BLADEMDA

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BLADEMDA

BLADEMDA

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Anesthesia Care and the Law
As costs continue to rise, healthcare policymakers are balancing a mandate by their constituents to make the system more efficient and accessible, all while maintaining safe, high-quality service delivery. Research suggests a CRNA-based anesthesia care model moves lawmakers a step closer to meeting that challenge.
The practice of anesthesia has an exemplary safety record whether provided by a CRNA working alone, an anesthesiologist working alone or a CRNA working with an anesthesiologist. In either scenario, deaths attributed to anesthesia during surgery are extremely rare, occurring approximately once in every 250,000-300,000 anesthetics provided.

A 2010 study found the most cost-effective anesthesia delivery model is a CRNA working as the sole anesthesia provider. Another landmark study confirmed there are no measurable differences in the quality or safety of anesthesia services delivered by CRNAs, anesthesiologists, or CRNAs supervised by anesthesiologists. Long before either of these studies were published, a 2001 federal rule allowed states to opt out of (be exempt from) the Centers for Medicare & Medicaid Services (CMS) requirement that CRNAs must be supervised by a physician for their facility to be reimbursed. To date, 17 states have opted out. Whether or not a state has opted out, CRNAs are not required to be supervised by physician anesthesiologists.

To promote patient access to safe, high-quality, cost-effective healthcare, the American Association of Nurse Anesthetists (AANA) has called for Medicare to eliminate the unnecessary CRNA supervision requirement and allow states and healthcare facilities to make their own decisions about how to best staff anesthesia departments based on state laws and patient needs. By making this change, Medicare can align national policy with state scopes of practice, promote healthcare delivery consistent with patient and community needs, and open the door for cost savings associated with delivery system innovation. This approach also is consistent with recent recommendations from the Institute of Medicine.

Given that CRNAs are highly educated, advanced practice registered nurses who consistently deliver anesthesia to patients using the same procedures as physician anesthesiologists, allowing these professionals to practice to their full scope just makes sense.
 

vaibh

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the thing is it we all say and talk about crnas but then when it comes to doing thing which differentiate us from crna how much are we doing ?
Are the attendings teaching residents to be more knowledgeable than crnas ?
Are we being professional at work and not bragging to get out at 3 :30 ? why did our speciality got hit by mid levels more than any other were people just lazy or didn't care ?
Are we taking responsibility of our patients more than just putting them to sleep and waking ?
It also depends on how much involved anesthesia deptt. leadership is in peri op settings , I guess rather than just cursing them and discussing between ourself we should prove our self as being able to provide superior care to patient and draw firm boundaries between us and crnas and would have been much helpful if Old " hide behind the drape" type anesthesiologist had a sense of responsibility towards our specialty.
 
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Funny.

Anesthesia has been my #1 choice for specialty ever since freshman year of high school.

However, given how much you guys (the ASA and everyone complicit with them) have done to protect the specialty, I have recently been looking into seriously considering other options.



Good job guys! :clap:
 
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BLADEMDA

BLADEMDA

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Funny.

Anesthesia has been my #1 choice for specialty ever since freshman year of high school.

However, given how much you guys (the ASA and everyone complicit with them) have done to protect the specialty, I have recently been looking into seriously considering other options.



Good job guys! :clap:

There is nothing we can do to cure the disease. The best we can hope for is remission of the cancer. How long until the AANA develops a fellowship (6 months) for their Doctors of Nurse Anesthesiologists.... I mean Nurse Anesthetists.;)
 

aneftp

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There are a very small percentage of MDs who cannot practice solo any more. Military type of crna jump all over this and make examples of this.

But since MDs have to cover and "bail out" some crnas. It masks many of the weaker crnas.

It becomes an ethical issue whether to let crna fly solo in complex cases. Refuse transfers from outside hospitals. Force those smaller hospitals with crna only to do their own complex cases to unmask whether they are safe or not.
 

anbuitachi

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Funny.

Anesthesia has been my #1 choice for specialty ever since freshman year of high school.

However, given how much you guys (the ASA and everyone complicit with them) have done to protect the specialty, I have recently been looking into seriously considering other options.



Good job guys! :clap:
Honestly, this is my biggest concern. I cant even see this being reversed in the near future. i only see it getting worse. and its scary b/c anesthesiology is such a specialized field, w/o much ability to open a clinic in case there are no jobs.

Plus the fact that the published salary remains high, meaning plenty of IMG/FMG will jump in this noncompetitive field and I know they are willing to work for very low salaries + long hours, which will make my situation even worse when i graduate. Sigh...
 

cognitus

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So I guess I'm a ******* for getting into anesthesia just this past year? Can I get TWO good reasons why I made a GOOD decision?
 

pgg

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So I guess I'm a ******* for getting into anesthesia just this past year? Can I get TWO good reasons why I made a GOOD decision?
I'll give you three:

1) No clinic.
2) No clinic.
3) No clinic.



It pays enough, it'll continue to pay enough, and the actual work is enjoyable and rewarding. Don't get hung up on the gloom. Go in with eyes open and realistic expectations, and there's no reason it can't be a happy career for you.
 

vaibh

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Honestly, this is my biggest concern. I cant even see this being reversed in the near future. i only see it getting worse. and its scary b/c anesthesiology is such a specialized field, w/o much ability to open a clinic in case there are no jobs.

Plus the fact that the published salary remains high, meaning plenty of IMG/FMG will jump in this noncompetitive field and I know they are willing to work for very low salaries + long hours, which will make my situation even worse when i graduate. Sigh...
@anbuitachi - this is such a med student thinking, dude the main threat to speciality is not from FMG/ IMG its from midlevels - " Noctors" . And its just in US where we have crna problem, not in europe or other countries.Plus most fmg / img who match have very competitive credentials.

@cognitus - This is where entire health care might be headed with cost containment and politicians hospital administrators managing things. I would apply to anesthesia again if I were to. Many reason -
1. I love what I do, i think its one of the most satisfying specialty if you know what you are doing.
2. Its one of the specialty where u make significant difference in patients life , yes imagine yourself or your relative going for a big surgery wouldn't you be nervous? wouldn't you like someone who is smart and empathic with you who can trust with your life ?
Just be professional and take responsibilty of patient and you will cherish your job
 

PainDrain

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When/if it all hits the fan I plan on making drastic moves. It sounds crazy but retraining isn't unrealistic. I would first consider another fellowship before another residency. I have also thought of moving out of the country. I would have to see my income halved before I took any of these steps.
 

imfrankie

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When/if it all hits the fan I plan on making drastic moves. It sounds crazy but retraining isn't unrealistic. I would first consider another fellowship before another residency. I have also thought of moving out of the country. I would have to see my income halved before I took any of these steps.
Not unrealistic at all: one of the neurosurgeons where I trained was a pathologist before retraining.
 

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Are malpractice insurance rates the same for CRNAs as for physicians?
Obviously not. When they work under medical direction/supervision, many times the juries will consider the anesthesiologist to be much more liable (percentage-wise), even if it was the CRNA's mistake.
 

anbuitachi

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@anbuitachi - this is such a med student thinking, dude the main threat to speciality is not from FMG/ IMG its from midlevels - " Noctors" . And its just in US where we have crna problem, not in europe or other countries.Plus most fmg / img who match have very competitive credentials.
dood you misunderstood. what i meant is due to CRNAs threat to the specialty, fewer AMG's will go into it, leaving more unfilled slots for foreign trained students.
And FMG/IMG match with competitive credentials because otherwise they wont match. They need to study a lot for their high steps. However, this wont be the case if fewer and fewer AMGs go into anesthesiology. More and more FMG/IMG w/ non stellar credentials will be matched. Btw dont forget in several large countries, MD is equivalent to a Bachelors degree over there. Many go on to get PhD or other types of training after MD to help job prospects. when they come to the US, we view their application as impressive.

Not sure about your assumptions about IMGs. Do you truly think IMGs in general "are willing work for very low salaries + long hours"? Why wouldn't they also want like most people to have a good salary + reasonable hours?

Besides, not all or most IMGs are necessarily interested in anesthesiology. Anecdotally, the ones I know of seem mainly interested in IM actually.

I don't know if you mean to imply anesthesiology programs will be more willing to accept less than stellar credentials by accepting IMGs. Also anecdotally, but I know of some IMGs who have matched into anesthesiology. They tell me their Step 1 and 2 scores are > 230 if not > 240. I know of an anesthesiologist (aka anaesthetist) who was also fully trained in Australia (consultant aka attending) and moved to the US and is starting over again at a solid program.
Perhaps I was thinking more of FMG and non Caribbean IMGs. But no, everyone prefers higher salaries. But it's under my impression that FMG/ non carribbean IMG are more willing to work for less, because 1) they have close to no loans or much less than AMG. 2) even with reduced salaries, it's still higher (sometimes much higher) than their home countries salaries. For AMDs, we compare reduced salaries to past recent salaries. But to many FMGs, they are comparing USA salaries vs home country salaries or salaries that they can get if they continue to stay in the US, but work as something else (often times research) which is still usually lower than MD salary. Therefore, they are more willing to work for that 200k salary b/c to them it's still a very good salary.

Also, I am not saying IMGs are incompetent and not as good as AMG but i do think their quality varies a lot more b/c their Med school isn't standardized. They may have great step scores but how much does it really mean in their case? Some ppl study many months to couple of years for the step, and residency programs know that. Director of pathology told us that they receive plenty of IMG applications (he specifically mentioned Caribbeans applicants) with 270+ step 1 score. But he said its worth no where near as much as AMG's high step score, b/c Caribbeans curriculum is heavily focused on acing the steps.
 
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Please stop mixing Caribbean school graduates, who chose that route because they were not good enough for the American medical schools, with foreign "best and brightest" who did a medical school in their home countries.

Btw, this (above) is the answer I got from one of the professors in my program, when I asked whether I had any chances to be accepted as a FMG, years ago.

P.S.
The USMLE Step scores evaluate theoretical medical knowledge. You can bet that a candidate with 270 has more medical knowledge than a candidate with 220, even if the former might be lacking from other points of view (e.g. clinical). The reason a low-scoring AMG can beat a higher scoring FMG is exactly that: the AMG has already proven that s/he can function (well) in the system.

And money is not everything, guys. To be honest, I get pissed when I hear doctors who look down on $150-250 jobs/specialties, when 95+% of this country is making less. Debt is not an excuse, unless in the 300+K range (which is another sign of financial illiteracy - why isn't a state school good enough for college, or even medical school?).
 
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Given that CRNAs are highly educated, advanced practice registered nurses who consistently deliver anesthesia to patients using the same procedures as physician anesthesiologists, allowing these professionals to practice to their full scope just makes sense.
At least they didn't call us "MDAs" in the article. :rolleyes:

Otherwise, screw 'em. If they want to practice on their own I want no part of it. Don't call me when there's a problem. Don't expect me to consult for you. Don't ask for my opinion. Talk to the surgeon if you don't understand something. I want no part of just being another deep pocket for plaintiffs attorneys while the nurses go on to pick all the low hanging fruit.

We don't really need CRNAs, honestly. I could take any ICU nurse and put them in their place, provided I actually do all the procedures and prescribe the anesthetic and that they call me when there's a problem. I just need them to sit in the chair and record the vitals while I make the decisions. If we had a system like this we wouldn't have a problem with CRNAs. So turn 'em loose (the CRNAs that is) and let me take ICU nurses into the OR.
 
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anbuitachi

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Thanks for the clarification, anbuitachi. I think the takeaway from what you say is there are important distinctions to be made among various IMGs. (I don't know if American PDs make these distinctions among IMGs. But not suggesting they should or anything like that since it's obviously their prerogative to accept/reject whoever they like.)

Australian anesthesiologists/anaesthetists do quite well in terms of salary (assuming they find a boss job). $400K+ I've been told. And from the sounds of it better hours/lifestyle too. Plus no CRNA threat at all. Although training is longer. But point being there's currently no financial incentive for these IMGs to move to the US. But some people do so for family or other reasons.

By the way I don't think all IMGs necessarily have "months" to study for the Steps. For example I only have a month of dedicated time over the summer. But I've been trying to study ("trying" haha) while in the hospital 40+ hrs per week. Also I'm guessing some IMGs may need longer to study at least for Step 1 because their med school focuses more on the clinical sciences than the basic sciences. So it could arguably even out, I don't know.
Definitely. Not all IMGs necessarily have months to study, but on average they have a lot more dedicated studying time (or have more control over it at least). I personally worked with a bunch of FMG applicants during my rotations and talked to them a great deal. What I came to understand is most of them study as much as they can until they feel like they can get a good score (b/c they understand they need a high score to get in to residency), vs in American schools, they give you about 5-8 weeks of dedicated studying time, and you have to take the test within that time before you can move on third year, as a result, MANY students are not as well prepared (eg not finishing uworld, barely finishing first aid, etc. yea this might be a shock to ppl on SDN since the avg score here is like a 255 hahaha)

Please stop mixing Caribbean school graduates, who chose that route because they were not good enough for the American medical schools, with foreign "best and brightest" who did a medical school in their home countries.

Btw, this (above) is the answer I got from one of the professors in my program, when I asked whether I had any chances to be accepted as a FMG, years ago.

P.S.
The USMLE Step scores evaluate theoretical medical knowledge. You can bet that a candidate with 270 has more medical knowledge than a candidate with 220, even if the former might be lacking from other points of view (e.g. clinical). The reason a low-scoring AMG can beat a higher scoring FMG is exactly that: the AMG has already proven that s/he can function (well) in the system.

And money is not everything, guys. To be honest, I get pissed when I hear doctors who look down on $150-250 jobs/specialties, when 95+% of this country is making less. Debt is not an excuse, unless in the 300+K range (which is another sign of financial illiteracy - why isn't a state school good enough for college, or even medical school?).
I hope you are not taking this personally. You could very well be a nobel prize winning caliber FMG doctor. Unfortunately, the thing is, the quality of FMGs vary a LOT. From working with FMG applicants and FMG/IMG attendings, some are excellent, but there are more who aren't (compared to AMG). For example, I noticed on average, that the Royal college of physcians graduates tend to be better than many other FMGs that I've worked with.

I agree with you on Step part.

Regarding money, some would agree with you, some may not. This is purely personal opinion. You can't seriously tell someone that 200k debt at 6% interest rate isnt an excuse. It might not be to YOU, but we all have different circumstances. [I'm not sure what you mean about state schools. We have a TON of state school graduates at my medical school]

Too long to quote, but yea I know some schools dont give out MDs at bachelor lvl but some countries do. I wasn't referring to every country outside of US.
Australia like you said its one example. Another huge example is China. It's WAYYYYYYYYYYYYYYYY easier to get into medical school from China, b/c theres no real limit unlike the US. And for many of those schools, you go straight from HS. Tuition is also farrr cheaper, and because of that, many MDs can't even fight jobs in China. But US accepts their MD as equivalent to US MD.

Regarding step, it's like what FFP said. Also it's not like my own preference or something. I was just quoting what a PD told me. It's great that they did well on Step 1 but in the end it's just a test. They want to see students who got into their own system and were able to do well in it vs some outside system they dont have much control over.
 

RxBoy

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All this talk of crnas are equivalent to Physicians doesnt mean diddly squat.

Medicine is a business. The truth of the matter is that almost any hospital system that employees CRNAs results in enormous deficits. If crnas formed a group and did their own billing, they would never be profitable without a subsidy. Some hospitals will agree to this (rural areas) but even this wont last.

At the end of the day what it will come down to is who can negotiate the highest insurance reimbursements, provide anesthesia as lean as possible, all while keeping the board running. The answer is major corporations. Corporations employ crna's, salary us, and centralize a lot of the process to save money (like billing). This will be the future. We will always be in the picture because they can exploit the 4:1 rule to maximize revenue. Private insurance companies pay less if only crna administers anesthesia (this is not true for medicaid/medicare which is literally pennies on the dollar). Not to mention the lost revenue if CRNAs had to use some of their time dealing with preop/pacu issues.

People forget that if you paid a crna to take call, cover ob, work 60-80 hrs, their total pay by hourly rate will approach our salaries. We also get paid more because we usually bill more. Not only do we bill for or time, but we bill for blocks, ob, consults, ect. Pound for pound, we pack the greatest punch.

Private groups have been making a killing the last 20 years exploiting crna's and junior anesthesiologists. 700k+ salaries. Corporations caught on to this beautiful gold mine and decided to join the party. Now its simply corporations exploiting all anesthesiologists and crna's. This will be the future. Private groups that can stay a float and hire their own crna's will probably last the longest. However, attrition will catch up to them eventually. Corporations will snag their contracts.

For new residents, anesthesia is good field if you do not expect 700k salaries sitting around. Especially with all things considered that are happening to other specialities.

No one gives a rats a$$ if crna's can do our job, it all comes down to the dollars.
 

RxBoy

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Its well known that hospitals simply do not want to deal with employing crna's. This is one of the reasons they like contracting with big corporate anesthesia groups.

Whether there is a true loss or not, in the end the hospital looks at its expense sheet and sees employed crnas as a huge expense. There is a big push by hospitals to have an 3rd party anesthesia groups absorb that cost.

This is actually a good article written by a crna on the subject:
http://dansimonson.com/2012/01/white-paper-sounding-an-alarm-for-hospital-employed-crnas/


"Let me state this clearly: if you are a hospital-employed CRNA, who works in a scenario where the hospital directly employs you but contracts with anesthesiologists (as opposed to hospitals where both CRNAs and anesthesiologists are directly employed), you are in a vulnerable position. You need to look closely at how your services are paid for. If your situation models what I have described above, then you need to understand that it will make perfect economic sense for the hospital to cut you loose and turn over all anesthesia services to a contracted entity such as the currently contracted anesthesiologists or to an anesthesia service such as Somnia or Premier. The small amount of revenue the hospital may potentially lose will be more than offset by the huge reduction in CRNA salaries and benefits."
 

fitguard2014

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Its well known that hospitals simply do not want to deal with employing crna's. This is one of the reasons they like contracting with big corporate anesthesia groups.

Whether there is a true loss or not, in the end the hospital looks at its expense sheet and sees employed crnas as a huge expense. There is a big push by hospitals to have an 3rd party anesthesia groups absorb that cost.

This is actually a good article written by a crna on the subject:
http://dansimonson.com/2012/01/white-paper-sounding-an-alarm-for-hospital-employed-crnas/


"Let me state this clearly: if you are a hospital-employed CRNA, who works in a scenario where the hospital directly employs you but contracts with anesthesiologists (as opposed to hospitals where both CRNAs and anesthesiologists are directly employed), you are in a vulnerable position. You need to look closely at how your services are paid for. If your situation models what I have described above, then you need to understand that it will make perfect economic sense for the hospital to cut you loose and turn over all anesthesia services to a contracted entity such as the currently contracted anesthesiologists or to an anesthesia service such as Somnia or Premier. The small amount of revenue the hospital may potentially lose will be more than offset by the huge reduction in CRNA salaries and benefits."
To be clear the reason for this is not the lack of billing for the crna's, but to whom it goes to. In the aforementioned scenario the contracted group accrues all of the billing while assuming none of payroll for the crna's. Thus the hospital recieves little to no money for anesthesia services while sssuming the cost. This situation is ripe for takeover and loss of position for BOTH crna's and anesthesiologists.
 

Baller MD

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Please stop mixing Caribbean school graduates, who chose that route because they were not good enough for the American medical schools, with foreign "best and brightest" who did a medical school in their home countries.

Btw, this (above) is the answer I got from one of the professors in my program, when I asked whether I had any chances to be accepted as a FMG, years ago.

P.S.
The USMLE Step scores evaluate theoretical medical knowledge. You can bet that a candidate with 270 has more medical knowledge than a candidate with 220, even if the former might be lacking from other points of view (e.g. clinical). The reason a low-scoring AMG can beat a higher scoring FMG is exactly that: the AMG has already proven that s/he can function (well) in the system.

And money is not everything, guys. To be honest, I get pissed when I hear doctors who look down on $150-250 jobs/specialties, when 95+% of this country is making less. Debt is not an excuse, unless in the 300+K range (which is another sign of financial illiteracy - why isn't a state school good enough for college, or even medical school?).
You do realize that state schools charge a lot as well right? I go to a state school and I'll have close to 400k in loans by the time I'm done.

And please don't call me an idiot for going to this school. Try living in California and try to get into a Cali school. Most students are forced to move out of state for their MDs bc of stiff competition.
 
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Wiseguy
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You do realize that state schools charge a lot as well right? I go to a state school and I'll have close to 400k in loans by the time I'm done.

And please don't call me an idiot for going to this school. Try living in California and try to get into a Cali school. Most students are forced to move out of state for their MDs bc of stiff competition.
I am sorry, I should have kept my mouth shut. It's easy for me to talk with my non-expensive foreign medical degree.
 

courtmike

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Interesting conversation.

As someone who utilizes CRNAs as 1099 contractors and bills QZ for them I have a different take.

In my group (im one of 5 primary MD partners) we use CRNAs to practice independently and to their full scope. We pay them an hourly which is higher slightly than anyone else pays in the area. We have a level of retention and satisfaction because of how we treat our CRNAs. We treat them as partners in the practice and do not restrict their practice, our senior CRNAs train our newer ones in anything they are not comfortable with (blocks central lines whatever). Due to this, none of our CRNAs are looking to run out the door to be independent. They feel valued, are treated well and paid well so they are happy. Its a real team environment where there isn't any egos.

We are growing, rapidly. We have taken a number of contract from other local groups who refuse to evolve. They are either MD only or team practice which is restrictive and demoralizing and therefore with a high rate of turnover. These practices require the highest subsidies. Some our our contracts require none and the ones we are subsidized for are well below what others are asking. We get calls every month from other facilities.

Some of our contracts we use CRNA only, some have an MD and 15 CRNAs and others have closer to a 1:6 ratio. None of them are medical direction models and none of them restrict anyone, we use everyone to their maximum capacity to the benefit of us all.

Someone mentioned CRNAs billing QZ get reimbursed less than in a team practice where the MD signs the CRNAs chart. That is entirely dependent upon the state you are in as well as your (or your billing companies) ability to negotiate the contract. In our case we only have one biller that pays QZ less and thats workers comp.

We also employ our own billers. This saves us the cost of a billing company and we keep it all in house.

Where AMCs have an advantage is their ability to do everything as an economy of scale. They can negotiate better unit rates with insurance companies which may decrease or eliminate a subsidy. This is their main advantage but it is a limited one. Remember as oppose to my company which only has two grps getting paid (MDs and CRNAs) an AMC has another group, the investors. Our model has been successful because we have adapted to the reality of healthcare economics.

Before I get called a traitor to the profession I want to remind you all that we are losing the war. We are wasting time in a battle against CRNAs (AANA) where we keep saying we are better and safer AND much more expensive but can never prove it. Regardless of what you believe the reality is we must evolve and adapt with the times or pay the price. I don't call CRNAs names, insult their profession or belittle them like a school yard bully because I have nothing to prove. I have been doing anesthesia for 15 years and my clinical acumen speaks for itself, I am not threatened by anyone. I treat them with respect, share my knowledge as they share theirs with me (whomever said they cant learn something from a CRNA is foolish). The result is a team of CRNAs who are fiercely loyal to me and my partners as we are to them. They feel valued professionally and financially and therefore stay, creating continuity resulting in low (none) turnover which is a stability surgeons and hospital admins want.

Want to know the future of anesthesiology, I am it.
 
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Wiseguy
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courtmike, you are a partner, not an employee, and the CRNAs are employed by your group, not the hospital. Hence it's normal that you have a great relationship; you have many hundreds of thousands of reasons to be happy.

I don't have a problem working alongside CRNAs, just not with them. I don't like fixing other people's mistakes on my license, not for the money I get as an employee. It's that simple.

P.S. Welcome aboard. We need more partners around here; the view is very gloomy from our towers.
 
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GA8314

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So I guess I'm a ******* for getting into anesthesia just this past year? Can I get TWO good reasons why I made a GOOD decision?
I love anesthesia. I really do. It's not perfect but it's a good way to make a living. Yes, there are challenges. As an individual, NEVER let your skills diminish. Especially if your are in an ACT model. I am dead f..cking serious when I say that, not only now, but in 10 or 15 years, I will NEVER NOT be able to run a room efficiently. But, in the meantime, I'll continue honing my diagnostic and medical knowledge, as well as develop regional and other skills. Experience counts in this field, not unlike others.

You can get better with practice, and if you pay attention and stay engaged, there is NO reason to lose one's skills. I find it very rewarding that I can drop a TEE probe and have a pretty good idea of major pathology, do a host of regional techniques, handle very sick patients etc., and know what the f.ck I am doing.

If you can say the same, then you WILL have a place in this market and will always have a comfortable life. We need to meet these challenges but I am not all that worried.....
 

sevoflurane

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Interesting conversation.

As someone who utilizes CRNAs as 1099 contractors and bills QZ for them I have a different take.

In my group (im one of 5 primary MD partners) we use CRNAs to practice independently and to their full scope. We pay them an hourly which is higher slightly than anyone else pays in the area. We have a level of retention and satisfaction because of how we treat our CRNAs. We treat them as partners in the practice and do not restrict their practice, our senior CRNAs train our newer ones in anything they are not comfortable with (blocks central lines whatever). Due to this, none of our CRNAs are looking to run out the door to be independent. They feel valued, are treated well and paid well so they are happy. Its a real team environment where there isn't any egos.

We are growing, rapidly. We have taken a number of contract from other local groups who refuse to evolve. They are either MD only or team practice which is restrictive and demoralizing and therefore with a high rate of turnover. These practices require the highest subsidies. Some our our contracts require none and the ones we are subsidized for are well below what others are asking. We get calls every month from other facilities.

Some of our contracts we use CRNA only, some have an MD and 15 CRNAs and others have closer to a 1:6 ratio. None of them are medical direction models and none of them restrict anyone, we use everyone to their maximum capacity to the benefit of us all.

Someone mentioned CRNAs billing QZ get reimbursed less than in a team practice where the MD signs the CRNAs chart. That is entirely dependent upon the state you are in as well as your (or your billing companies) ability to negotiate the contract. In our case we only have one biller that pays QZ less and thats workers comp.

We also employ our own billers. This saves us the cost of a billing company and we keep it all in house.

Where AMCs have an advantage is their ability to do everything as an economy of scale. They can negotiate better unit rates with insurance companies which may decrease or eliminate a subsidy. This is their main advantage but it is a limited one. Remember as oppose to my company which only has two grps getting paid (MDs and CRNAs) an AMC has another group, the investors. Our model has been successful because we have adapted to the reality of healthcare economics.

Before I get called a traitor to the profession I want to remind you all that we are losing the war. We are wasting time in a battle against CRNAs (AANA) where we keep saying we are better and safer AND much more expensive but can never prove it. Regardless of what you believe the reality is we must evolve and adapt with the times or pay the price. I don't call CRNAs names, insult their profession or belittle them like a school yard bully because I have nothing to prove. I have been doing anesthesia for 15 years and my clinical acumen speaks for itself, I am not threatened by anyone. I treat them with respect, share my knowledge as they share theirs with me (whomever said they cant learn something from a CRNA is foolish). The result is a team of CRNAs who are fiercely loyal to me and my partners as we are to them. They feel valued professionally and financially and therefore stay, creating continuity resulting in low (none) turnover which is a stability surgeons and hospital admins want.

Want to know the future of anesthesiology, I am it.
:android:

Trollling, trolling, trolling. Yeah.... NO! Apprently you are no different than a CRNA.... ohh.... wait... :idea:

Full scope? What exactly do you think is going on with 1:15? I'm calling it for what it is... BS.
 
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Mman

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Employing CRNAs is a money loser for whoever does it. In our state, 100% of whoever employs them is paying out more in salary than they recoup in billing. It's an expense. Who eats that expense is up for negotiation.
 

gasdoc77

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Interesting conversation.

As someone who utilizes CRNAs as 1099 contractors and bills QZ for them I have a different take.

In my group (im one of 5 primary MD partners) we use CRNAs to practice independently and to their full scope. We pay them an hourly which is higher slightly than anyone else pays in the area. We have a level of retention and satisfaction because of how we treat our CRNAs. We treat them as partners in the practice and do not restrict their practice, our senior CRNAs train our newer ones in anything they are not comfortable with (blocks central lines whatever). Due to this, none of our CRNAs are looking to run out the door to be independent. They feel valued, are treated well and paid well so they are happy. Its a real team environment where there isn't any egos.

We are growing, rapidly. We have taken a number of contract from other local groups who refuse to evolve. They are either MD only or team practice which is restrictive and demoralizing and therefore with a high rate of turnover. These practices require the highest subsidies. Some our our contracts require none and the ones we are subsidized for are well below what others are asking. We get calls every month from other facilities.

Some of our contracts we use CRNA only, some have an MD and 15 CRNAs and others have closer to a 1:6 ratio. None of them are medical direction models and none of them restrict anyone, we use everyone to their maximum capacity to the benefit of us all.

Someone mentioned CRNAs billing QZ get reimbursed less than in a team practice where the MD signs the CRNAs chart. That is entirely dependent upon the state you are in as well as your (or your billing companies) ability to negotiate the contract. In our case we only have one biller that pays QZ less and thats workers comp.

We also employ our own billers. This saves us the cost of a billing company and we keep it all in house.

Where AMCs have an advantage is their ability to do everything as an economy of scale. They can negotiate better unit rates with insurance companies which may decrease or eliminate a subsidy. This is their main advantage but it is a limited one. Remember as oppose to my company which only has two grps getting paid (MDs and CRNAs) an AMC has another group, the investors. Our model has been successful because we have adapted to the reality of healthcare economics.

Before I get called a traitor to the profession I want to remind you all that we are losing the war. We are wasting time in a battle against CRNAs (AANA) where we keep saying we are better and safer AND much more expensive but can never prove it. Regardless of what you believe the reality is we must evolve and adapt with the times or pay the price. I don't call CRNAs names, insult their profession or belittle them like a school yard bully because I have nothing to prove. I have been doing anesthesia for 15 years and my clinical acumen speaks for itself, I am not threatened by anyone. I treat them with respect, share my knowledge as they share theirs with me (whomever said they cant learn something from a CRNA is foolish). The result is a team of CRNAs who are fiercely loyal to me and my partners as we are to them. They feel valued professionally and financially and therefore stay, creating continuity resulting in low (none) turnover which is a stability surgeons and hospital admins want.

Want to know the future of anesthesiology, I am it.
What do you think would be the impact of these models on the job market? Do you think it would decimate it for the new grads and anyone that hasn't yet made "partner". In such a scenario, why would partners hire more partners if you could hire more CRNA's at a lesser rate and preserve if not bolster your income? This should be something to consider for those in training right now. These are scenarios that we may see play out in the future, and they are very concerning.
 
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RxBoy

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Interesting conversation.

As someone who utilizes CRNAs as 1099 contractors and bills QZ for them I have a different take.

.
This will be fought by every anesthesiologist. This model is recipe for disaster. Although I do know this model exists in select outpatient centers, it will never be accepted by any anesthesiology society.

Why? Because the billing is not structured for this model. Right now, as a partner you eat mouthfuls and think it tastes great. You salary crna's and collect the billing. So every time you bail out a crna during a missed spinal, difficult central line placement, or OR crisis... You really dont care because in the end you are collecting the billing anyways.

Now what happens if some corporation buys you out for a couple bucks and breaks up the partnership? Now they hire anesthesiologists to work along side crna's. The anesthesiologist will not be able to bill for any fire they put out. They are basically there to insure crna's collect for their OR time without killing patients.

Lets say they put these salaried anesthesiologists to work, doing their own cases alongside non medically directed CRNAs. The CRNAs will collect all the billing for asa 1 and 2's with fast turnover rooms. The anesthesiologist is off doing his asa 4 thoracotomy with medicaid. The amount the crna would bill is exponentially greater. How would any anesthesiologist accept doing all the high risk low reimbursable procedures?

Unless billing changes, this model will never be accepted. If you are the future, anesthesiology would be destroyed.
 
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RxBoy

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Interesting conversation.

Regardless of what you believe the reality is we must evolve and adapt with the times or pay the price. I don't call CRNAs names, insult their profession or belittle them like a school yard bully because I have nothing to prove. I have been doing anesthesia for 15 years and my clinical acumen speaks for itself, I am not threatened by anyone. I treat them with respect, share my knowledge as they share theirs with me (whomever said they cant learn something from a CRNA is foolish). The result is a team of CRNAs who are fiercely loyal to me and my partners as we are to them. They feel valued professionally and financially and therefore stay, creating continuity resulting in low (none) turnover which is a stability surgeons and hospital admins want.
I do agree with this though. No one should be disrespectful or belittle crna's. Majority of them are not militant and very happy with the ACT model. Teamwork and respect are very important. Its part of being professional. But don't think for a second that I think they can serve MY role. There is mutual respect in our group and it works very smooth.
 
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dr doze

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I do agree with this though. No one should be disrespectful or belittle crna's. Majority of them are not militant and very happy with the ACT model. Teamwork and respect are very important. Its part of being professional. But don't think for a second that I think they can serve MY role. There is mutual respect in our group and it works very smooth.
You sure about that chief? What do you think that they say in their living rooms about the whole anesthesiologist CRNA dynamic? Where do you think those PAC contributions and letters to legislators are coming from? Where are the CRNAs who willing to stand up and say that CRNA only anesthesia is a step down from ACT or MD Anesthesia?
 

Arch Guillotti

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You sure about that chief? What do you think that they say in their living rooms about the whole anesthesiologist CRNA dynamic? Where do you think those PAC contributions and letters to legislators are coming from? Where are the CRNAs who willing to stand up and say that CRNA only anesthesia is a step down from ACT or MD Anesthesia?
I think they bitch and moan like crazy behind our backs.
 

Mman

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You sure about that chief? What do you think that they say in their living rooms about the whole anesthesiologist CRNA dynamic? Where do you think those PAC contributions and letters to legislators are coming from? Where are the CRNAs who willing to stand up and say that CRNA only anesthesia is a step down from ACT or MD Anesthesia?
I'm gonna go ahead and disagree. The reason you don't see CRNAs stand up and praise the ACT model is because of fear of retribution and being ostracized. The overwhelming majority IMHO are perfectly happy working under the direction of an anesthesiologist. Only a minority of less intelligent ones think they are just as good and can do it alone.
 
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Before I get called a traitor to the profession I want to remind you all that we are losing the war. We are wasting time in a battle against CRNAs (AANA) where we keep saying we are better and safer AND much more expensive but can never prove it.
Do you support the expansion of Anesthesia Assistants and the AAAA? Oh, wait. Nevermind. You got banned.
 

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I trust our moderators, but I don't really understand why courtmike was banned.
 
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BLADEMDA

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I trust our moderators, but I don't really understand why courtmike was banned.
Courtmike could easily have been MikeM from MilitantCRNA.org
 

dr doze

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I'm gonna go ahead and disagree. The reason you don't see CRNAs stand up and praise the ACT model is because of fear of retribution and being ostracized. The overwhelming majority IMHO are perfectly happy working under the direction of an anesthesiologist. Only a minority of less intelligent ones think they are just as good and can do it alone.
I think that the majority of those with a few years experience believe that they would do just fine alone on PS 1 and 2 patients. I think that the majority would like the right to be able to practice that way. Even if they choose not to exercise it.
 

RxBoy

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You sure about that chief? What do you think that they say in their living rooms about the whole anesthesiologist CRNA dynamic? Where do you think those PAC contributions and letters to legislators are coming from? Where are the CRNAs who willing to stand up and say that CRNA only anesthesia is a step down from ACT or MD Anesthesia?
Of course they talk about us behind our backs... Just like we talk about them, or surgeons, or circulators, or PACU nurses... They dont have to openly criticize independent practice. They just have to support the ACT model and apply good teamwork. I am certain the majority of CRNAs are content working alongside anesthesiologists. Working 7 to 3 pm M-F taking home 150k. Its the militant drivin ego maniacs that want to work 7 days/week, take call, make an extra 50k all in the name of proving you do not need an anesthesiologist.

The newer CRNAs are probably the most ACT friendly. Its a generation Y thing. They see work as a means to enjoy their life. Same can even be said of the incoming generation of anesthesiologists. I hope the trend continues.
 

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