Interesting perspective by ASA president, Dr. Lema

[toughlife]

The day of the MDA being able to afford to relax and do one case is coming to an end. The President of the ASA is predicting it and so am I. Economics will force you to supervise 5 or 6 rooms. Economics will dictate that you use a Mid-Level Provider during the day. At night and the weekend (depending on your practice) the MDA will be more involved personally with the delivery of the anesthetic. With Medicare becoming the predominant payer (it already is in my area) you will make $180,000 per year GROSS (40 hours per week) by doing your own Anesthesia. Perhaps, with a hospital subsidy you can make more.

But, what will happen once the Private Payers join in the bloodletting? How will minimal subsidied practices (like the ones in the West) survive as MDA only?

Examine the facts: On Long Island the average private payer reimburses an MDA at SIX times Medicare!! In my practice (SouthEast) private payers reimburse me at THREE and HAlf MEDICARE RATES! However, in my practice the private payers only make up about 10% of the payer mix. So, even a drastic reduction by private payers can be compensated by fighting with my hospital administrators for a SMALL increase in subsidy.

The All MDA model is possible if we are willing to reduce our incomes substantially (about $275,000). This reduction of income does not come with a reduction in work or responsibility as the average work week will remain at 52 hours for this money (private practice). But, at this level of income MDA's are competitive with CRNA's and are a viable alternative.

However, a better approach to the problem is what I have already posted:

1. Reduce the number of programs/positions by 20%

2. Open new AA programs in large numbers

3. Increase the value of Board Certification by listing Perioperative Physician, Critical Care, Basic TEE, etc. Mandate one Fellowship Year with Board Eligibilty in that subspecialty after the year.

With these three changes we can win. We can ensure job security and a shot a good Physician level income. Think about it.

You pay me $275K a year for 52 hours and I will throw in an extra 8-hour day as a bonus for hiring me.

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[ReefTiger]

So, I have a couple of questions...

Ether have you read this? If so, I'm still waiting for an answer.

Ether,

You have undoubdetly spent a lot of time thinking about the issues, and the ASA certainly needs more individuals like you. It is entirely irrelevant if people agree or disagree with what you have to say, the important issue is that you have an opinion and are clearly passionate about it. Please don't take this the wrong way (I appreciate your passionate stance, and I am respectful of your seniority and experience), but do you direct an equal amount of energy towards those in the ASA who can actually make a difference? You may make a difference and elighten a few individuals here, but I fear that by the time the average reader of this forum is practicing (and certainly if your predictions hold true), it will be too late. My questions are...do you hold a leadership position in the ASA? Are you in contact with the leaders? If so, in what ways? What ways have worked for you, and what ways haven't?

I don't intend this line of questioning to be a challenge...just wondering how to effectively become an advocate and play my part in controlling the future of my chosen career.

Also, medicare is the number one problem as you said. But do you get to code/bill differently if care was given by fellowship trained anesthesia personnel? The extra certification serves no financial purpose otherwise.

Less physician anesthesiologists just increases the midlevel to physician ratio which adds fuel to the independent practice engine. AA's may help, they may not.

If we are to evolve we should be involved in the care of the patient including inpatient evaluation and control of care 1-2 days preop, intra op and 1-2 days post op to maximize benefit. This allows us to retain physician status (since some think we lose/are losing it), and we can bill for H and P, and hospital care (follow up notes). This is drastically different than what we do now, but would follow with some of the visions of Dr. Lema.

Ether, I don't disagree with everything you say, but just wonder where is your action?

I am a member of the AMA, ASA, State Anesthesia Society, contribute to ASA and State society PAC, and have personally met and spoken with one of our US House Representatives regarding the teaching rule and the rural pass through bill.

You have obviously forgotten what residency is like. It is not like we have first hand knowledge of private practice economics, or hospital group negotiations. We can't just walk up to our program directors and say we'd like to have perioperative physician and consultant in anesthesiology on our certificates and expect it to happen.

These changes need to happen from those like you. Mil gave you Lema's email address. Maybe you'd show all on this board a copy of the email you sent him, and maybe how he responded.

 

[SleepIsGood]

MacGvyer brings out a great point.

Why in the world does everyone assume that AA's are the easy fix to the CRNA problem. It's true RIGHT NOW, they do not desire the same autonomy and $$ as a MD. HOwever, who is to say this will not happen?

Folks, do you think CRNAs first came across as 'militant' workers. Of course not. Their organization (AANA) put out statments that they would be a helping hand on the problem of not having enough Anesthesiologists. Once they were allowed SOME power, now they want more...it's human nature.

Similarly, AAs appear to be a good alternative now. 1)it's a great way to win the battle against CRNAs by having the two of them fight each other. However, what's the other side of the coin? The other side is that we 'build' this profession who is laying low now...in 5-10 years they'll also want to stab us in the back.

To whomever a little knowledge/power is given...they will always want more. No one wants to be a 'subordinate' for the rest of their lives.

Also already ppl (ie surgeons,etc) believe that you dont need MDs to provide anesthesia. Introducing/Supporting another whole set of paraprofessionals into our professions just exemplifies what they believe.

It's unfortunate that physicians never band together. As someone stated above the ideal situation would have it so that we would ALL hold out. Strike or form Unions. It's extremely unfortunate that MDs got suckered into having to comply by the anti-trust laws which ban us from creating unions/striking. At the basic level we need laws like that which inhibit our collaboration to be repealed.

It's hard to swallow this pill..but dentists got it right. Their reimbursements are unwavering. They make good $$. Many of them only accept cash. It's funny when MDs think like this we are seen as being "money hungry". I feel that as MDs we feel like it's taboo to talk about money. Guys as many have stated above, medicine is a business. We have overhead. Medicine is in my opinion is the most satisfying profession in the world. However, satisfaction wont pay my loan, mortgage payments, car payments, and insurance.

Additionally, become VISIBLE at your hospital. I urge each one of you residents/attendings to please get involved at your hospital. As the ASA president stated join atleast ONE committee. In the past, anesthesiologists were rarely ever seen in these committees, as a result our fate was decided FOR us.

 

[CremeSickle]

Well said.

I think the reason why we have not heard of any 'uprising' from the AAs is only b/c there are so few of them (even after 30 years) that they NEED us. The more you add the less that will be the case.

Im sure CRNAs started somewhat the same way. Give an inch take a mile.

MacGvyer brings out a great point.

Why in the world does everyone assume that AA's are the easy fix to the CRNA problem. It's true RIGHT NOW, they do not desire the same autonomy and $$ as a MD. HOwever, who is to say this will not happen?

Folks, do you think CRNAs first came across as 'militant' workers. Of course not. Their organization (AANA) put out statments that they would be a helping hand on the problem of not having enough Anesthesiologists. Once they were allowed SOME power, now they want more...it's human nature.

Similarly, AAs appear to be a good alternative now. 1)it's a great way to win the battle against CRNAs by having the two of them fight each other. However, what's the other side of the coin? The other side is that we 'build' this profession who is laying low now...in 5-10 years they'll also want to stab us in the back.

To whomever a little knowledge/power is given...they will always want more. No one wants to be a 'subordinate' for the rest of their lives.

Also already ppl (ie surgeons,etc) believe that you dont need MDs to provide anesthesia. Introducing/Supporting another whole set of paraprofessionals into our professions just exemplifies what they believe.

It's unfortunate that physicians never band together. As someone stated above the ideal situation would have it so that we would ALL hold out. Strike or form Unions. It's extremely unfortunate that MDs got suckered into having to comply by the anti-trust laws which ban us from creating unions/striking. At the basic level we need laws like that which inhibit our collaboration to be repealed.

Additionally, become VISIBLE at your hospital. I urge each one of you residents/attendings to please get involved at your hospital. As the ASA president stated join atleast ONE committee. In the past, anesthesiologists were rarely ever seen in these committees, as a result our fate was decided FOR us.

 

[toughlife]

I want to say that this thread is rewarding to read and it makes me very happy to see that people are finally taking more time to read and be informed about the threat and future we face if we stand at the sidelines.


I am way pro-physician and always thought it was our inherent right to fight to protect ourselves and the patients. I am glad people realize what we are up against and get involved.

Anesthesiology is full of bright people that can make great things happen.

Keep up the great work!

 

[EtherMD]

You pay me $275K a year for 52 hours and I will throw in an extra 8-hour day as a bonus for hiring me.

I would't hire anyone for that level of pay as the local AMC is offering more for a 40 hour a week job. Don't sell yourself short on income. The real world is quite expensive and Uncle Sam takes a big bite out of your income.
Unlike other fields we have no way to hide our income.

I do appreciate the humour of your posts.

I will contact Dr. Lema. I will let you know if he responds; but, realize people have lives and they need a few days to respond.

 

[toughlife]

Here's his e-mail address: [email protected]

Why don't you e-mail him?

Why don't we email ALL academic chairs? What do we have to lose? I'd be glad to start collecting their email addresses

It's time they know what the future leaders of anesthesiology are thinking and what we expect of them.

 

[EtherMD]

Well said.

I think the reason why we have not heard of any 'uprising' from the AAs is only b/c there are so few of them (even after 30 years) that they NEED us. The more you add the less that will be the case.

Im sure CRNAs started somewhat the same way. Give an inch take a mile.

You forgot one thing: The AANA hates the very concept of AA's. The AANA will fight tooth and nail to keep AA's from even getting licensed. Do you really think the AANA will ever embrace the AAAA? The AANA views AA's as inferior and the ASA's "failed experiment" to replace the CRNA.

For you to dismiss the concept of AA's bringing a balance to the market place is naive and bad economics. The AANA believes that CRNA's were the FIRST Anesthesia Providers in the USA. They believe that its membership represents the "true anesthetists" of the USA. I am sorry you fail to see the benefit of having the AAAA to counter the AANA. History does not have to repeat itself (allow AA's to gain Independence) provided we learn from it.

Finally, the USA will never produce enough MDA's to provide solo anesthesia in the operating room. Particularly, in today's economic climate Mid-Level Providers under the supervision of an Anesthesiologist makes good fiscal sense. With Medicare paying Anesthesia so little and even less next year how long will MDA only practices survive?

 

[EtherMD]

So, I have a couple of questions...

Ether have you read this? If so, I'm still waiting for an answer.



Also, medicare is the number one problem as you said. But do you get to code/bill differently if care was given by fellowship trained anesthesia personnel? The extra certification serves no financial purpose otherwise.

Less physician anesthesiologists just increases the midlevel to physician ratio which adds fuel to the independent practice engine. AA's may help, they may not.

If we are to evolve we should be involved in the care of the patient including inpatient evaluation and control of care 1-2 days preop, intra op and 1-2 days post op to maximize benefit. This allows us to retain physician status (since some think we lose/are losing it), and we can bill for H and P, and hospital care (follow up notes). This is drastically different than what we do now, but would follow with some of the visions of Dr. Lema.

Ether, I don't disagree with everything you say, but just wonder where is your action?

I am a member of the AMA, ASA, State Anesthesia Society, contribute to ASA and State society PAC, and have personally met and spoken with one of our US House Representatives regarding the teaching rule and the rural pass through bill.

You have obviously forgotten what residency is like. It is not like we have first hand knowledge of private practice economics, or hospital group negotiations. We can't just walk up to our program directors and say we'd like to have perioperative physician and consultant in anesthesiology on our certificates and expect it to happen.

These changes need to happen from those like you. Mil gave you Lema's email address. Maybe you'd show all on this board a copy of the email you sent him, and maybe how he responded.

I will e-mail Lema. By the way your certificate does say "consultant in anesthesiology" because I just checked mine on the wall. I want your certificate to say much, much more so you can justify the subsidy you will need to survive. The hospital administrators, private payers and patients will want to know why LEGALLY you are worth more than a CRNA. By adding the other qualifications and subspecialization to your certificate you have the LEGAL proof you are much more than an Anesthetist.

If we want the private payers to pay us as Physicians we will need more than Anesthetist as the reason.

 

[EtherMD]

I want to give you guys some food for thought:

Ten years ago (1997) if you asked me the likelihood that in ten years time
(2007) CRNA's would be practicing independently and MDA salaries would be 40% lower I would have responded with "I don't think so or extremely unlikely"
I would have predicted flat salaries because of Medicare changes and CRNA's still under the direction/supervision of an MDA.

Today (2007) if you ask me that same question about ten years from now
(2017) my response would be very different: "probably many more Solo CRNA Groups throughout the USA outbidding MDA's for contracts and MDA salaries reduced by about 30-40%." In addition, most MDA's are supervisors and covering 5 or 6 rooms. Solo MDA practices extremely limited to highest paying patients.

Unless we take some drastic action soon things do not look good.

 

[Bertelman]

What I'm saying is that our specialty has a LOT of these people in it....and we need to trim the fat.....

I don't think announcing a significant decrease in residency slots nationwide will effectively trim any fat. If anything, I see this scaring away future med students, resulting in another dark period of recruitment, with established programs struggling to fill.

 

[johankriek]

. By adding the other qualifications and subspecialization to your certificate you have the LEGAL proof you are much more than an Anesthetist.

.

we are more than anesthetists.. we are Anesthesiologists..

 

[CremeSickle]

we are more than anesthetists.. we are Anesthesiologists..

 

[APRV]

I have a serious question. How could we go from Schubert predicting a major shortage in anesthesia providers for years to come in this 2001 (Mayo Clin Proc. 2001 Oct;76(10):995-1010) article, to the point we are at now in just six years?

 

[EtherMD]

You people just don't get it. To the AANA the term Anesthetist and Anesthesiologist are equal. More importantly, Medicare agrees with them!

Thus, you need more LEGAL Proof to show the Payers, Administrators and Patients your qualifications above a CRNA. AS it stands now, the AANA claims its membership is EQUAL to you. Without a LEGAL document listing all your qualifications where is your proof?

This why you need a Certificate with "teeth" to show the world and the Advanced Nurses what a Residency in Anesthesiology means in 2007.
Your certificate should list/state your qualifications:

1. Consultant in Anesthesiology
2. Perioperative Medicine
3. Basic TEE and U/S
4. Critical Care Medicine
5. CA-4 Year- Subspecialization year with Board Eligibility

These changes will only make you STRONGER in the House of Medicine. Either adapt to the new economic climate and fight for a place in the new paradigm or we die as a specialty.

 

[EtherMD]

I have a serious question. How could we go from Schubert predicting a major shortage in anesthesia providers for years to come in this 2001 (Mayo Clin Proc. 2001 Oct;76(10):995-1010) article, to the point we are at now in just six years?

The market place is pretty balanced right now for providers. In fact, the demand is slightly greater than the supply. This is true for Anesthesiologists and CRNA's. But, it may not stay that way for much longer. The Programs are pumping out new Graduates just below the all-time high numbers.

Similarly, the CRNA programs are gearing up to meet the demands of the market place. Rather than risk losing market share to the AA's (which the AANA despises) new CRNA schools are opening rapidly. Since the implementation of a Master's degree requirement, CRNA school graduates are at an all time high and each year more graduate.

The future remains uncertain as to the number of MDA's the USA will need in ten years. This depends on whether the MDA "solo" option remains a viable economic choice for employment. A lot depends on Private Payers continuing to shell out 3.5-6 times Medicare for reimbursement. We are the ONLY specialty getting paid this multiple of Medicare that I am aware of by Private Payers. When Universal Health Care hits the USA there may be a LOT of former solo MDA practitioners looking for a job.

In short, the market place and economics dictate the need for the number of Anesthesiologists in the USA. Thus, since nobody can predicte the future with certainty the exact number of MDA's needed in 2017 is anyone's guess.
For your sake, it is better to under-estimate than over-estimate the number needed (see previous posts about the law of supply vs. demand and the Mid-1990's).

 

[EtherMD]

I don't think announcing a significant decrease in residency slots nationwide will effectively trim any fat. If anything, I see this scaring away future med students, resulting in another dark period of recruitment, with established programs struggling to fill.

A Vascular Surgeon's son at my hospital is in his first year of Plastic Surgery
(direct match-shortened program). I met him last year during his one month rotation at my hospital. He told me there were two hundred applicants for each spot at his Program. Everyone is dying to get one of these direct, shortened Plastic Surgery Spots. Why? $$$$$ when you finish.

So, cutting the number of Anesthesiology spots by 20% would not hurt the specialty or the match PROVIDED there was good economic opportunity when you finish the program. LESS MEANS MORE sometimes in the real world. A better Graduate with more economic opportunity in this case.

Returning to the number of spots of the late 1990's would be a good start.
This would make the specialy more competitive and not less.

 

[badgas]

MacGvyer brings out a great point.

Why in the world does everyone assume that AA's are the easy fix to the CRNA problem. It's true RIGHT NOW, they do not desire the same autonomy and $$ as a MD. HOwever, who is to say this will not happen?

Folks, do you think CRNAs first came across as 'militant' workers. Of course not. Their organization (AANA) put out statments that they would be a helping hand on the problem of not having enough Anesthesiologists. Once they were allowed SOME power, now they want more...it's human nature.

Similarly, AAs appear to be a good alternative now. 1)it's a great way to win the battle against CRNAs by having the two of them fight each other. However, what's the other side of the coin? The other side is that we 'build' this profession who is laying low now...in 5-10 years they'll also want to stab us in the back.

To whomever a little knowledge/power is given...they will always want more. No one wants to be a 'subordinate' for the rest of their lives.

Also already ppl (ie surgeons,etc) believe that you dont need MDs to provide anesthesia. Introducing/Supporting another whole set of paraprofessionals into our professions just exemplifies what they believe.

It's unfortunate that physicians never band together. As someone stated above the ideal situation would have it so that we would ALL hold out. Strike or form Unions. It's extremely unfortunate that MDs got suckered into having to comply by the anti-trust laws which ban us from creating unions/striking. At the basic level we need laws like that which inhibit our collaboration to be repealed.

It's hard to swallow this pill..but dentists got it right. Their reimbursements are unwavering. They make good $$. Many of them only accept cash. It's funny when MDs think like this we are seen as being "money hungry". I feel that as MDs we feel like it's taboo to talk about money. Guys as many have stated above, medicine is a business. We have overhead. Medicine is in my opinion is the most satisfying profession in the world. However, satisfaction wont pay my loan, mortgage payments, car payments, and insurance.

Additionally, become VISIBLE at your hospital. I urge each one of you residents/attendings to please get involved at your hospital. As the ASA president stated join atleast ONE committee. In the past, anesthesiologists were rarely ever seen in these committees, as a result our fate was decided FOR us.

I'm glad to hear someone else say this. I think that physicians are going to have to put their foot down with medicare and insurance companies eventually. My only question is why not sooner than later? Regarding physician unions, who cares if they are illegal. Are they going to put all physicians in jail? No. Physicians hold some serious power because no one can force us to work, yet our service is desparately needed. However, we let medicare and insurance companies turn into our boss due to the fear of losing that $12 from a medicare or anthem pt. Why not all take a month off, show them who's boss and collect ALL of what we bill? It works for dentists, why not us? We need to stop the runaway train that is medicare and insurance companies before it runs even further out of control. I realize that everyone banding together is an extremely difficult concept for many of the reasons that mil mentioned above, but if it doesn't happen, physicians are going to wake up making 50K/year one day. And instead of tackling the problem head on, we always look for options to go around it and only get screwed a little instead of a lot. Instead of saying "medicare cuts? go ahead! but don't plan on us accepting any of it if you do" we say "could we just delay the cuts for a while?" I think that everyone needs to grow a pair and say "F*** you, pay me." In no other business do you see the bill being paid whatever the party feels like paying.. if paying at all. And it's not just the money, it's the fact that we are turning into the insurance companies/medicares bitch.

In terms of cutting back on anesthesiology positions, it makes sense... just not at this time. At this moment, there is a lot of lobbying from the nurses about how they don't need us at all. They are pumping out more and more of them, and to cut back anesthesiologists would be foolish. Using derm as an example makes no sense because they have no competition fighting for their piece of the pie. And of course, instead of fighting to keep the OR time that has belonged to anesthesiologists for so long, we once again roll over and let them invade. Why start looking at other alternatives such as critical care and let them just walk all over us? And I realize that a monkey could run a lap chole case, but so what? We went through the training to be that monkey if we so chose. Don't tell me that nurses couldn't run a FP clinic or rub some steroids on a rash in place of a dermatologist or even perform a lap chole! So I say lets fight to keep our option of being either supervisors or lap chole monkies, but not give in because someone else really wants our job.

 

[EtherMD]

I'm glad to hear someone else say this. I think that physicians are going to have to put their foot down with medicare and insurance companies eventually. My only question is why not sooner than later? Regarding physician unions, who cares if they are illegal. Are they going to put all physicians in jail? No. Physicians hold some serious power because no one can force us to work, yet our service is desparately needed. However, we let medicare and insurance companies turn into our boss due to the fear of losing that $12 from a medicare or anthem pt. Why not all take a month off, show them who's boss and collect ALL of what we bill? It works for dentists, why not us? We need to stop the runaway train that is medicare and insurance companies before it runs even further out of control. I realize that everyone banding together is an extremely difficult concept for many of the reasons that mil mentioned above, but if it doesn't happen, physicians are going to wake up making 50K/year one day. And instead of tackling the problem head on, we always look for options to go around it and only get screwed a little instead of a lot. Instead of saying "medicare cuts? go ahead! but don't plan on us accepting any of it if you do" we say "could we just delay the cuts for a while?" I think that everyone needs to grow a pair and say "F*** you, pay me." In no other business do you see the bill being paid whatever the party feels like paying.. if paying at all. And it's not just the money, it's the fact that we are turning into the insurance companies/medicares bitch.

In terms of cutting back on anesthesiology positions, it makes sense... just not at this time. At this moment, there is a lot of lobbying from the nurses about how they don't need us at all. They are pumping out more and more of them, and to cut back anesthesiologists would be foolish. Using derm as an example makes no sense because they have no competition fighting for their piece of the pie. And of course, instead of fighting to keep the OR time that has belonged to anesthesiologists for so long, we once again roll over and let them invade. Why start looking at other alternatives such as critical care and let them just walk all over us? And I realize that a monkey could run a lap chole case, but so what? We went through the training to be that monkey if we so chose. Don't tell me that nurses couldn't run a FP clinic or rub some steroids on a rash in place of a dermatologist or even perform a lap chole! So I say lets fight to keep our option of being either supervisors or lap chole monkies, but not give in because someone else really wants our job.

I enjoyed reading your post. Funny and very passionate about defending our turf. Realistic? No way. How will MDA's be viewed by other Doctors if we stop accepting Medicare? What about the hospitals? Remember, the AMC's and CRNA Groups are waiting in the corner for their shot at the hospital contract.

The AANA would step up and say Medicare is good enough for our membership. If you give us SOLO practice in rights in every State we will take care of all the Anesthesia. Let the MDA's go back to Residency for another specialty.

Nobody wants to give up the fight. On the contrary, the time has come for strategic moves to save the specialty. But, it is not business as usual and more rhetoric will not save Anesthesiology from the Nurse Anesthetists.

It starts with beefed up credentials and working with a Mid-Level Provider whose not trying to steal your job.

The USA needs Mid-Level Providers or a 50% increase in new graduates per year for at least ten years. More realistically, Medicare will FORCE some programs to close over the next five years. Why not look "strong" by becoming "lean and mean" next year voluntarily. Reduce the numbers to the late 1990's and "hedge your bets" in case all MDA's end up as supervisors.
Ramp-up the AA programs while there is still time. By 2017 this option will be pretty much dead as the AANA will be in control of the Anesthesia Market place. For some us, the AANA is almost there today.

You will not be able to defeat the AANA with a direct approach (at the Federal level) as the ASA has been trying for the past twenty years. The AANA has many more wins than losses over the ASA in the political arena.
The best bet is with the AA's and the opportunity to staff our operating rooms with a Mid-Level Provider whose parent organization's official stance is to work under the supervision of an MDA At all times.

The choice may not be ours for much longer so decide soon: Continue to fight a brave but losing war with the AANA or find another Mid-Level Provider ASAP.

 

[OB1🤙]

What would be the means of making AAs the "preferred" mid-level provider of anesthesia nationally? What steps would have to be taken on the state and national level?

I agree that if I have a choice of mid-level to help provide anesthesia in the team model, I'd prefer to work with people who recognize the differences in our training and do not presume that they can function as a doctor (at least, whose national leadership organization does not believe such things since most CRNAs themselves probably don't share this delusion).

But how do you get from here to there? Especially with the volume of CRNAs being put out relative to AAs?

If it's going to be the job of the ASA, what specifically does the ASA have to do to effect this change?

 

[EtherMD]

What would be the means of making AAs the "preferred" mid-level provider of anesthesia nationally? What steps would have to be taken on the state and national level?

I agree that if I have a choice of mid-level to help provide anesthesia in the team model, I'd prefer to work with people who recognize the differences in our training and do not presume that they can function as a doctor (at least, whose national leadership organization does not believe such things since most CRNAs themselves probably don't share this delusion).

But how do you get from here to there? Especially with the volume of CRNAs being put out relative to AAs?

If it's going to be the job of the ASA, what specifically does the ASA have to do to effect this change?

Fair question. Let's assume (and this is a big assumption) that 75% of ASA members agree we need to start more AA programs. First, how will we influence the market place with a dozen more programs? Easy. The AANA will "panic" once they see the ASA's response to the continued propoganda.
The psychological impact of starting 12 new programs over 24 months will serve as a wake up call to the AANA: Be reasonable or we WILL REPLACE YOU.

This is ACTION and not more hot air. This is the the type of response the AANA will understand. Again, just a dozen programs will get the ball rolling and roll it will.

Working the AAAA the ACademic Chairs could easily start 12 programs. All it takes is a little interest and motivation.

 

[toughlife]

Fair question. Let's assume (and this is a big assumption) that 75% of ASA members agree we need to start more AA programs. First, how will we influence the market place with a dozen more programs? Easy. The AANA will "panic" once they see the ASA's response to the continued propoganda.
The psychological impact of starting 12 new programs over 24 months will serve as a wake up call to the AANA: Be reasonable or we WILL REPLACE YOU.

This is ACTION and not more hot air. This is the the type of response the AANA will understand. Again, just a dozen programs will get the ball rolling and roll it will.

Working the AAAA the ACademic Chairs could easily start 12 programs. All it takes is a little interest and motivation.

I'd like to hear what JWK has to say about this idea.

 

[SleepIsGood]

...

The AANA would step up and say Medicare is good enough for our membership. If you give us SOLO practice in rights in every State we will take care of all the Anesthesia. Let the MDA's go back to Residency for another specialty.
....

If we had a MAJORITY and yes I do understand getting a MAJORITY of ASA members to agree on thing would be difficult. Nevertheless, if that were the case I believe even Medicare would realize that physicians were necessary to supervise CRNAs and that CRNAs couldnt practice SAFELY alone. I dont believe that medicare/hospitals would be that naive to completely do away with physicians and opt to utilize CRNAs.

If we were to do this, I think we could get medicare/hosp admins to come to the table and we could negotiate reimbursement rates,etc.

Unfortunately, the hardest part is to get anesthesiologists to all 'boycott'. I dont know how we could get this accomplished. Here on this board for example there's already such disparity.

EtherMD---while I agree with a lot of your assertions and do agree that our situation is dire, I do not believe fueling yet ANOTHER paraprofessional group into our profession is the alternative. Again, think of what surgeons and other MDs would think? They would assume and rightfully so that 'anyone can do anesthesia'. I think bringing more paraprofs into the field just creates more disdain toward our profession. The AAs will eventually do what the CRNAs are doing to us right now.

I am vehemently pro-physician. The easy fix to all of this is to cut production and demand. It's up to the older anesthesiologists to #1-stop teaching/producing these CRNAs (which by the way occurs at academic institutions) #2- Stop hiring CRNAs.

The demand for each anesthesiologist will then increase as they will be the sole anesthesia provider available.

EtherMD--the reason myself and others do not agree with you is this. People went into anesthesia for different reasons. The profession is what it is today. Some ppl went into it for academics, others for money, others to do pain or CCM. To automatically change residencies and increase it yet another year (where my debt to income ratio increases yet again) is not pragmatic. Yes, 10 yrs ago if I did another year of residency the benefits were there. I could come out and make more $$. Nowadays, doing more training doesnt equate to better pay when paraprofs are around trying to do the same work for less.

 

[EtherMD]

If we had a MAJORITY and yes I do understand getting a MAJORITY of ASA members to agree on thing would be difficult. Nevertheless, if that were the case I believe even Medicare would realize that physicians were necessary to supervise CRNAs and that CRNAs couldnt practice SAFELY alone. I dont believe that medicare/hospitals would be that naive to completely do away with physicians and opt to utilize CRNAs.

If we were to do this, I think we could get medicare/hosp admins to come to the table and we could negotiate reimbursement rates,etc.

Unfortunately, the hardest part is to get anesthesiologists to all 'boycott'. I dont know how we could get this accomplished. Here on this board for example there's already such disparity.

EtherMD---while I agree with a lot of your assertions and do agree that our situation is dire, I do not believe fueling yet ANOTHER paraprofessional group into our profession is the alternative. Again, think of what surgeons and other MDs would think? They would assume and rightfully so that 'anyone can do anesthesia'. I think bringing more paraprofs into the field just creates more disdain toward our profession. The AAs will eventually do what the CRNAs are doing to us right now.

I am vehemently pro-physician. The easy fix to all of this is to cut production and demand. It's up to the older anesthesiologists to #1-stop teaching/producing these CRNAs (which by the way occurs at academic institutions) #2- Stop hiring CRNAs.

The demand for each anesthesiologist will then increase as they will be the sole anesthesia provider available.

EtherMD--the reason myself and others do not agree with you is this. People went into anesthesia for different reasons. The profession is what it is today. Some ppl went into it for academics, others for money, others to do pain or CCM. To automatically change residencies and increase it yet another year (where my debt to income ratio increases yet again) is not pragmatic. Yes, 10 yrs ago if I did another year of residency the benefits were there. I could come out and make more $$. Nowadays, doing more training doesnt equate to better pay when paraprofs are around trying to do the same work for less.

I have explained my position in detail and ad nauseum. I ATTEMPTED to list
THREE ways the ASA could respond to the AANA threat. All three are logical and are based on Lema's lecture. Lema and I agree on the most likely outcome of our current path. You on the other hand, want to "hold the line" and take the traditional path. Bad move. The AANA BELIEVES CRNA's can practice solo very safely. They market this belief to every legislator that will listen. I do respect that we disagree and will leave it at that.

Remember this post because in ten years you will see the truth and you will not like it.

 

[EtherMD]

How about a positive view of the future. Even I am tired of the "negativity" posted by none other than me. Let's assume that the ASA and Academic Chairs respond to the threat of the AANA/CRNA with my proposals:

1. The reduction of spots leads to high demand. Partnership tracks remain short with an average 24 month time frame. Starting salaries remain high because demand is > than supply. The 20% reduction worked well and hospitals are forced to "pony-up" in order to get good staff.

2. The creation of 10-12 AA Programs has sent a clear message to the AANA that we mean business. The AANA has backed-off its "solo" practice issue in all states for a while. Its membership is very anxious about more AA"s taking work away from them. They want to talk "peace" for now. In return for not starting additional AA programs the AANA is willing to issue a joint statement about the value of MDA's in large hospitals. The actual number of AA's is still small relative to CRNA's but the message was heard.

3. The ASA and Academic chairs decide to "beef-up" the certificate. All residents completing a fellowship are Board eligible for Anesthesiology, Critical Care and ONE SUBSPECIALTY. We are now referred to as Perioperative specialists. The market place and hospitals realize the value of these Physicians in their facility. The AANA no longer claims equivalence to these new graduates.

Wishful thinking? You bet.

 

[BuddhaCanooda]

Will there not be opportunities for market growth in providing anesthesia? I never thought supervising CRNAs would be negative if you are able to get up to 50% in some markets (split between MDA/CRNA). But if CRNAs are given more independence it does increase the numbers of players.

Should current (and prospective) residents plan on doing only ASA 3/4 cases to make it? As an Army doc I know that the CRNAs have a great deal of influence (esp at Tripler) in being autonomous.

What do current residents hear about the state of affairs?

BC

 

[EtherMD]

Will there not be opportunities for market growth in providing anesthesia? I never thought supervising CRNAs would be negative if you are able to get up to 50% in some markets (split between MDA/CRNA). But if CRNAs are given more independence it does increase the numbers of players.

Should current (and prospective) residents plan on doing only ASA 3/4 cases to make it? As an Army doc I know that the CRNAs have a great deal of influence (esp at Tripler) in being autonomous.

What do current residents hear about the state of affairs?

BC

BC,

You may want to start from the beginning of this thread. Please read Dr. Lema's lecture prior to any of the posts. The point of this thread is to comment on Lema's lecture about the specialty and its future.

Since nobody can predict the future we must use the rely on the past and our best guess about political outcomes to predict most likely practice scenarios.

As for where we are now, there is plenty of work in the field and 90% plus of CRNA's are supervised/directed by a Physician Anesthesiologist including ASA 1 and ASA 2 cases.

It is not where we are now that we are discussing it is where we may be going in the near future.

 

[johankriek]

Will there not be opportunities for market growth in providing anesthesia? I never thought supervising CRNAs would be negative if you are able to get up to 50% in some markets (split between MDA/CRNA). But if CRNAs are given more independence it does increase the numbers of players.

Should current (and prospective) residents plan on doing only ASA 3/4 cases to make it? As an Army doc I know that the CRNAs have a great deal of influence (esp at Tripler) in being autonomous.

What do current residents hear about the state of affairs?

BC

I dont know anything about the army but all i know is that MY STANDARD for independent practice on all patients asa 1-5, i dont care if the patient is getting a haircut under anesthesia is Board Certification in anesthesia. PERIOD. anything else is just disingenuous. I know many CRNAs state they are board certified hence the C in their name. I would remind them that it is ILLEGAL to call yourself BOARD CERTIFIED if you are not by one of the ABMS member boards. www.abms.org

 

[militarymd]

I dont know anything about the army but all i know is that MY STANDARD for independent practice on all patients asa 1-5, i dont care if the patient is getting a haircut under anesthesia is Board Certification in anesthesia. PERIOD. anything else is just disingenuous. I know many CRNAs state they are board certified hence the C in their name. I would remind them that it is ILLEGAL to call yourself BOARD CERTIFIED if you are not by one of the ABMS member boards. www.abms.org

What about the Osteopathic boards?

or the American Board of Phyicians Specialists?

 

[Hypnos Doc]

First, things are never as bad as they seem but never as good as one thinks.
Second, all of medicine is undergoing a transformation as technology advancement abruptly changes traditional practice. Medicine will be different but better for patients and more accessible to Americans.
Third, anesthesiology is so diverse in its scope of practice that it is probably one of the better specialties to select. Consider that in my career, I was/am a cardiac anesthesiologist (heart transplants), Ob anesthesiologist, critical care specialist, regional anesthesiologist, cancer pain specialist, palliative care specialist, hospital chief, medical OR director, department chair and now society leader. I could not imagine any other specialty affording the opportunity to sample as many disciplines with only changing my place of employment once! I would encourage residents to explore anesthesiology because of the many opportunities to shift one's emphasis to another practice area throughout their careers.
Fourth, anesthesiologists are likely to medicially direct perioperative services, an up and coming career, because of our diverse training.
Fifth, no one can predict when changes will occur in any of the medical specialties and workforce issues as well as government inertia could easily delay any attempts at health care reform (I would not overly rely on this concept because the two leading democratic presidential candidates are known health care reformers).
Sixth, if I had to choose again, I'd still pick anesthesiology.
Thank you for the oppotunity to particiapate in this forum. -MJL

 

[BuddhaCanooda]

BC,

Since nobody can predict the future we must use the rely on the past and our best guess about political outcomes to predict most likely practice scenarios.

As for where we are now, there is plenty of work in the field and 90% plus of CRNA's are supervised/directed by a Physician Anesthesiologist including ASA 1 and ASA 2 cases.

It is not where we are now that we are discussing it is where we may be going in the near future.

You are right in that nobody can predict the future. However, the current budget crunch facing Medicare is likely to hit the specialty pretty hard in the next few years. The ability of mid-level providers to perform cases independently will not help either. My question is this, why is it looked down upon so badly if attendings are required to supervise more CRNA cases? Would it not be better to supervise ASA one and two cases and do work on ASA three and above cases?

I once rotated through the anesthesiology department at Walter Reed. There I saw CRNAs run many ASA one and two cases. The attendings handled the more difficult cases, naturally. The mid-level providers could not touch regional or pain management. The attendings would supervise the mid-level providers for the less difficult cases. Is this the particular model the rest of the specialty will be heading towards? In other words does the MD only practice have a limited remaining life span?

OT - I will be applying for residency in the upcoming year and will need to make a decision between anesthesiology and neurology. Any thoughts on either? Has anyone here ever done both fields?

BC

 

[The_Sensei]

Hey, I was thinking.......anyone else feel that EtherMD is really Mark Lema, going incognito? Hmmmmmmmmm

 

[Bertelman]

Nah- Hypnos Doc has a different style. Something's up, though. Ether's got too many posts. Must have Web access in the OR.

 

[EtherMD]

First, things are never as bad as they seem but never as good as one thinks.
Second, all of medicine is undergoing a transformation as technology advancement abruptly changes traditional practice. Medicine will be different but better for patients and more accessible to Americans.
Third, anesthesiology is so diverse in its scope of practice that it is probably one of the better specialties to select. Consider that in my career, I was/am a cardiac anesthesiologist (heart transplants), Ob anesthesiologist, critical care specialist, regional anesthesiologist, cancer pain specialist, palliative care specialist, hospital chief, medical OR director, department chair and now society leader. I could not imagine any other specialty affording the opportunity to sample as many disciplines with only changing my place of employment once! I would encourage residents to explore anesthesiology because of the many opportunities to shift one's emphasis to another practice area throughout their careers.
Fourth, anesthesiologists are likely to medicially direct perioperative services, an up and coming career, because of our diverse training.
Fifth, no one can predict when changes will occur in any of the medical specialties and workforce issues as well as government inertia could easily delay any attempts at health care reform (I would not overly rely on this concept because the two leading democratic presidential candidates are known health care reformers).
Sixth, if I had to choose again, I'd still pick anesthesiology.
Thank you for the oppotunity to particiapate in this forum. -MJL

Dr. Lema,

I appreciate the post. At least think about my proposals as possible soultions to the problems facing our specialty.

1. Restoring the number of graduates to the late 1990's number is a good thing. Those graduates had multiple job offers, high starting pay and short partnership tracks. How was that a bad thing? Why should not the next Group get that same opportunity? The Group who graduated in the Mid 1990's had a much tougher time. Long partnership tracks and low starting pay (academics and private practice).

2. How can supporting a dozen or so AA programs hurt the specialty or the ASA? The total number of AA's in the market place is very small and adding a dozen more programs would bring the total number to 16. Compare this to the number of CRNA programs: 110 plus and growing. But, this would send a message to the AANA that you mean business. Cooperate or we will replace you in the O.R. Why not give the next Group of graduates a CHOICE about which Mid-Level Provider they want in the O.R?

3. A Better Certificate- This can only help the specialty. Your vision of the future requires more than a legal certificate which states "Consultant in Anesthesiology." The next Group of Residents deserves better from the leadership. These young men and women will need a real, legal certificate to help differentiate themselves from the Mid-Level Providers. PLEASE give it to them.

Finally, thank you for yor post and your lecture. It takes a brave Anesthesiologist to openly state the specialty's problems and potential future; but, it takes even more courage to do something about it. Please remain steadfast in your resolve to change things for the better. The next Group of Residents' careers depend on it.

 

[EtherMD]

Nah- Hypnos Doc has a different style. Something's up, though. Ether's got too many posts. Must have Web access in the OR. [/QUOTE

I have web access in the Operating room at multiple areas. Dr. Lema's post is carefully worded unlike mine. Read his post again and look at the things he does not say and that is how you know it is coming from someone more "political" than me.

 

[johankriek]

What about the Osteopathic boards?

or the American Board of Phyicians Specialists?

you said that the osteopathic boards are a jokeandthat anyone who takes them just concedes to the fact thatthey cant pass the american boards..

 

[bestiller]

are you kidding me? are you for real? As if I have to distinguish myself from a CRNA on any level. there is no comparison what i bring to the OR with what a CRNA brings to the OR. If you think you need a cardiac pain or critical care fellowship to distinguish yourself from a crna you need to re evaluate yourself as a physician. so what do you propose.. One more Year of training mandatory. go home my friend.. give it up. go back to your office and think again. more time in indentured servitude. while loans are racking interest. actually the banks would love you..

the answer is ONe anesthesiologist, one patient.. point blank.. simple isnt it? you hire crnas for stuff like what i use my anesthesia tech for( awesome) Put on monitors size up the lma.. tape the ivs, that kind of thing.. pump out more and more anesthesiologists. try to push out the old "****s early to put this specialty back on track..
CRNAs arent as cheap as you think.. I know plenty of physicians who would work for the pay they make..

Surely you are not saying an "all" anesthesiologist administered practice model is a good thing from a financial stand point, are you? If so you would severely be limiting profits by chaining yourself to the stool. A small core group of MD's and large number of CRNA/AA's in a fee for service practice model with said CRNA/AA's signing over %50 of their billing is by farthe most lucritive model of all the models I have ever been associated with for all providers involved. It makes the CRNA/AA's hungry to do all the cases they can as opposed to milking a salary time clock. In my group MD's don't touch OB, for instance. It accounts for so much time at the hospital and is such a small portion of income it is totally CRNA administered with an MD available but never physically present and still collecting %50 of that income. At the end of the year everyone goes home happy. Though I will admit our OB and Cardiac are facility subsidized

 

[militarymd]

you said that the osteopathic boards are a jokeandthat anyone who takes them just concedes to the fact thatthey cant pass the american boards..

I know what I said....I'm asking you what you think.

 

[johankriek]

Surely you are not saying an "all" anesthesiologist administered practice model is a good thing from a financial stand point, are you? If so you would severely be limiting profits by chaining yourself to the stool. A small core group of MD's and large number of CRNA/AA's in a fee for service practice model with said CRNA/AA's signing over %50 of their billing is by farthe most lucritive model of all the models I have ever been associated with for all providers involved. It makes the CRNA/AA's hungry to do all the cases they can as opposed to milking a salary time clock. In my group MD's don't touch OB, for instance. It accounts for so much time at the hospital and is such a small portion of income it is totally CRNA administered with an MD available but never physically present and still collecting %50 of that income. At the end of the year everyone goes home happy. Though I will admit our OB and Cardiac are facility subsidized

umm, what im saying i dont see any benefit to supervising a stable of nurses. I do one on one anesthesia and i make as much or more than a friend who supervises a stable of nurses. and I dont see on gaswork the job postings pay you more for supervising a stable of nurses.. SO i would rather not. In my state that would be fraud and you would be put in jail for assault and battery in respects to what you said about your OB department.

 

[johankriek]

I know what I said....I'm asking you what you think.

I dont think osteopaths can put down Board Certified since its not part of abms. The controversey started when people started using board certified in the yellow pages..They never stated it was MICKEY mouse' board. board certified none the less..

ABMS is the standard in this country..

 

[The_Sensei]

I dont think osteopaths can put down Board Certified since its not part of abms. The controversey started when people started using board certified in the yellow pages..They never stated it was MICKEY mouse' board. board certified none the less..

ABMS is the standard in this country..

Wrong! Osteopaths can and DO put down "Board Certified" since they are legitimately board certified. At least hospitals recognize it this way.

 

[johankriek]

Wrong! Osteopaths can and DO put down "Board Certified" since they are legitimately board certified. At least hospitals recognize it this way.

osteopaths can puit down board certified if they are certified by an abms board. ask military md hell tell you

 

[The_Sensei]

osteopaths can puit down board certified if they are certified by an abms board. ask military md hell tell you

I don't need to ask him...I'm just trying to tell you this:

DOs can put down "board certified" whether they are certified by the ABMS, the AOBA, or whatever other board there is out there (I forget which one it is). Mil please confirm this.....

 

[militarymd]

abps...is another one.

In a prior thread.....I said that we (physicians) should undergo a single examination process for board certification....

However, there are 3 boards that certifiy physicians.

 

[bestiller]

umm, what im saying i dont see any benefit to supervising a stable of nurses. I do one on one anesthesia and i make as much or more than a friend who supervises a stable of nurses. and I dont see on gaswork the job postings pay you more for supervising a stable of nurses.. SO i would rather not. In my state that would be fraud and you would be put in jail for assault and battery in respects to what you said about your OB department.

I don't see how, for example, 7 MD's doing 1 on 1 anesthesia makes equal $ or greater $ than 1 MD supervising(billed as "unsupervised") 7 CRNA/AA's who have signed over 50% of their billing. IMO taking in 50% of 7 cases beats 1/7th of a pie. Multiply this scenerio by having MD partners at other facilities supervising in the same billing manner the same number of CRNA/AA's. This quickly adds up. As far as fraud and battery I am not sure where you live but the key in our practice arrangement is to bill all cases as "unsupervised" to get outside of TEFRA requirements. There is no need to bill " medically supervised" when you are already getting 50% of the CRNA/AA's billing anyway. I see what you are saying if the MD is salaried or a hosp. employee about making the same whether he/she supervises or does cases.

 

[UTSouthwestern]

First, things are never as bad as they seem but never as good as one thinks.
Second, all of medicine is undergoing a transformation as technology advancement abruptly changes traditional practice. Medicine will be different but better for patients and more accessible to Americans.
Third, anesthesiology is so diverse in its scope of practice that it is probably one of the better specialties to select. Consider that in my career, I was/am a cardiac anesthesiologist (heart transplants), Ob anesthesiologist, critical care specialist, regional anesthesiologist, cancer pain specialist, palliative care specialist, hospital chief, medical OR director, department chair and now society leader. I could not imagine any other specialty affording the opportunity to sample as many disciplines with only changing my place of employment once! I would encourage residents to explore anesthesiology because of the many opportunities to shift one's emphasis to another practice area throughout their careers.
Fourth, anesthesiologists are likely to medicially direct perioperative services, an up and coming career, because of our diverse training.
Fifth, no one can predict when changes will occur in any of the medical specialties and workforce issues as well as government inertia could easily delay any attempts at health care reform (I would not overly rely on this concept because the two leading democratic presidential candidates are known health care reformers).
Sixth, if I had to choose again, I'd still pick anesthesiology.
Thank you for the oppotunity to particiapate in this forum. -MJL

Dr. Lema, thank you for posting your thoughts on this subject.

My offer to speak here in Dallas still stands.

One topic I would like to hear your opinion on is a publicity campaign to extoll the virtues of our field, which would not have to directly attack midlevel providers, but instead promote the diversity of training, level of training, and in general clarify the training that an anesthesiologist receives. Many patients do not even realize that an anesthesiologist is a board certified physician.

It would seem to be a logical method of promoting the importance of our field and its practitioners across the board.

 

[The_Sensei]

Dr. Lema, thank you for posting your thoughts on this subject.

My offer to speak here in Dallas still stands.

One topic I would like to hear your opinion on is a publicity campaign to extoll the virtues of our field, which would not have to directly attack midlevel providers, but instead promote the diversity of training, level of training, and in general clarify the training that an anesthesiologist receives. Many patients do not even realize that an anesthesiologist is a board certified physician.

It would seem to be a logical method of promoting the importance of our field and its practitioners across the board.

I couldn't agree more. Why not have a mass media campaign (much like the CRNAs) extolling the virtues of having an anesthesiologist involved in your care? At my hospital, just last week, the CRNAs were all wearing badges that read "Rest Easy A CRNA is by Your Side" in honor of CRNA week. The propaganda storm at the hospital included tables with brochures, posters, etc. We as anesthesiologists somehow feel above these marketing ploys. NO MORE! The ASA should use some of the thousands of dollars I have donated over the years to take out SOME form of ad telling John Q. Public just who we are.

 

[johankriek]

I don't see how, for example, 7 MD's doing 1 on 1 anesthesia makes equal $ or greater $ than 1 MD supervising(billed as "unsupervised") 7 CRNA/AA's who have signed over 50% of their billing. IMO taking in 50% of 7 cases beats 1/7th of a pie. Multiply this scenerio by having MD partners at other facilities supervising in the same billing manner the same number of CRNA/AA's. This quickly adds up. As far as fraud and battery I am not sure where you live but the key in our practice arrangement is to bill all cases as "unsupervised" to get outside of TEFRA requirements. There is no need to bill " medically supervised" when you are already getting 50% of the CRNA/AA's billing anyway. I see what you are saying if the MD is salaried or a hosp. employee about making the same whether he/she supervises or does cases.

its all about risk.... thats what this field is about.. the work is easy.. the more nurses you supervise.. the more risk you take on.. and the more risk should be commensurate with the reward... thats why i dont do it.. hey when im 20 years in maybe ill take that on and when i have protected all of my assets... so you cant pay someone who supervises 2-3 crnas per day the same as someone like me who does his own cases for the past 4 years. but some how I do make the same if not more..

and to I agree I would support whole heartedly the notion of having more Anesthesiology Assistant schools plus adding some more spots in our residency. plust putting out an ad campaign in the fifty states. And writing letters to the legislature extolling the virtues of anesthesiologists.

 

[johankriek]

I don't see how, for example, 7 MD's doing 1 on 1 anesthesia makes equal $ or greater $ than 1 MD supervising(billed as "unsupervised") 7 CRNA/AA's who have signed over 50% of their billing. IMO taking in 50% of 7 cases beats 1/7th of a pie. Multiply this scenerio by having MD partners at other facilities supervising in the same billing manner the same number of CRNA/AA's. This quickly adds up. As far as fraud and battery I am not sure where you live but the key in our practice arrangement is to bill all cases as "unsupervised" to get outside of TEFRA requirements. There is no need to bill " medically supervised" when you are already getting 50% of the CRNA/AA's billing anyway. I see what you are saying if the MD is salaried or a hosp. employee about making the same whether he/she supervises or does cases.

its all about risk.... thats what this field is about.. the work is easy.. the more nurses you supervise.. the more risk you take on.. and the more risk should be commensurate with the reward... thats why i dont do it.. hey when im 20 years in maybe ill take that on and when i have protected all of my assets... so you cant pay someone who supervises 2-3 crnas per day the same as someone like me who does his own cases for the past 4 years. but some how I do make the same if not more..

and to I agree I would support whole heartedly the notion of having more Anesthesiology Assistant schools plus adding some more spots in our residency. plust putting out an ad campaign in the fifty states. And writing letters to the legislature extolling the virtues of anesthesiologists.

 

[bigdan]

I couldn't agree more. Why not have a mass media campaign (much like the CRNAs) extolling the virtues of having an anesthesiologist involved in your care? At my hospital, just last week, the CRNAs were all wearing badges that read "Rest Easy A CRNA is by Your Side" in honor of CRNA week. The propaganda storm at the hospital included tables with brochures, posters, etc. We as anesthesiologists somehow feel above these marketing ploys. NO MORE! The ASA should use some of the thousands of dollars I have donated over the years to take out SOME form of ad telling John Q. Public just who we are.

Finally!

What about a "You have the option of a doctor to provide your care". TV commercials, radio, print? Our buddies in big Pharma can vouch for how well direct-to-consumer ads work. Take the high road and not bash the CRNAs, but let the public know...

dc