in states which allow generic independent CRNA practice to begin with by virtue of state law, *and* (b) where the governor (not the legislature) has signed an "opt-out" exclusion to allow CRNAs to practice independently for the specific purpose of receiving Medicare reimbursement. Opt-out pertains strictly to CRNA eligibility to bill Medicare as an independent practitioner.

4. In states which already allow independent CRNA practice, but which haven't "opted-out," independent CRNA practice cannot bill Medicare. Well, they can bill, but they don't have any realistic hope of receiving payment unless that state has also "opted-out."

5. Hospital specific staff bylaws can always be more restrictive than state law or insurance billing rules, but not looser.

Clear as mud? Just an example of what happens when Big Brother gets involved in the financing of health care. I see the OP is a med student. Have you done a rotation yet at a VA hospital? That's just a glimpse of what nationalized health care will resemble in a decade, if Obamacare is allowed to stand by the Supreme Court.

 

[ICd8U]

Just make sure you're not mixing apples and oranges with your question here.

1. Individual state nurse practice acts are an all-or-nothing thing, when talking about CRNA supervision requirement. If CRNA supervision is required by state law it's not quantified. Changing state law is pretty generic: it's a political battle with all that entails.

2. Medicare requires MD supervision of CRNAs for Medicare reimbursement purposes. Medicare limits the ratio of MD:CRNA supervision to 1:4 for billing purposes.

3. Opt-out allows Medicare reimbursement of CRNA independent practice, but only (a) in states which allow generic independent CRNA practice to begin with by virtue of state law, *and* (b) where the governor (not the legislature) has signed an "opt-out" exclusion to allow CRNAs to practice independently for the specific purpose of receiving Medicare reimbursement. Opt-out pertains strictly to CRNA eligibility to bill Medicare as an independent practitioner.

4. In states which already allow independent CRNA practice, but which haven't "opted-out," independent CRNA practice cannot bill Medicare. Well, they can bill, but they don't have any realistic hope of receiving payment unless that state has also "opted-out."

5. Hospital specific staff bylaws can always be more restrictive than state law or insurance billing rules, but not looser.

Clear as mud? Just an example of what happens when Big Brother gets involved in the financing of health care. I see the OP is a med student. Have you done a rotation yet at a VA hospital? That's just a glimpse of what nationalized health care will resemble in a decade, if Obamacare is allowed to stand by the Supreme Court.

2. CRNAs can be "medically directed" at a maximum number of 1:4, however an MD can "medically supervise" at a ratio higher than that, they just cannot bill for medical direction. Makes sense, right?

4. In states that haven't opted out CRNAs are required to be "supervised" by a physician to bill medicare however in many rural settings that supervision is satisfied by the surgeon (or ER doctor, hospitalist, ect) signing the chart as the supervising physician. So essentially CRNAs in these non opt out state settings practice anesthesia independently already with the chart signing being little more than a formality. No hospital would put up with an anesthesia department that cannot bill for medicare cases so if they have a CRNA only department they will either pressure the surgeon into signing the chart or hire an Anesthesiologist to supervise the anesthetists.

 

[Monty Python]

2. CRNAs can be "medically directed" at a maximum number of 1:4, however an MD can "medically supervise" at a ratio higher than that, they just cannot bill for medical direction. Makes sense, right?

4. In states that haven't opted out CRNAs are required to be "supervised" by a physician to bill medicare however in many rural settings that supervision is satisfied by the surgeon (or ER doctor, hospitalist, ect) signing the chart as the supervising physician. So essentially CRNAs in these non opt out state settings practice anesthesia independently already with the chart signing being little more than a formality. No hospital would put up with an anesthesia department that cannot bill for medicare cases so if they have a CRNA only department they will either pressure the surgeon into signing the chart or hire an Anesthesiologist to supervise the anesthetists.

Are you sure about that? I thought Medicare required CRNA supervision specifically by an anesthesiologist to receive Medicare reimbursement, in states which haven't opted-out. However I'm certainly no expert.

 

[ICd8U]

Are you sure about that? I thought Medicare required CRNA supervision specifically by an anesthesiologist to receive Medicare reimbursement, in states which haven't opted-out. However I'm certainly no expert.

In no state are CRNAs required to be supervised by an anesthesiologist.

Anesthesia must be administered only by -- (1) A qualified anesthesiologist; (2) A doctor of medicine or osteopathy (other than an anesthesiologist); (3) A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under State law; (4) A certified registered nurse anesthetist (CRNA), as defined in § 410.69(b) of this chapter, who, unless exempted in accordance with paragraph (c)of this section, is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed; or (5) An anesthesiologist's assistant, as defined in § 410.69(b) of this chapter, who is under the supervision of an anesthesiologist who is immediately available if needed.

http://www.asahq.org/For-Members/Pr...Supervision-Rules-for-Nurse-Anesthetists.aspx

The reality is that the opt out is less about CRNAs practicing anesthesia independently and more about the PERCEPTION that they are practicing independently.

I don't believe that there has been any rush to CRNA only practice following an opt out..... Most practices stay as they are. After all, the hospital medical staff are the group that ultimately makes the decision as to weather CRNAs must be supervised and how that supervision will take place at a particular facility, opt out or no.

 

[Monty Python]

In no state are CRNAs required to be supervised by an anesthesiologist.



http://www.asahq.org/For-Members/Pr...Supervision-Rules-for-Nurse-Anesthetists.aspx

The reality is that the opt out is less about CRNAs practicing anesthesia independently and more about the PERCEPTION that they are practicing independently.

I don't believe that there has been any rush to CRNA only practice following an opt out..... Most practices stay as they are. After all, the hospital medical staff are the group that ultimately makes the decision as to weather CRNAs must be supervised and how that supervision will take place at a particular facility, opt out or no.

I stand corrected. Thank you for the clarifying information.

 

[Consigliere]

The title of this thread should be: East Coast States Haven't Opted Out - Yet

 

[Arch Guillotti]

Are you sure about that? I thought Medicare required CRNA supervision specifically by an anesthesiologist to receive Medicare reimbursement, in states which haven't opted-out. However I'm certainly no expert.

I don't know about the Medicare part but I am 100% certain that CRNA's practice in non-opt out states by themselves and are "supervised" by the surgeon.

 

[Mman]

Sorry for the lack of formatting, I couldn't get the page to cut and paste more neatly.

No Supervision or Direction Requirement (including hospital statutes/regulations)

The following 24 states, and the District of Columbia, have no supervision or direction requirement concerning nurse anesthetists in nurse practice acts, board of nursing rules/regulations, medical practice acts, board of medicine rules/regulations, hospital licensing statutes, hospital licensing rules/regulations, or their generic equivalents:

Alaska Nebraska
California New Hampshire
Colorado New Mexico
Delaware North Carolina
District of Columbia North Dakota
Hawaii Oregon
Idaho South Carolina
Illinois Tennessee
Iowa Texas
Maryland Vermont
Minnesota Washington
Mississippi Wisconsin
Montana

That list is not entirely correct. I live in one of those states and CRNAs are expressly prohibited from independent practice by the medical board regulations. They always require physician supervision.