Future of Anesthesia new CMS rule

[sevoflurane]

Colorado is the latest of the states to opt out. I can assure you that CRNA's are working independently outside of medically underserved areas.

Take a look at this and tell me you are not a bit worried. This began less than 10 years ago. What will happen in 10 years from now. We have to work together to avoid any further derailment.

http://www.aana.com/Advocacy.aspx?id=2573

Looking the other way is a big part of the problem.

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[mastamark]

I haven't read all of the posts ahead of me, please forgive if I am repeating something.

The bottom line is that Anesthesiology will always be a physician occupied specialty. Anesthesiologists are trained to deliver anesthesia, give perioperative care, pain management et al, AS PHYSICIANS.

CRNAs can have autonomy all day long, but that doesn't give them physician rights. It allows them to do procedures without physician supervision. I'm a future anesthesiologist hopeful and this doesn't bother me at all.

If you look at all other mid-level positions, there are similarities and they wont effect doctors as bad as previously thought. For example, a paramedic is trained to do intubations, and some other techniques that only physicians perform, but they are not doctors. FNPs can freeze off warts, suture, write prescriptions and have autonomy already in many states, but I don't see the extinction of Family Docs anytime soon. RTs can do a ton of "doctorly" procedures and evaluations but the medical specialty of pulmonology is still needed.

I don't think for one minute that anesthesiology is threatened by increasing practice rights for a discipline that will never be "physician level." Even with the influx of CRNAs and their future doctorate entry level change and their increased autonomy, their is a big time shortage of anesthesia providers. Also, physician pain management practice will continue to be for docs. If you wanna give gas, you will have the opportunity.

These doomsday scenarios have been prognosticated over-and-over again and it usually ends up changing very little. I can't cite any better examples than the FNP(independent in many states) and PA situation.

All that said, I think it is still a good idea for all of us students to get active and educate the public and our legislators.

Limited research shows that CRNAs can deliver anesthesia care alone as safely as Anesthesiologists but there should be more studies, aimed at larger groups as a whole. The biggest study cited looked specifically at Medicare patients. Well knowing that the type of surgeries for medicare patients can differ greatly throughout lifespans should leave room for more study.

Overall I think there is plenty of room at the table for CRNAs as well as Anesthesiologists, with the shortage and all. Don't think much will change.

Sorry for being so wordy this morning folks.

 

[mastamark]

Oh and also, the thing they may eventually work out good for the specialty is the presence of more specialized areas(eg. pain management, critical care, cardiac and/or neuro anesth etc). <---Doctor specialties

I can see, with my limited "doe-eyed" vision, the future opening pathways into other specialties(eg. sleep med pathway) as well as newer sub-specialties that are more suited to the times as things do change in medicine.

In the end, you will still be a doctor and your practice options are more expansive than a technician. I could actually see docs in the future not wanting to do gen anesth procedures.

 

[anynoise]

Oh and also, the thing they may eventually work out good for the specialty is the presence of more specialized areas(eg. pain management, critical care, cardiac and/or neuro anesth etc). <---Doctor specialties
.

Crnas practice in all the above areas. especially neuro anesthesia,

 

[mastamark]

Crnas practice in all the above areas. especially neuro anesthesia,

Didn't know that. Still doesn't make me any more cynical about the future of the specialty.

 

[ComfortableWolf]

Colorado is the latest of the states to opt out. I can assure you that CRNA's are working independently outside of medically underserved areas.

Take a look at this and tell me you are not a bit worried. This began less than 10 years ago. What will happen in 10 years from now. We have to work together to avoid any further derailment.

http://www.aana.com/Advocacy.aspx?id=2573

Looking the other way is a big part of the problem.

Are there any Attendings on here that practice at the larger hospital/ academic centers in any of the opt out states (I am specifically interested in OR, CA, CO, MT, WA, AK)...

Are you as an attending only considered equal to a CRNA or does the opt out only happen at the smaller more rural places in your state? Is there even an academic center in MT? AK?

If I would move to a place like AK, MT is my resume viewed the same as a CRNA? What if I am Cards/ICU or Peds trained?

What about a place like Seattle or Denver... more populous regions of their respective states?

I am particularly interested in hearing from younger Attendings or senior residents. Med student optimism is encouraging but not informative or comforting.

 

[cfdavid]

This is one of the most depressing threads I have read in a long time...

If all the above is accurate than Anesthesia residency Is just one huge Ponzi Scheme... It is one thing to work your tail off for <50k a year if your are being trained/apprenticed to become a high earning professional, it is a completely different thing to go through med school to become a "glorified CRNA.". I had recently decided to switch into anesthesiology from a different residency because I had seen ICU/Cardiac Anesthesiologists do the most amazing things with unstable patients... Truly masters of physiology... Some of the best doctors I have seen...
I am at a "top ten" academic institution ( whatever that means) and CRNAs are not a major presence.
I did my research and understood there would be some battle with mid levels... But I plan on doing cardiac or ICU and thought that this would provide relative shelter


I am one of those "top tier" non-passive types who has made a switch because I developed a deep respect the Anesthesiologists mastery of physiology


But this thread is killing my enthusiasm... It is hitting me in the gut
I am truly worried I have made the wrong decision. Have I been played the fool?
I guess this post is mostly a visceral response with out much added content,but g-d damn this thread is making me depressed and angry.

Thanks for tolerating the venting.

Do not get down and out over this. These discussions happen often. It's better to be vigilant and proactively thinking about our challenges than to not discuss them at all and then be blindsided later.

The ICU/Cardiac anesthesiologists that you've mentioned are exactly the types of folks (not those specific specialties but rather the clear impact they had on not only you, but certainly most others they've worked with over the years) which we must emulate.

Stick to your goal. To some extent, we as residents need to embrace this battle, but most importantly we need to keep our eye on the ball and become good anesthesiologists. Then, once board certified etc. etc. we can become more active and even implement proper change at our various institutions.

Keep the faith. I'm not daunted by this at all, though I am also passionate about protecting the integrity of our profession. Stay focused on becoming that master which drove you into this career in the first place.

 

[davidjones]

I'm in rads not anesthesia, but work often with them, and even though I'm only a resident, I have to say, for complete comfort in unstable patients TIPS/GI bleeds, post-partum hemorrhage, , I've seen attendings, specifically ask for an MD/DO, and not a CRNA.

They are ok for things like UFEs and cancer stuff since those patietns are stable, but there is usually an anesthesia attending around to increase comfort level. The only places I know of that prefer RN to MD/DO are Ambulatory surgery centers, or private practice groups that just want to crank out procedures/surgeries to generate RVUs and CRNAs have less of an effect on the bottom line.

In general though I don't think I'm different from other people who rely on anesthesia in wanting a physician, whose training is of a known quantity/quality, to manage the stuff north of the neck, than a CRNA who may have done online work.

 

[BLADEMDA]

Here's how I see it. This issue is about to come to a head. As anesthesiologists (and prospective ones), we see our patients in a completely different light than the CRNA...

Complications mean so much more to us who have pored over the science behind the physiology in that we can act infinitely more sensibly than the trained monkey.
Eventually, the country will see this. Unfortunately, it looks like they will find out the hard way - well before any unbiased study can show them.

The insurance companies will take note first. Anesthesiologists have enjoyed the benefit of lowered rates over the years due to fewer complications....CRNA's will bare the brunt of the full load of liability.

The for-profit CRNA factories will keep saturating the market, and as CRNA salaries continue to drop, the malpractice insurance will rise. Keep in mind...these are already people with nursing degrees and years spent in nursing (ie: not the most financially sound individuals to begin with).

The CRNA bubble will burst. CRNA's will no longer be able to afford the astronomical malpractice fees, Surgeon's will be fed up with the liability as well, and the life of the CRNA will be worse off than it was before this push for autonomy, as hospitals will just straight up stop employing them at surgeon's requests.

I for one think CRNA's do have a place in medicine (as do many mid-level care providers)...If they stay in their place, harmony can be maintained. They are the autopilot of the jet liner....programs exist that would launch and land planes sans pilot, but how many passengers would submit their take-off and landing to the autopilot program just to save a few dollars on their boarding pass.

Currently,

Solo CRNAs (No Anesthesiologist) pay about $4000-$5,000 for malpractice while Anesthesiologists pay $15,000-$20,000. That's a 3-4 fold difference in rates. I guess the Solo CRNA isn't just as good as an MD he/she is much better!

 

[BLADEMDA]

Actually, everyone basically agrees that the current trend spells doom for anesthesiology. It's just that a few posters think it's too late for reversal of said trend.

It's not too late. It may be the 7th inning but we can still win the game. But, who are our star players? Where is the plan for victory?

 

[jwk]

Currently,

Solo CRNAs (No Anesthesiologist) pay about $4000-$5,000 for malpractice while Anesthesiologists pay $15,000-$20,000. That's a 3-4 fold difference in rates. I guess the Solo CRNA isn't just as good as an MD he/she is much better!

That's more than it used to be a few years back. Malpractice rates are set by, among other things, claims history. As more and more CRNA's move to independent practice (especially outside the GI and plastic surgery clinics), more and more will get sued, and their perceived risk to malpractice companies will continue to increase as will their premiums.

 

[BLADEMDA]

That's more than it used to be a few years back. Malpractice rates are set by, among other things, claims history. As more and more CRNA's move to independent practice (especially outside the GI and plastic surgery clinics), more and more will get sued, and their perceived risk to malpractice companies will continue to increase as will their premiums.

Malpractice Carriers need to set rates based upon the practice pattern of the CRNA. For example, take a look at the following:

1. CRNA- Supervised by an Anesthesiologist. Rate= $3500

2. CRNA- Supervised but some GI/MAC cases 1 day a week= $4500

3. CRNA- No Medical Supervision or Direction. MAC CAses only, $5,000

4. CRNA- No Medical Supervision. GA cases 5 days a week, $15,000

Of course, there can be more variation but the point is since the surgeon doesn't know Jack Sh#$ about anesthesia the CRNA doing number 4 listed above shouldn't be paying less than Anesthesiologist. This is just another example of AANA hypocrisy at its finest.

 

[BLADEMDA]

Do not get down and out over this. These discussions happen often. It's better to be vigilant and proactively thinking about our challenges than to not discuss them at all and then be blindsided later.

The ICU/Cardiac anesthesiologists that you've mentioned are exactly the types of folks (not those specific specialties but rather the clear impact they had on not only you, but certainly most others they've worked with over the years) which we must emulate.

Stick to your goal. To some extent, we as residents need to embrace this battle, but most importantly we need to keep our eye on the ball and become good anesthesiologists. Then, once board certified etc. etc. we can become more active and even implement proper change at our various institutions.

Keep the faith. I'm not daunted by this at all, though I am also passionate about protecting the integrity of our profession. Stay focused on becoming that master which drove you into this career in the first place.

Well Said CF David. But, we are slowly losing this "war" with the AANA one paper cut at a time. Just imagine how long it would take to kill a patient with paper cuts and you will have a good understanding of the decades old AANA strategy.

 

[BLADEMDA]

Look, there will be jobs for ANESTHESIOLOGISTS in 2020. The AANA's plan is to DEGRADE this field into Nursing. It's a job an Advanced Practice Nurse can do SOLO per the AANA. It appears the current administration agrees with them.

So, what does this mean to you going forward circa 2020? Well, it means that it will be much harder to earn a living sitting on a stool and giving Gas. There will still be Boutique SurgiCenters for the few who can get that type of job. In addition, some lucrative areas will be able to afford the "MD" anesthesia model.

However, the majority of stool sitting positions will go to CRNAS or AAs. Technology and our own safety initiatives (Nothing to do with the AANA here) has advanced to the point that we aren't REQUIRED as the primary stool sitter. This means we need another role/function in the perioperative setting. CMS wants more midlevels and less of us. They are SPELLING IT OUT FOR YOU.

Hence, the future is most likely more Anesthesiologists in the USA supervising more midlevels for less money. That's why you need to bring something valuable to the table. A Unique skill set or Certification. Are you TEE Certified? Are you CCM trained? Do you do PAIN? How about Peds?
Even being the Badd-Arse Regional expert is a skill set most CRNAS do not possess.

Don't run from the fight. Get better. Get stronger. Support our PACs. But, first KNOW THY ENEMY.

 

[AK1010]

you sound like an absolute idiot when you use the term MDA, just letting you know

Are you kidding me? You quote my entire post and the most constructive thing you have to say is THAT?! Do you really have such an inferiority complex where you feel compelled to call out fellow doc's for using what has now become common vernacular? Because if that's the case, if you are so insecure, than I think you chose the wrong field buddy.
BLADEMDA is pretty outspoken on these forums...I'd love to hear your position on the usage of the term.

 

[anynoise]

A Unique skill set or Certification. Are you TEE Certified? Are you CCM trained? Do you do PAIN? How about Peds?
Even being the Badd-Arse Regional expert is a skill set most CRNAS do not possess.

Don't run from the fight. Get better. Get stronger. Support our PACs. But, first KNOW THY ENEMY.

Hold the phone.. lets focus please.
Basically, what you are implying is that FOUR YEARS OF ANESTHESIOLOGY RESIDENCY IS NOT ENOUGH?

are you serious?

More additional years is needed. to make it five or six. YOu cant achieve fluency in TEE or ccm without a fellowship. certainly a pain fellowship is needed to achieve bd certification.

If we cant show value after 4 years of post graduate medical education there is a major problem in the system.

I know what you are saying.. you dont really believe you need a fellowship but you DO to show hey i am bringing something to table. But man thats a long time in residency

 

[drpainfree]

Hold the phone.. lets focus please.
Basically, what you are implying is that FOUR YEARS OF ANESTHESIOLOGY RESIDENCY IS NOT ENOUGH?

are you serious?

More additional years is needed. to make it five or six. YOu cant achieve fluency in TEE or ccm without a fellowship. certainly a pain fellowship is needed to achieve bd certification.

If we cant show value after 4 years of post graduate medical education there is a major problem in the system.

I know what you are saying.. you dont really believe you need a fellowship but you DO to show hey i am bringing something to table. But man thats a long time in residency

again, I said all is too late...an analogy of the situation: when Nasdaq dropped 50% during internet bubble in 2000 from 5000 pts to 2000 pts, it doesn't matter how STRONG, how profitable your company is, you'll be sold out. When the large macraeconomics of medicine is spiraling down, the resistance is futile.

I'm not saying you won't have a job. But that's about it, job is all you will have in 10 years, whether it's paid well or not, whether there's professional respect or not...Nasdaq is never back to 5000 pts again, actually, it's still in 2000s after more than 10 years.

What do you do then? You move away from Nasdaq, go into real estate (but know when to get out), invest in foreign countries, etc, etc.

Think about your alternatives before it's too late. Obviously, as long as you don't mind work in Kaiser or VA, you'll still be fine.

 

[dbth77]

Are you kidding me? You quote my entire post and the most constructive thing you have to say is THAT?! Do you really have such an inferiority complex where you feel compelled to call out fellow doc's for using what has now become common vernacular? Because if that's the case, if you are so insecure, than I think you chose the wrong field buddy.
BLADEMDA is pretty outspoken on these forums...I'd love to hear your position on the usage of the term.

Looks like the other thread is going swimmingly for you...

 

[Gasmaster]

Is there not going to be the option to just do your own cases 1:1 and get paid a similar salary to a CRNA? working a few shifts per week for 175k doesn't sound that bad. pick up an extra shift or two per week and round out around 250k/year?

I went into anesthesia to do my own cases, no interest in babysitting nurses or AAs. hopefully that option will still be available!

 

[Nooblet]

.

 

[Gasmaster]

No one is rolling over. I don't ever expect to be a CRNA.... Not in shortness of clinical training, lack if confidence, of dearth of overall intelligence. However, if I have to take a lower paying salary to ensure I can practice the type of medicine I want to, I'll do that in a heartbeat. I'll never teach or impart any of my clinical knowledge to a CRNA and I never plan to be part of a group that works with them if I can help it (by the way, that goes for AA too.... Apparently the new plan is to use them to run our ORs because they can't practice in their own?)

Wanna win back anesthesia?
Do your own cases. Don't teach nurses or AAs anything. And work your butt off. Show the masses we aren't just executive supervisors. Just my opinion though

 

[marnie123]

This is a very interesting quote right here. What this implies is that at anytime AAs could fight for independence at the state level.

Let us be honest for a moment and focus on the big picture, if we are fighting CRNAs why are we embracing AAs? Why make the same mistake twice? I just do not understand this??

The only evidence I have seen that AAs will not fight for the same rights as CRNAs (ergo: fight us) is them saying on here "no really I promise".

Am I missing something???

AA scope of practice is a function of state law, not federal. Please don't lump us in with the nurses.

 

[cfdavid]

This is a very interesting quote right here. What this implies is that at anytime AAs could fight for independence at the state level.

Let us be honest for a moment and focus on the big picture, if we are fighting CRNAs why are we embracing AAs? Why make the same mistake twice? I just do not understand this??

The only evidence I have seen that AAs will not fight for the same rights as CRNAs (ergo: fight us) is them saying on here "no really I promise".

Am I missing something???

I can only speak from minimal experience as I considered AA school while also applying to med school. So, I did have some interaction with some folks down at Case Western's AA program.

I think the difference is one of culture, in a nutshell.

Perhaps JWK could expound on this further as he's much better equipped to answer the question in some depth.

 

[BLADEMDA]

AAs pose no threat to Anesthesiology. None. They are our true assistants and allies. AAs are licensed via the Boards of Medicine. Their scope of practice is defined by the Board of Medicine.

CRNAs are our adversaries in almost every area. They seek power and money at the expense of patient safety. Their scope of practice is defined by the Board of Nursing. This mean usurping practice rights which they have not earned. Just take a look at Pain Medicine as a perfect example of Nursing boards' expansion of practice parameters for APNs.

It is pure AANA propaganda not to understand who are our friends and who are our enemies. This type of confusion only helps the latter while hurting the former.

 

[jwk]

AAs pose no threat to Anesthesiology. None. They are our true assistants and allies. AAs are licensed via the Boards of Medicine. Their scope of practice is defined by the Board of Medicine.

CRNAs are our adversaries in almost every area. They seek power and money at the expense of patient safety. Their scope of practice is defined by the Board of Nursing. This mean usurping practice rights which they have not earned. Just take a look at Pain Medicine as a perfect example of Nursing boards' expansion of practice parameters for APNs.

It is pure AANA propaganda not to understand who are our friends and who are our enemies. This type of confusion only helps the latter while hurting the former.

You beat me to it - thanks!

The simple fact is that there will never be enough anesthesiologists to put one with every single surgical patient 100% of the time. With the ACT concept (at least the groups and hospitals that actually do it 24/7 and not just 7-3 M-F), an anesthesiologist is involved with the care of every single patient.

The other thing to remember about AA's is that many of us are dues-paying members of the ASA, contribute to ASA-PAC, and participate on several ASA committees. We're not out there just talking the talk - we walk the walk.

 

[sevoflurane]

The other thing to remember about AA's is that many of us are dues-paying members of the ASA, contribute to ASA-PAC, and participate on several ASA committees. We're not out there just talking the talk - we walk the walk.

 

[Nooblet]

.

 

[marnie123]

Well, I see nothing that stops them from biting the hand that feeds them. I hope you are right.....

 

[dogbone65]

Malpractice Carriers need to set rates based upon the practice pattern of the CRNA. For example, take a look at the following:

1. CRNA- Supervised by an Anesthesiologist. Rate= $3500

2. CRNA- Supervised but some GI/MAC cases 1 day a week= $4500

3. CRNA- No Medical Supervision or Direction. MAC CAses only, $5,000

4. CRNA- No Medical Supervision. GA cases 5 days a week, $15,000

Of course, there can be more variation but the point is since the surgeon doesn't know Jack Sh#$ about anesthesia the CRNA doing number 4 listed above shouldn't be paying less than Anesthesiologist. This is just another example of AANA hypocrisy at its finest.

Don't know where you got your numbers but they are wrong. I pay $4000/year for any anesthesia I give any where.

 

[BLADEMDA]

Don't know where you got your numbers but they are wrong. I pay $4000/year for any anesthesia I give any where.

Yes. I know CRNAs pay $4,000 a year for Malpractice insuranace regardless of which type of setting they practice in. My post above was in reference to PROPER pricing of CRNA insurance in order to reflect practice setting.

 

[sevoflurane]

Don't know where you got your numbers but they are wrong. I pay $4000/year for any anesthesia I give any where.

Do you practice independently w/o supervision?

 

[jwk]

Yes. I know CRNAs pay $4,000 a year for Malpractice insuranace regardless of which type of setting they practice in. My post above was in reference to PROPER pricing of CRNA insurance in order to reflect practice setting.

Oh no - it DOES vary by practice setting. If they practice exclusively in an ACT environment with anesthesiologists around, it's cheaper than it would be if they're independent.

 

[pgg]

Currently,

Solo CRNAs (No Anesthesiologist) pay about $4000-$5,000 for malpractice while Anesthesiologists pay $15,000-$20,000. That's a 3-4 fold difference in rates. I guess the Solo CRNA isn't just as good as an MD he/she is much better!

Locally, the rates aren't terribly different.

But this is California, rates are very low to start with and punitive damages are capped. My first year premium for a $1/3 million claims made policy was well under $2K. At maturity it's around $10K. Of course there'll be a tail to think about ...

I know one CRNAs who recently acquired her own policy. She was looking at $4-6K/year to start with maturity a bit less than $10K.

 

[BLADEMDA]

The ASA Professional Liability Committee reported that the average annual premium in 2007 was $23,481 for a $1 million/$3 million policy, based on a survey of 35 insurance companies


Rate have fallen since then with most paying $15,000-18,000 per year.

The average CRNA pays far less for Solo Practice. Anyone care to find out how much?

 

[deleted126335]

The ASA Professional Liability Committee reported that the average annual premium in 2007 was $23,481 for a $1 million/$3 million policy, based on a survey of 35 insurance companies


Rate have fallen since then with most paying $15,000-18,000 per year.

The average CRNA pays far less for Solo Practice. Anyone care to find out how much?

No idea, but this is not an apples to apples comparison for many reasons that have been discussed multiple times.

-solo CRNAs tend to do softball cases more often: endos, cataracts, cosmetics, other office procedures.
-rural solos do a bit more stuff, but rural areas tend to be less plaintiff friendly.
-solo CRNA's are frequently not truly solo from a medical/legal standpoint: hospital, employer, surgeon are more likely to get dragged in than an anesthesiologist, thus diluting out responsibility.

Malpractice rates are based on actuarial loss data. These rates are going up for APN's as a group. Don't know about CRNAs in particular.

 

[imfrankie]

The ASA Professional Liability Committee reported that the average annual premium in 2007 was $23,481 for a $1 million/$3 million policy, based on a survey of 35 insurance companies


Rate have fallen since then with most paying $15,000-18,000 per year.

The average CRNA pays far less for Solo Practice. Anyone care to find out how much?

Tremendous regional differences in what anesthesiologists pay for malpractice as you know.

 

[Taurus]

So it starts. Train NP's and CRNA's at the peril of your own profession.

Medicare Hospital Rule Change to Save $5 Billion, U.S. Says

"All hospital operators could allow nurses and physician assistants to perform more duties now restricted only to doctors"

http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1
​

 

[anynoise]

So it starts. Train NP's and CRNA's at the peril of your own profession.

Medicare Hospital Rule Change to Save $5 Billion, U.S. Says

"All hospital operators could allow nurses and physician assistants to perform more duties now restricted only to doctors"

http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1
​

darn shame!!!! end is near (