Impact of states opt out

[BigSkyDreams]

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Howdy,

I have a few questions about the impact of the opt out rules.

http://www.asahq.org/Washington/summary2003.htm

Since this was published Montana, Washington and North Dakota opted out of supervision. I think the list includes:

Kansas
Iowa
Nebraska
Idaho
Minnesota
New Hampshire
New Mexico
Alaska
Montana
North Dakota
Washington

How will this limit jobs in the future, etc? Please post links to other articles about the pros and cons. Thanks.

http://www.asahq.org/Washington/06optOuts.pdf

 

[Brachial_Plexus]

Hey....if you have been following the job offerings on the website gaswork.com you'll see that the number of jobs is dropping precipitously. I'd don't know what this means in so far as the future of anesthesiology, but I am mildly concerned.

 

[2ndyear]

I wouldn't worry about the gasworks drop in jobs at all. It shouldn't be a reliable indicator. More reliable sources are residency graduates. I can't tell the future, but at least this year the jobs are still there from the reports that I have heard. Anyway you look at it though, the numbers are still pointing to an overall shortage of anesthesia care providers for some years to come. Would the ASA be pushing the AA program if it weren't? Of course not... Then again, will the current job market continue past 2007 (the most recent estimates I've seen foretelling a shortage)? Probably not.

We're still feeling the effect of the down years when programs didn't put out enough docs. But now if next years match class hears bad things about the future of gas, this could all change but I doubt that it will. Some classes now have 25% or even more of the students matching in anesthesia. This is a popular specialty. In any case the ASA is really pushing ICU medicine. There is a huge shortage of ICU docs right now. This will never be done by a CRNA, period.

Neither will pedi hearts, livers, big neuro cases, etc. Surgeons aren't dumb. They want an MD/DO on their big cases and this isn't going to change, ever. Patients dying makes them look real bad. This whole CRNA thing will fly over before too long and we will have nothing to worry about in the long run. At least I hope, but I'm just a fourth year med student so what do I know.

 

[NaeBlis]

Originally posted by Ether Screen
I worry somewhat. I'm happy that I don't plan to train, live or work in any of the 12 states that have opted out. But, it means bad working conditions in the future for all of us finishing residency 4-6 years from now.

Notice the trend. In 2001, the first year of the new ruling, only Iowa opted out, but it has been 5 states per year since then. The trend will likely continue. CRNA groups lobby hard for this, you should take a look at their websites and forums.

Economics seem to drive the trend. Hiring CRNAs as employees for in a private group or hospital will result in good returns for a busy practice. Why bring in a new MDA looking for his full fee, or looking to split his fee with the CRNAs he supervises, when you can hire someone for ~$80,000 and keep the difference in billing.

I wish I had known about this before I applied for residency.

I've been trying to stay out of discussions like these, these discussions tend to draw trolls, but i suppose I can put in my two cents once or twice a year.

First, what exactly does the opt out mean. It means that medicare will alow a CRNA to bill for her services with out supervison of a doctor (not an MDA, but any doctor). There aren't really many other laws that mandate supervision, there never really have been. The states that have opted out are thos that there has always been an MDA shortage, and where the CRNAs have been working alone for decades. They were able to bill medicare typically by citing the surgeon as a supervisor. Even in these states most hospital still require MDA supervision.

As for being cheaper, the CRNA's and MDA's can bill insuarance for the exact same rate, so there is no financial advantage to insurance companies. As for groups hiring CRNA's for cheap to replace MDA's, well I don't know Where you got your info, but if there is any CRNA out there making only 80k she must be working like 2-3 days a week. CRNA's make about 130-140k right out of school even in the most populated areas, pluss benefits, adn they typically demand to work far fewer hours than an MDA. Overall the benefit is minimal these days. In any case there is a huge shortage of both types of providers.

2ndyear, whatever estimates you have read are outdated, Look in the sas site, there was a review of the supply of MDA's and CRNA's, the shortage was expected to last another 5-7 years from now, but now is expected to last longer.

That being said, they are midlevel providers in nearly every field, and there always will be. As a Doctor you will always be the best trained, and you will always be able to find work and be well compensated.

 

[antiadriani]

Correct me if I am wrong, but I think the "opt-out", just acknowledges what has been realistic all along...that many CRNAs, especially in underserved areas have been practicing without supervision. This is because there are not enough anesthesiologists out there to supervise, or they all seem to flock to "desireable" areas to live.

All of us (SRNAs, and ology residents alike) have seen the outcome studies with the team approach. If that is the case, with more team outcome studies, wont most institutions prefer ologist supervised care anyway?

These opt-out decisions should not come as a suprise, since many states "supervision" does not require anesthesiologist led anyway. In other words, who are we fooling when for my CMMS reimbursement I just have some psychiatrist with a medical degree sign the dotted lign?

If you are worried residents, just push the "team" approach outcomes...then check out the 75% of rural anesthesia that is provided by CRNAs. I know I dont want to be out there all alone.

And for Gods sakes, do check out the ICU medicine positions...I got so tired of overspecialized docs who did not have a clue about critical care screwing up my patients on the units. This is where your training will truly be exemplified.

Last...are their any studies out there about AA's and outcomes? I know they have been practicing for decades, but do we really need a third provider? How long will it take them to realize that they are the "functional equivalents" of CRNAs, and start demanding their autonomy?

 

[juddson]

I find this whole discussion chilling.

My feeling is that if the outcome studies do not show a "meaningful" disadvantage to CRNA and AA provision of gas, there is little to stand in the way of their scope of practice expanding to exactly that point where such disadvantages ARE meaningful.

I have no idea where that point is. But I fear we are not there yet.

Now a story.

My wife went in for a cerclage a few weeks ago. The MDA and a CRNA did the preop, both participating about equally. During the procedure, the CRNA administered the spinal while the MDA held my wife's hand. Several times during the procedure, the CRNA asked the MDA if she should administer this or that. After the procedure, but before leaving the OR, the team raised my wife's head and her BP went to almost nothing. At this point the MDA appeared to call all the shots, but the CRNA still did all the work. During recovery, the MDA made all the decisions regarding medications (to raise BP) and for pain.

Was the MDA "directing" the CRNA or "supervising" the CRNA? Is what happened above standard, or did the relative lack of medical decisionmaking by the CRNA reflect, perhaps, her newness the the field (I have NO IDEA how long she had been practicing).

The MDA never left the room (ie, did not seem to be looking after other CRNA's). How can this be cost effective. Surely an MDA alone is cheaper than an MDA and a CRNA.

In any event, I hear all the time that surgeons use CRNA's all the time. If outcomes were bad, I suppose this would not happen. If this practice is not hitting them in the checkbook, I FEAR the days for regular MDA's are numbered.

I am VERY interested in this field, but it scares the **** out of me.

Judd

 

[DireWolf]

As someone who is considering anesthesiology, I find this trend disturbing. Obviously many specialties are facing encroachment from mid-level practitioners, but this is downright scary. With unequal costs and "similar" outcomes among MDAs and CRNAs, hospitals will almost always choose to sweeten the bottom line. If this trend continues, all 50 states will have this legislation within the next decade. I don't see how any good is going to come of this.

 

[2ndyear]

Here is a link to numbers, for those who wish. It's pretty good stuff on shortage, etc.

http://www.asahq.org/Newsletters/2003/11_03/grogono.html

In regards to the CRNA equivilance studies, yes they have been done and I have seen them and yes they do show that CRNA's are just as safe. The ASA comment that I can't find the link to is basically that there is a selection bias in the studies. Healthy patients, routine cases. I'm sure experience of the CRNA would be a HUGE confounding variable as well.

Check out this link as well, it's from '98 but it's good candid discussion by people in the know. Obviously this is not a new problem.:

http://www.asahq.org/Newsletters/1998/06_98/LTE_0698.html

On another note, nearly every specialty has mid-levels chomping at the bit for more rights. PhD's are going to be prescribing psych meds, NPs already do tons of FP stuff. I can't remember the last time I saw an MD/DO when I went to urgent care, always PA's. PA's want to read films in rads. Jeez, I have even seen PA's that basically run ICU's. I can't believe that every action is for the benefit of the patient. I mean, how does independent practice better serve the patient for a CRNA? They aren't going to those states because of the independent right are they? No, they're already there and the surgeon is signing the paperwork.

Who wants to bet on the first 20/20 or Dateline episode on this CRNA issue after the first big unsupervised CRNA lawsuit? I can hear Baba already...

 

[NaeBlis]

Originally posted by 2ndyear
\In regards to the CRNA equivilance studies, yes they have been done and I have seen them and yes they do show that CRNA's are just as safe. The ASA comment that I can't find the link to is basically that there is a selection bias in the studies. Healthy patients, routine cases. I'm sure experience of the CRNA would be a HUGE confounding variable as well.

Not exactly true. There was once study done about 3 years ago that show mda alone has better outcome in terms of death than CRNA, and the combo was better than either. I will post the url later. Last year the CRNA's sponsered a study that showed the result was in favor of the mda'S again but not by a statistcally significant amount. It also showed the combo was better. The CRNA's say our study is bad, but they lock the explanation on their website so only their members can get to it. The asa says theirs is bad and publishes and open explanation on the asa website. The flaws revolve around it being medicare data which while widely used is notoriously unreliable. And while it gives death data fairly acuarately it doesn't say much about other morbidity (CHF and the like).

So you have 1 study that proves MDA's being superior, and another that shows the difference is not significant but present. Once you get into the field, and once you have clinical experience and begin to she the skills and training of nurses, you can begin to understand that the MDA has better training and better outcomes in respect to both mortality and morbidity. ONce a real valid study is published it will prove this. The asa was planning to do this about 10 years ago, but it was deemed to be very expensive to perform, and the CDC pulled out of it.

One not about our resident doomsayer, macgyver. He is an md/phd, and has not had ANY clinical experience. He make vague generalizations about every field based on god knows what. He often changes his theory as well, once you start to put evidence against him. One year ago he was saying that no MDA's would have jobs in 5 years.

 

[NaeBlis]

Silber JH, Kennedy SK, Even-Shoshan O, et al. Anesthesiologist direction and patient outcomes. Anesthesiology. 2000; 93:152-163

here is the sudy supporting improved outcome with MDA. Had trouble linking it, i'm sure you all have access to medline or something else, and can find it on your own.

 

[BigSkyDreams]

Howdy,

I was visiting with one of the CRNAs here and talked about this subject. I can't say that this person?s views are reflective of the profession but they made three points worth considering.

1) The opt out plan is catching up to the reality of the situation.
2) There is need and room for both providers, they had few good words about AA however (ironic, no?)
3) Anesthesia is historically a nursing profession, interesting if for no other reason than to explain the territorial attitude.

There is an article out in the AANA Journalthis month:

Distribution of US Anesthesia Providers and Services
AANA Journal, February 2004, Vol. 72, No. 1

I didn't find a link to the article so if anyone does please post it.