Is this a feasible way to push back from Mid-level encroachment?

[jwk]

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Dang guys/gals. Surgeons aren’t idiots, where is this coming from?


This.
Exactly why my old group started with AAs. Too much attitude, too much of the time.
They’re working under your license, so you make the rules.

ACT practices can and do work, and it all depends on the anesthesiologist actually being in charge and setting the tone. We follow the 7 steps of TEFRA for medical direction. An anesthesiologist sees every patient pre-op, formulates the plan, is there for every induction (and/or does every SAB/epidural/block), present for every emergence, etc., etc. It's not that hard to do, but it takes organization and a culture that "this is the way we're going to do things".

We use AAs and CRNAs, but expectations and job descriptions are crystal clear and start at the interview process. We don't micromanage, but we do expect common sense and open lines of communication.

 

[MoMoGesiologist]

ACT practices can and do work, and it all depends on the anesthesiologist actually being in charge and setting the tone. We follow the 7 steps of TEFRA for medical direction. An anesthesiologist sees every patient pre-op, formulates the plan, is there for every induction (and/or does every SAB/epidural/block), present for every emergence, etc., etc. It's not that hard to do, but it takes organization and a culture that "this is the way we're going to do things".

We use AAs and CRNAs, but expectations and job descriptions are crystal clear and start at the interview process. We don't micromanage, but we do expect common sense and open lines of communication.

How many rooms are you supervising?

 

[deleted162650]

If an organization can have the same procedure done for half to a third of the cost, that's what it will do. It's just more efficient.

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There are no cost savings with CRNAs. The amount billed is the same regardless of MD only, ACT, QZ, or CRNA only. Nice try though.

 

[Man o War]

There are no cost savings with CRNAs. The amount billed is the same regardless of MD only, ACT, QZ, or CRNA only. Nice try though.

Yep.
Wait until the hospital starts seeing those numbers for CRNA time and a half after 40 hours.
Remember the Michigan 68? Their overtime cost was one of the reasons that whole thing went down.
A friend of mine’s group was asked to take over the CRNAs because the OT costs were out of control. I believe it was already at 600k a little over halfway through the year. And we all know things get much busier the last half of the year.
But you won’t see that fun fact on any of the AANA propaganda.

 

[jwk]

How many rooms are you supervising?

Me personally? None, since I'm an AA. Our ratios vary from 1:1 to 1:4, depending on time of day, type of case, acuity, etc.

 

[deleted126335]

There are no cost savings with CRNAs. The amount billed is the same regardless of MD only, ACT, QZ, or CRNA only. Nice try though.

There is a cost savings on Anesthesia payroll. E.g. A hospital has 20 ORs plus an OB service. A private group might staff the rooms with 20 CRNAs plus relief. Staff with 6-7 docs. Use and bill medical direction.

Everybody now employed by hospital or AMC. Still staff the rooms with all CRNAs. Staff with 3-4 docs or less. Bill QZ.

You save 3-4 FTE docs salaries. Of course, that assumes no change in productivity, efficiency, complications, unplanned overnight admissions, patient satisfaction, length of stay, ICU admissions and duration, increased use of consults, cancellations, cost of complications, cost of malpractice, that the missing docs produced no other value besides their billing. Not to mention major morbidity and mortality.

That is what the AANA has been trying to sell for 40 years. They haven't gained much. They are only now gaining more because money has never been tighter.

Administrators are now desperate to buy.

 

[nimbus]

Ummm... You know CRNA salaries are less than half of Anesthesiologist salaries, right? Sorry to break it to you, but it hospitals save money by hiring them.

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Salty was referring to the fact that insurance companies pay for anesthesia services without regard to who the provider is. Could be solo MD, a care team or a solo CRNA. For any given procedure, the reimbursement is the same. A doctor caring for a knee scope gets what a CRNA would get. There is no doctor “premium”. An independently practicing CRNA would make what an MD makes. It’s just that most CRNAs work on salary in ACTs.

 

[nimbus]

And I was referring to the fact that CRNAs get paid less, therefore making them attractive to hospitals. I guess it's hard to admit the obvious when you're (literally) invested in this.

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They may make less but the parties who pay for the care are not paying any less. That’s just a fact. Many people, including you, have no idea how anesthesia reimbursement works. CRNAs make less because they are splitting the fee with a supervising anesthesiologist. If they are practicing independently and making less, it is because they are being robbed by their agency or the hospital or some other third party middleman.

 

[deleted162650]

And I was referring to the fact that CRNAs get paid less, therefore making them attractive to hospitals. I guess it's hard to admit the obvious when you're (literally) invested in this.

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In a model where the hospital is directly employing both docs and CRNAs, then yes, the hospital will save money by having more CRNA’s and less docs (although not as much as you think). The overall system sees no savings as @nimbus already clarified for you. The patient and the 3rd party payer (be it private insurance or the government) pays exactly the same.

Personally, I don’t care if the hospital saves money. Where do the savings go? To the non-clinical execs/admins pockets. I’m not ok with corporate keeping some of the professional fees for themselves. I think clinicians should get to keep what they generate. Hell, even in a CRNA only model I would much rather see the CRNAs billing for themselves than being robbed as hospital employees.

 

[zero0]

If ASA does not support us, what don't WE do something instead? We can set up our own pro-MD organization; we can promote ourselves through social medium etc.

Patients mainly care about safety and cost. If cost is the same (for the patient), even dumb patients know the difference between nurses and MDs. If enough patients inquire about MD anesthesia service, administrators, surgeons may start to ask for it too.

People are grossly unaware about how healthcare actually functions, and I don't blame them; there are a lot of moving pieces. Most people I talk to just assume that during surgery everything is handled by physicians or that, if it's handled by nurses, it's not important. Once I give them my usual spiel about most post-op complications being anesthesia related and that they really should have an anesthesiologist for their case if it's remotely complicated, they come around quick. All this leads me to believe that we would benefit significantly from a well-run PR campaign informing people about who actually pumps theirs or their loved one's gas.

Personally, I'm not sure about the ASA, and I mean that literally. I just haven't gotten around to doing my legwork on them, but if what I've read here is true, then we're better off taking things into our own hands. These days, a single tweet trending can go a long way.

 

[John1513]

I have come to learn that the term “hostile work environment” is often employed by the offending party... ie the person/group who does something to invite said hostility.

 

[chocomorsel]

@zero0, I was unaware that most post op complications were anesthesia related. Where is this info? I would think it would be surgical and comorbidity related.

 

[chocomorsel]

@Bloxorz, you are totally clueless.

Either you are a naive or brainwashed CRNA. I would bet the latter. There are CRNAs working independently making 300k + because they bill themselves and don’t get a salary from the hospital or MD group. Tell a patient that it saves them money to use a CRNA, and their clueless butts believe it, but it’s a lie.

Where in training are you?

 

[Psai]

And I was referring to the fact that CRNAs get paid less, therefore making them attractive to hospitals. I guess it's hard to admit the obvious when you're (literally) invested in this.

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Always kills me when crnas make arguments for increasing their own salaries by acting like they care if the hospital makes more. Or even when they pretend that the patient sees any cost savings whatsoever.

The people who go into anesthesia nursing are all in it to play doctor and make bank. Don't come in here all sanctimonious as though this weren't the case. Greedy people who want to make half a mil and leave at 3 pm on the dot, who cares if the patient is still lying there on the operating table? Heart of a nurse indeed.

 

[ghastly75]

Always kills me when crnas make arguments for increasing their own salaries by acting like they care if the hospital makes more. Or even when they pretend that the patient sees any cost savings whatsoever.

The people who go into anesthesia nursing are all in it to play doctor and make bank. Don't come in here all sanctimonious as though this weren't the case. Greedy people who want to make half a mil and leave at 3 pm on the dot, who cares if the patient is still lying there on the operating table? Heart of a nurse indeed.

I do see this all the time in my group- CRNA’s/AA’s who talk a big game of being team players and caring about the patient...until 3, 5, or 7, comes along then they want out. And weekends, forget it- “ain’t no working on the weekends”. That’s fine, it’s just a slap in the face to see this hypocrisy.

 

[nimbus]

I do see this all the time in my group- CRNA’s/AA’s who talk a big game of being team players and caring about the patient...until 3, 5, or 7, comes along then they want out. And weekends, forget it- “ain’t no working on the weekends”. That’s fine, it’s just a slap in the face to see this hypocrisy.

It’s not just AA’s/CRNA’s. No one ever drags their feet to start the 7am case. But between 3-6pm? Let the games begin!!

 

[dannyboy1]

I do see this all the time in my group- CRNA’s/AA’s who talk a big game of being team players and caring about the patient...until 3, 5, or 7, comes along then they want out. And weekends, forget it- “ain’t no working on the weekends”. That’s fine, it’s just a slap in the face to see this hypocrisy.

Plenty of MD’s that work shifts. Also there are plenty of CRNA’s that take call. Nothing wrong with expecting to be relieved on time or to have a reasonable overtime mechanism in place. We are not running a charity...

 

[QueenJames]

The answer to your question is that you be a smart, hardworking PHYSICIAN.

You make it clear you are the leader, and you deal with people in a respectful manner.

If you do good work, and are knowledgable about what you do, you will make a good name for yourself.

Don't go out of your way teach CRNAs and other midlevels a bunch... and don't be a lazy greedy bastard that the old school gas docs were that got us into this stupid mess.

 

[Planktonmd]

This type of useless discussion gives me a headache... I think I am just getting too old for this futile conversation 🙁

 

[jwk]

Plenty of MD’s that work shifts. Also there are plenty of CRNA’s that take call. Nothing wrong with expecting to be relieved on time or to have a reasonable overtime mechanism in place. We are not running a charity...

Thank you - a voice of common sense.

Our entire group of MDs, AAs, and CRNAs is on some type of shift setup. For a group that runs multiple facilities, including several hospitals 24/7, it's the only way to make it work.

Our anesthetists work salary plus OT. Like most groups, we cover the most locations first thing in the morning. As the day goes on, and especially after 3pm, we start paring down rooms. That doesn't mean one room after 3pm. We start the day with 100 operating locations, and 50-60 of those are still running at 3pm. Better for us to keep people around who want to work late and make more money with OT, than to have a LOT more shift people that may or may not be sitting around waiting for their shift to end. We can do everything with shift workers - but it would take another 50 anesthetists to do it. That doesn't make good economic sense. Better to have 50 anesthetists that want to work late, maybe an hour, maybe four, maybe eight, but only use them as long as they're needed.

Our physician schedule is done on shifts with an indeterminate ending. Lots of docs early in the day, they peel off as rooms close. More docs come on in the afternoon to cover later rooms, and there's a doc at each hospital at night, with additional backup available from home. A shift has a certain value depending on the average length or time of the shift. Those that are longer, or later in the day, or nights, or weekends, or holidays, have more value than a regular day shift. There is overlapping coverage that meshes with our anesthetist shifts so that our coverage ratios are never worse than 1:4, but typically 1:2 to 1:3 for the bulk of the day's OR schedule.

For a small group this may make no sense at all, but for a huge group like ours, it's the only way.

 

[zero0]

@zero0, I was unaware that most post op complications were anesthesia related. Where is this info? I would think it would be surgical and comorbidity related.

Just parroting something I heard during my pre-med days...

Wasn't able to find anything that directly tabulates frequency, but a cursory search shows WebMD, Stanford, other universities, and a couple more of the usual suspects list respiratory complications, along with pain, urinary retention, thrombosis, ileus, etc., as one of the main post-op causes of morbidity.

The intro from Google in this article names respiratory complications as number 1 overall, but I don't have access to the full article 🙁

Chapter 5. Postoperative Complications | CURRENT Diagnosis & Treatment: Surgery, 13e | AccessSurgery | McGraw-Hill Medical

 

[calvnandhobbs68]

We’ve known about the problem for years. It hasn’t changed substantively in a while.

As I keep saying and probably sound like a broken record, the situation is more dire elsewhere.

IM and FM (outpatient) have essentially given up already and have full practice authority for nurses all over the place. Peds (again, outpatient) is under pressure mostly from sheer volume. The next frontier is EM coming to a hospital near you (first it’ll be less docs more mid levels, then more shifts, then...). Surgical critical care on the horizon, and many areas already have midwives running their own boutique birthing centers.

Inpatient general medicine as well has NPs all over the place. Our medicine and peds floors have NPs everywhere.

Inpatient medicine in general is the place that is the most vulnerable for NPs. As much as people try to crap on outpatient specialities, the fact is that you can stick a huge "Calvnandhobbs68, MD" on your advertising/office and people know what that means. People also have the time and capacity to make a decision about whether they want to see an MD vs an NP or not, can look you up online, etc. Some amount of this decision is based on insurance coverage but honestly for initial visits people try to get in to who they can get into first and then tend to stay pretty loyal to your practice unless they don't like you for some reason. Distinguishing yourself as a "Medical Doctor" vs a "Nurse Practitioner" on an outpatient basis is much easier than on the inpatient side.

Most of the time patients/families are so out of it or overwhelmed on the inpatient side they don't even care who you are anyway. How many times have you seen patients say "the nurse is here to see me" when it's the f**ing female attending? Or complain that they "haven't seen the doctor for days" when doctors from 3 different teams saw them every morning? You think they're reading your tiny "Attending" or "Resident" on your name badge and comparing that to the "NP, CRNA, RN, BSN, MSN"? They probably think the more letters the better actually. The more emergent/urgent it is, the less patients can compare or care about who's doing the thinking/procedure. The guy with the STEMI isn't going to be trying to figure out who's cathing him and the woman with a stroke won't be asking who's authorizing the tPA. If you have a similar complication/readmission rate, then the hospital doesn't care who's providing the care as long as all the liability boxes are checked. Hospital administrators with no medical background don't know what you do day to day. All they care about is how much you can bill for vs how much you cost to keep on. If they can shift that balance, they will.

Inpatient medicine is totally driven by the government/insurance companies/hospitals. Outpatient is where market forces (in terms of some patient decision making) can somewhat come to bear.

 

[calvnandhobbs68]

There are no cost savings with CRNAs. The amount billed is the same regardless of MD only, ACT, QZ, or CRNA only. Nice try though.

You totally do not get how the economics of medicine work. This is really the first step in understanding the NP/CRNA phenomenon.

There are no cost savings for the overall healthcare system or insurance company/Medicare if they bill at the same rate. There are tons of cost savings with CRNA for the HOSPITAL. The HOSPITAL gives zero craps about if the overall healthcare system saves money and conversely will love to charge the insurance company as much money as they possibly can anyway. The math is fairly simple.

If both the MD and CRNA bill for $1,000,000 worth of anesthesia billing a year.
But the MD costs $300,000/year to retain.
And the CRNA costs $150,000/year to retain.
The hospital makes an extra $150,000/year.
Sweet! They can hire another CRNA and with an extra body, if they have the surgical volume, can actually bill for another $1,000,000 worth of cases because they now have two bodies for the price of one!

The same model is why practices hire CRNAs as well. Just substitute "practice" for "hospital" because unless you're a partner, you won't be seeing any of that extra money. If they weren't cheaper to hire, nobody would hire them...

 

[chocomorsel]

It’s not just AA’s/CRNA’s. No one ever drags their feet to start the 7am case. But between 3-6pm? Let the games begin!!

I personally hate 7 am starts. Wish the ORs would all start about 0745. I don’t mind staying late most times. But not all the time.

My first practice out of residency had no one on 2nd or 3rd call. It wasn’t needed for call days as much as “late” days. Because of the lack of this it most often happened that a colleague and I were always the ones who stayed late all the time. Everyone else bounced due to laziness, kids, laziness and seniority. I tried to ask them to change it, but these old farts were checked out and taking full advantage of their age and seniority.

 

[Psai]

That's a simplistic version. If the anesthesiologist can do blocks, cardiac cases, etc. then they expand the hospital's ability to do a wider variety of cases. If there is a complication or lawsuit from a stupid decision from a midlevel, a multimillion dollar lawsuit or a refusal of payment from an insurance company can wipe out the supposed cost savings in one fell swoop.

Also, the number of hours worked is not the same. Generally physicians work more than midlevel and don't get time and half for "overtime". If you have two midlevel providers seeing 20 patients vs one physician seeing 20 patients, the base salary may be the same but now you're paying for 2 sets of benefits instead of one.

 

[deleted171991]

That's a simplistic version. If the anesthesiologist can do blocks, cardiac cases, etc. then they expand the hospital's ability to do a wider variety of cases. If there is a complication or lawsuit from a stupid decision from a midlevel, a multimillion dollar lawsuit or a refusal of payment from an insurance company can wipe out the supposed cost savings in one fell swoop.

Also, the number of hours worked is not the same. Generally physicians work more than midlevel and don't get time and half for "overtime". If you have two midlevel providers seeing 20 patients vs one physician seeing 20 patients, the base salary may be the same but now you're paying for 2 sets of benefits instead of one.

Let's clear one thing up: CRNAs ARE CHEAPER THAN ANESTHESIOLOGISTS. Why? Because if it weren't so, the ACT practices would try to hire as many physicians as they can, instead of as many CRNAs as they can. Whenever given the choice between a good solo anesthesiologist or a good CRNA, they will hire the latter. My previous academic place has replaced all solo anesthesiologists with CRNAs. Even a traveler CRNA can be cheaper than a permanent attending.

 

[chocomorsel]

Let's clear one thing up: CRNAs ARE CHEAPER THAN ANESTHESIOLOGISTS. Why? Because if it weren't so, the ACT practices would try to hire as many physicians as they can, instead of as many CRNAs as they can. Whenever given the choice between a good solo anesthesiologist or a good CRNA, they will hire the latter. My previous academic place has replaced all solo anesthesiologists with CRNAs. Even a traveler CRNA can be cheaper than a permanent attending.

CRNAs are a cheaper cost only to the groups and hospitals that hire them. And certainly not to hospitals/facilities that let them come on as independent contractors.

They are NOT CHEAPER TO THE INSURANCE COMPANIES OR TO THE PATIENTS/PUBLIC. We have to define the two situations.

The problem is, CRNAs want to confuse the public that they are going to cost them less than docs. That’s the lie they keep spreading.

 

[calvnandhobbs68]

That's a simplistic version. If the anesthesiologist can do blocks, cardiac cases, etc. then they expand the hospital's ability to do a wider variety of cases. If there is a complication or lawsuit from a stupid decision from a midlevel, a multimillion dollar lawsuit or a refusal of payment from an insurance company can wipe out the supposed cost savings in one fell swoop.

Also, the number of hours worked is not the same. Generally physicians work more than midlevel and don't get time and half for "overtime". If you have two midlevel providers seeing 20 patients vs one physician seeing 20 patients, the base salary may be the same but now you're paying for 2 sets of benefits instead of one.

There’s already places having CRNAs doing blocks....as evidenced by some of the very people in this thread saying so.

You gotta think like an administrator man.

Say a CRNA has one more lawsuit than an MD over a 10 year period that the hospital actually has to pay out for (and lawsuits resulting in actual settlement/money paid out are pretty few and far between actually, most MDs even in high risk specialities will only have a handful in their whole career). It has to be a pretty big ass lawsuit for the cost savings to be totally negated. From a business perspective, even if you have to pay out 3 million bucks, if you saved/made an extra 3 million and 1 dollar over that time period, you came out ahead. It’s dollars and cents to them.

 

[Psai]

Let's clear one thing up: CRNAs ARE CHEAPER THAN ANESTHESIOLOGISTS. Why? Because if it weren't so, the ACT practices would try to hire as many physicians as they can, instead of as many CRNAs as they can. Whenever given the choice between a good solo anesthesiologist or a good CRNA, they will hire the latter. My previous academic place has replaced all solo anesthesiologists with CRNAs. Even a traveler CRNA can be cheaper than a permanent attending.

Here CRNA base salaries are climbing towards the same level as new academic hires, with fewer hours to boot. The hiring practices reflect that and solo cases are still being performed.

This situation was created by people who would rather spend their time doing other things rather than patient care. Instead of performing necessary skills, they farm it out to the midlevel even when they are standing right there to supervise. The whole situation is really backwards.

 

[coffeebythelake]

Ummm... You know CRNA salaries are less than half of Anesthesiologist salaries, right? Sorry to break it to you, but it hospitals save money by hiring them.

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Not when the anesthesiologists work more hours, are able to do more, and not have the constraints of overtime pay. The pay per hour comes very close.

That might change? Lots of CRNA diploma mills around graduating weak nurses and saturating their own market?

 

[Man o War]

You can’t arbitrarily say CRNAs are cheaper. A lot depends on a lot. Primarily: how many hours are the docs vs CRNAs working, what about call burden? What are the docs making? How is overtime being utilized? What is the cost of the benefit package per head?
Well run practices figure out the sweet spot and execute it. Poorly run ones let OT get out of control or are over/under staffed with either docs or CRNAs which completely negates the supposed cost savings.

 

[deleted162650]

You totally do not get how the economics of medicine work. This is really the first step in understanding the NP/CRNA phenomenon.

There are no cost savings for the overall healthcare system or insurance company/Medicare if they bill at the same rate. There are tons of cost savings with CRNA for the HOSPITAL. The HOSPITAL gives zero craps about if the overall healthcare system saves money and conversely will love to charge the insurance company as much money as they possibly can anyway. The math is fairly simple.

If both the MD and CRNA bill for $1,000,000 worth of anesthesia billing a year.
But the MD costs $300,000/year to retain.
And the CRNA costs $150,000/year to retain.
The hospital makes an extra $150,000/year.
Sweet! They can hire another CRNA and with an extra body, if they have the surgical volume, can actually bill for another $1,000,000 worth of cases because they now have two bodies for the price of one!

The same model is why practices hire CRNAs as well. Just substitute "practice" for "hospital" because unless you're a partner, you won't be seeing any of that extra money. If they weren't cheaper to hire, nobody would hire them...

I understand exactly how it works. That why I posted this:

In a model where the hospital is directly employing both docs and CRNAs, then yes, the hospital will save money by having more CRNA’s and less docs (although not as much as you think). The overall system sees no savings as @nimbus already clarified for you. The patient and the 3rd party payer (be it private insurance or the government) pays exactly the same.

Personally, I don’t care if the hospital saves money. Where do the savings go? To the non-clinical execs/admins pockets. I’m not ok with corporate keeping some of the professional fees for themselves. I think clinicians should get to keep what they generate. Hell, even in a CRNA only model I would much rather see the CRNAs billing for themselves than being robbed as hospital employees.

Now please, try to keep up.

 

[Status Sciaticus]

CRNAs are a cheaper cost only to the groups and hospitals that hire them. And certainly not to hospitals/facilities that let them come on as independent contractors.

They are NOT CHEAPER TO THE INSURANCE COMPANIES OR TO THE PATIENTS/PUBLIC. We have to define the two situations.

The problem is, CRNAs want to confuse the public that they are going to cost them less than docs. That’s the lie they keep spreading.

Hypothetically, if insurance companies started reimbursing less for a less skilled provider (CRNA), then the extra $$ that the hospital will be making in the supervision model will be diminished. Its already happening in EM where NPs/PAs are reimbursed at 85% of an MD/DO provider. While 15% is not much, it may be more in anesthesia. Would it not then make sense to lobby for this with insurance companies? I'm sure the PP docs would be against this since they hire and profit off CRNAs as well.

There’s already places having CRNAs doing blocks....as evidenced by some of the very people in this thread saying so.

You gotta think like an administrator man.

Say a CRNA has one more lawsuit than an MD over a 10 year period that the hospital actually has to pay out for (and lawsuits resulting in actual settlement/money paid out are pretty few and far between actually, most MDs even in high risk specialities will only have a handful in their whole career). It has to be a pretty big ass lawsuit for the cost savings to be totally negated. From a business perspective, even if you have to pay out 3 million bucks, if you saved/made an extra 3 million and 1 dollar over that time period, you came out ahead. It’s dollars and cents to them.

You're not accounting for the bad PR that the hospital gets in a lawsuit, which costs them future business.

 

[calvnandhobbs68]

Hypothetically, if insurance companies started reimbursing less for a less skilled provider (CRNA), then the extra $$ that the hospital will be making in the supervision model will be diminished. Its already happening in EM where NPs/PAs are reimbursed at 85% of an MD/DO provider. While 15% is not much, it may be more in anesthesia. Would it not then make sense to lobby for this with insurance companies? I'm sure the PP docs would be against this since they hire and profit off CRNAs as well.



You're not accounting for the bad PR that the hospital gets in a lawsuit, which costs them future business.

There’s no PR if they settle. Which is the majority of the time.

And honestly again it’s less than you think. The hospital I’m at has been sued publicly enough for the newspaper a couple times while I’ve been here and I’m failing to see any ill consequence of this so far. If anything our patient volume has only gone up.

 

[deleted171991]

Hypothetically, if insurance companies started reimbursing less for a less skilled provider (CRNA), then the extra $$ that the hospital will be making in the supervision model will be diminished. Its already happening in EM where NPs/PAs are reimbursed at 85% of an MD/DO provider. While 15% is not much, it may be more in anesthesia. Would it not then make sense to lobby for this with insurance companies? I'm sure the PP docs would be against this since they hire and profit off CRNAs as well.

There are already states where this is illegal. 😉

 

[deleted162650]

Hypothetically, if insurance companies started reimbursing less for a less skilled provider (CRNA), then the extra $$ that the hospital will be making in the supervision model will be diminished. Its already happening in EM where NPs/PAs are reimbursed at 85% of an MD/DO provider. While 15% is not much, it may be more in anesthesia. Would it not then make sense to lobby for this with insurance companies?

The second you make it OK to reimburse CRNA's less than docs, you are gonna have a huge amount of lobby money pushing for complete CRNA independence from the insurance companies. Bad idea.

 

[chocomorsel]

The second you make it OK to reimburse CRNA's less than docs, you are gonna have a huge amount of lobby money pushing for complete CRNA independence from the insurance companies. Bad idea.

Please explain.

 

[Psai]

Please explain.

If independent nurse anesthetists have lower reimbursement by fiat, then insurance companies will have an incentive to push for independent nursing practice over physician or collaborative practices. They would prefer to reimburse at 85% if the risk profile and other billing issues remained equal (I doubt that this would be the case).

In a hospital based employment model, the hospital would be incentivized to hire more physicians for increased billing, assuming that the per hour financial burden is similar between the provider and the physician.

I think the best way to reduce salary burden is to be able to predict accurately the need for each full time physician and nurse anesthetist so that you don't have people pulling in overtime or relying on expensive locums. But it's difficult to do and people would rather waste time on things that would make less difference such as attempting to decrease turnover time or avoiding "expensive" medications such as iv tylenol.

 

[chocomorsel]

Have they pushed for this independence for midlelves in the IM/FM? Because as @calvnandhobbs68 as stated they already get paid less.
I am a little clueless honestly in other fields outside my own.

 

[MoMoGesiologist]

In our ICUs we have NPs and PAs who take a lot of time to take care of and get to know patients and families. They do a really good job in their subspecialized roles and patients and their families seem to really like and trust them. Meanwhile, the residents have more patients to cover and have to do notes and procedures so we spend much less time with our patients. We just don't build the same rapport and maybe that's our fault. The APRNs will do consents and discuss goals of care or withdrawing care for patients. A lot of the faculty like having them around as they are well trained (vs residents who need to learn the unit) and do a lot of direct patient care.

If I were a patient or my family was in the unit, to be completely honest, I would really value the input of the APRNs who take the time to talk with me vs faculty who seem to disappear after rounds. I understand attendings are smarter and making the big decisions which the NPs/PAs are carrying out, but if we want patients to value doctors and prevent mid level encroachment, it may help to spend more time with our patients despite how busy we may be.

I see it in the ORs as well where CRNAs are spending more time with patients in preop and with surgeons as well intraop building rapport. How can we expect to demonstrate value to patients and surgeons and admin when we are less visible than the nurses? We do hard work and make a lot of saves, but if a tree falls in the forest and no one is around to hear it, who gives a hoot?

 

[Status Sciaticus]

There are already states where this is illegal. 😉

Fair enough, but its not like rules havent been changed before.😉

The second you make it OK to reimburse CRNA's less than docs, you are gonna have a huge amount of lobby money pushing for complete CRNA independence from the insurance companies. Bad idea.

I dont think its as simple as that. Lets look at CRNA independence from a different perspective. If they are independent, they are not practicing on your license. You have more sense of security, and a lower risk of malpractice/lawsuits. You will lose out on more of the ASA1/2 cases, but given our population today, obesity often puts patients into ASA3. The downside is that, in this independent CRNA practice, there will be more adverse outcomes. A few of those will change the tune real quick. Unfortunately, this happens to be the ethical hurdle that physicians cant get over, myself included. But if they are saying that they are truly equal and that CRNA = MD, then they are accountable for taking on that responsibility.

 

[deleted162650]

If independent nurse anesthetists have lower reimbursement by fiat, then insurance companies will have an incentive to push for independent nursing practice over physician or collaborative practices. They would prefer to reimburse at 85%

This. And even scarier than having insurance companies favor mid level care would be having the government favor mid level care. I’m sure MediCare would love to be able cut reimbursement by 15%. Hey why not mandate all ASA 1-2 patients can only be cared for by mid levels?? See where it leads?

 

[nimbus]

I remember reading an article that blamed a surgical backlog at the Denver VA on a shortage of anesthesia providers. They did 350 cases/month with something like 5 anesthesiologists and 8 CRNAs. That sounded crazy to me because in my practice we easily do that with 4-5 anesthesiologists alone.

I work in an area that is primarily MD only. Yet our reimbursement per unit is lower than many parts of the country where most practices use CRNAs. So I don’t see how CRNAs are “cheaper”. We get more done with fewer bodies and less cost to patients and insurers. I’d argue that MD only is cheaper and we still make a decent living.

 

[GravelRider]

Have they pushed for this independence for midlelves in the IM/FM? Because as @calvnandhobbs68 as stated they already get paid less.
I am a little clueless honestly in other fields outside my own.

Some states allow NPs to open up independent primary care practices without a collaborating physician.

https://www.ama-assn.org/sites/default/files/media-browser/specialty group/arc/ama-chart-np-practice-authority.pdf

 

[coffeebythelake]

I remember reading an article that blamed a surgical backlog at the Denver VA on a shortage of anesthesia providers. They did 350 cases/month with something like 5 anesthesiologists and 8 CRNAs. That sounded crazy to me because in my practice we easily do that with 4-5 anesthesiologists alone.

Well I guess it depends what kind of cases they were doing

 

[nimbus]

Well I guess it depends what kind of cases they were doing

They probably do typical VA cases....general, vascular, maybe hearts, ortho. We do all of those plus trauma.

 

[deleted171991]

They probably do typical VA cases....general, vascular, maybe hearts, ortho. We do all of those plus trauma.

You forget that a big VA like Colorado also covers SICU and pain. Plus one doc in preanesthesia testing. And they probably do big cases, unlike the typical VA. Plus the surgeons are way slower than in PP (typically the worst the university hospital can spare). Plus some of the people are part-time (especially in a big academic center).

They definitely had some staffing problems (at least in the SICU), because they were hiring even 2 years ago. And there was some ongoing big-time construction.

Still, only 350...?

 

[Psai]

You forget that a big VA like Colorado also covers SICU and pain. And they probably do big cases, unlike the typical VA. Plus the surgeons are way slower than in PP (typically the worst the university hospital can spare). Plus some of the people are part-time (especially in a big academic center).

They definitely had some staffing problems (at least in the SICU), because they were hiring even 2 years ago.

Still, only 350...?

13 people is double the staffing you need for 350 cases and that's assuming single coverage

 

[ProRealDoc]

In our ICUs we have NPs and PAs who take a lot of time to take care of and get to know patients and families. They do a really good job in their subspecialized roles and patients and their families seem to really like and trust them. Meanwhile, the residents have more patients to cover and have to do notes and procedures so we spend much less time with our patients. We just don't build the same rapport and maybe that's our fault. The APRNs will do consents and discuss goals of care or withdrawing care for patients. A lot of the faculty like having them around as they are well trained (vs residents who need to learn the unit) and do a lot of direct patient care.

If I were a patient or my family was in the unit, to be completely honest, I would really value the input of the APRNs who take the time to talk with me vs faculty who seem to disappear after rounds. I understand attendings are smarter and making the big decisions which the NPs/PAs are carrying out, but if we want patients to value doctors and prevent mid level encroachment, it may help to spend more time with our patients despite how busy we may be.

I see it in the ORs as well where CRNAs are spending more time with patients in preop and with surgeons as well intraop building rapport. How can we expect to demonstrate value to patients and surgeons and admin when we are less visible than the nurses? We do hard work and make a lot of saves, but if a tree falls in the forest and no one is around to hear it, who gives a hoot?

Our CRNAs don't see patients in preop. They are setting up rooms and moving patients in and out of the OR.

 

[ProRealDoc]

I remember reading an article that blamed a surgical backlog at the Denver VA on a shortage of anesthesia providers. They did 350 cases/month with something like 5 anesthesiologists and 8 CRNAs. That sounded crazy to me because in my practice we easily do that with 4-5 anesthesiologists alone.

I work in an area that is primarily MD only. Yet our reimbursement per unit is lower than many parts of the country where most practices use CRNAs. So I don’t see how CRNAs are “cheaper”. We get more done with fewer bodies and less cost to patients and insurers. I’d argue that MD only is cheaper and we still make a decent living.

That's because they all want to go home by 3pm 😉