Lies, More lies and Propaganda

[BLADEMDA]

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Anesthesiologists are gaming the system

By Jay Horowitz - 07/04/13 01:00 PM ET





As the health care reform debate is unfolding in state capitols, we are seeing strong movement towards the fulfillment of the Institute of Medicine’s (IOM) Future of Nursing report. That report endorsed the greater use of Advanced Practice Registered Nurses (APRNs) in solving the issues of workforce, access to care and cost effectiveness, while maintaining or enhancing quality of care.

Certified Registered Nurse Anesthetists (CRNAs) are among the APRN groups that are an important part of this solution. They are not, however, seeking "expanded practice" or a new scope of practice or reimbursement mechanisms. CRNAs, as they have throughout history (preceding anesthesiologists), administer anesthesia in the same places and utilize the same techniques as their physician counterparts and do so cost effectively, with no compromise in quality of care, according to two recent studies in the peer-reviewed journals “Health Affairs” and “Nursing Economics”.



These facts have historically lead to an almost continuous turf battle, all centered on reimbursement. The current environment serves only to promote a new intensity to this conflict, as organized medicine feels increasingly threatened. The evidence is clear, patient safety is not an issue. It never has been.


As part of a compromise that led to CRNAs being the first advanced nursing group to obtain direct reimbursement from federal agencies in the 1980s, a novel billing scheme emerged. This system allowed anesthesiologists to recoup double the revenue by “medically directing” (sometimes referred to as “supervising”) as many as four CRNAs, than they would by personally administering an anesthetic. To bill for this “medical direction” the anesthesiologist must meet seven criteria. Failing to meet even one of these criteria makes a claim submitted for “medical direction” fraudulent. Recently a $1.2M settlement was reached between the University of California-Irvine and the federal government over exactly this type of fraudulent billing. This is the tip of the iceberg.











Now, even in light of this settlement (or perhaps more correctly, because of this settlement), the American Society of Anesthesiologists (ASA) wishes to relax the federal rules for reimbursement. Instead of meeting the current requirement for being “immediately available”, a patient in the operating room could have an anesthesiologist who is farther away than that–a specific distance or time “impossible to define”, and this would still be considered “supervising.” This is all too reminiscent of the situation in Minnesota in the 1990s when anesthesiologists were billing for medical direction–from the golf course! This led to a $10M+ settlement and institution of corporate integrity policies. (Perhaps it’s time for ASA to review those policies?) Yet, everything old is new again when trying to protect one's turf.


To make this whole issue even more absurd are two recent studies published in the journal “Anesthesiology,” the official publication of the ASA, and “Anesthesia & Analgesia.” In one, communications with “supervising” anesthesiologists were evaluated revealing that less than 2 percent of such communications originated from those being “supervised” in the OR. In the other, the authors revealed significant lapses in the ability to meet the accountability rules as the number of “medically directed” CRNAs increased – lapses which occurred 99 percent of the time! The study also identified a 22-minute delay when anesthesiologists try to meet the guidelines in order to properly bill for medical direction. With Medicare anesthesia provider reimbursement at a rate of $1.43 per minute, and perhaps millions of such delays every year, the waste of Medicare dollars adds up very quickly, even when the criteria can be met. But this is only a small part of the inherent economic fiasco. While patients waits for an anesthesiologist, the standard Operating Room charges are also accumulating at a rate of $25-50 per minute!


In contrast with the above, and with a philosophy similar to the IOM report, the United States Air Force recently updated its policies for the provision of anesthesia services. The policy states that collaboration among anesthesia providers, independent of specific training background, is the preferred practice model. Unlike the civilian market, there is no financial incentive or profit motive involved in providing anesthesia services to our military heroes and their families, just the desire to provide safe and efficient care.


The solution to this problem is exquisitely simple. The president, via his HHS Secretary, must eliminate reimbursement for medically directed anesthesia claims other than those incurred when teaching students or residents. All anesthesia professionals privileged to relieve pain and suffering should actually administer anesthetics. As a society we simply cannot afford to have highly trained anesthesiologists, whose residencies are financed by taxpayers, “supervising”. If a procedure requires multiple anesthesia providers due to surgical acuity or complexity, the current regulations provide for full reimbursement. The system currently incentivizes inefficiency without any gain in quality or safety, and potentially pays for services not rendered. This change eliminates the waste of millions or even billions of taxpayer-supported health care dollars and the submission of fraudulent claims. This would force anesthesia departments to become more efficient and allow all Americans to receive the same high level of care as our military heroes.

Horowitz, CRNA, ARNP, practices in Florida.


Read more: http://thehill.com/blogs/congress-b...iologists-are-gaming-the-system#ixzz2YLuoAFOE
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[BLADEMDA]

In Florida 75% of all practices bill "QZ" which means the terms of Medical Direction were not met or the CRNA did the case with minimal supervision.

Medicare doesn't save a dime whether Medical Direction occurs or QZ. This means the "system" doesn't save a dime by allowing CRNAs to anesthetize sick patients alone. Since the whole premise of this article is about "gaming the system" one can clearly see the only group actually ripping off the government is the solo CRNA. The cost to train and educate a CRNA is a fraction of that of an Anesthesiologist. Hence, a CRNA should be at least 1/3-1/2 cheaper than an Anesthesiologist as that is the entire argument of the AANA/CRNA profession. Then why does the govt. reimburse an Independent CRNA at the same fee structure as a Board Certified Anesthesiologist?

The Propaganda of this article is quite obvious if one examines the cost structure of CRNA reimbursement. It is the CRNA who is gaming the system and doing it quite well.

 

[IDBasco]

Tell the author. This audience knows the score.

 

[aneftp]

What I don't understand is why CRNAs are against AAs?

Hmmm. Don't AAs (most of whom have a science background with their 4 year degree) and 2 years anesthesia school.


Isn't that similar to CRNAs with a nursing degree and 2-3 years of CRNAs school?

But but but CRNAs will say they have one year of critical care experience. And that makes them much much more qualified.

And CRNAs say MDs have 3 years anesthesia training which is the same as many Crna programs.

The sad part is CRNAs have a much stronger lobbying entity. It always easier for a "nursing organization" to lobby for more power than an MD.

What I am particularly concerned about is the AANA neglects they are graduating so many SRNAs. Many of whom game the systems themsleves. It used to be nurses would work 5-10 years than decide to go to Crna school and become Crna around age 30-35. Those CRNAs have real world experience.

Now you got young breeds who know the system. They will have their BSN degree age 22. Work on year in ER/ICU than finish Crna school by age 26. A 26 year old Crna has almost no life experience and AANA neglects to tell the public they want those CRNAs to practice solo as well.

A 30 year old newly minted anesthesia attending has far more hours of training and education compared to the 26 year old Crna.

Why doesn't the ASA push this onto the public? The AANA simply won't have a response for this. It's so clear cut the public can understand 26 year old vs 30 year old.

Sure a Crna with 10-15 year experience can have excellent skills and I trust them. Many have years and years of knowledge. But the AANA makes no distinction in their push for independent practice.

While we all know newly minted MDs from anesthesia residency can fly on their own right away.

 

[24858]

Why are we training these bastards at all anyway? Lets stop Srnas training and replace them with residents and aas. This is why I am pushing people to go to one of their monthly state anesthesia chapter meetings and have put on the schedule getting aas the right to practice in their state.

 

[ferning]

Crabs in a barrel

Why dont you guys see the forest from the trees, where almost 3 trillion in healthcare expenditures end up?

Labor with healthcare utility shouldnt be arguing, or fighting over scraps like a pair of wild dogs.

Take a step out of your egocentric situation and look critically at the greater healthcare economic scheme, 3 trill is bankrupting society and its not going to docs or nurses. Labor has no cost in so far that it provides its own ongoing capital. Yet capital alone cannot because it needs labor to turn into something with utility and adds productive value to the intial capital through human ingenuity and sweat.

passive investors and those who provide no labor utility in our healthcare system suck both of you dry as well as society.

Healthcare is a societal need like a fire department, you allow it to be monetized and private investors in and what do u expect?

There was a short period in american history when this was done with fire departments, but it lasted a minute cause when the guy on one end of the block couldnt foot the bill the guy at the other end lost his house too because of the spread. Healthcare is the same, but it just isnt such an immediate and violent cause & effect like a fire.

 

[Shimmy8]

My wife is a MICU nurse with 5 years of experience in MICU at a very high acuity university hospital in the South...patients are sick as hell. She LAUGHS at the thought of any nurse being able to pursue grad school (NP or CRNA) without at least 5 years of critical care experience.

She also cringes at a few of her younger colleagues who have been accepted to CRNA school.

Sample size and all, but still.

 

[Perrotfish]

nvm

 

[aneftp]

My wife is a MICU nurse with 5 years of experience in MICU at a very high acuity university hospital in the South...patients are sick as hell. She LAUGHS at the thought of any nurse being able to pursue grad school (NP or CRNA) without at least 5 years of critical care experience.

She also cringes at a few of her younger colleagues who have been accepted to CRNA school.

Sample size and all, but still.

Tell that to AANA. We all know that.

Like I said. There are young folks who going into college wanting to be Crna and knowing the system. They will be CRNAs by time they are 26 years old.

 

[aneftp]

Crabs in a barrel

Why dont you guys see the forest from the trees, where almost 3 trillion in healthcare expenditures end up?

Labor with healthcare utility shouldnt be arguing, or fighting over scraps like a pair of wild dogs.

Take a step out of your egocentric situation and look critically at the greater healthcare economic scheme, 3 trill is bankrupting society and its not going to docs or nurses. Labor has no cost in so far that it provides its own ongoing capital. Yet capital alone cannot because it needs labor to turn into something with utility and adds productive value to the intial capital through human ingenuity and sweat.

passive investors and those who provide no labor utility in our healthcare system suck both of you dry as well as society.

Healthcare is a societal need like a fire department, you allow it to be monetized and private investors in and what do u expect?

There was a short period in american history when this was done with fire departments, but it lasted a minute cause when the guy on one end of the block couldnt foot the bill the guy at the other end lost his house too because of the spread. Healthcare is the same, but it just isnt such an immediate and violent cause & effect like a fire.

Easier said than done. Way too many interested parties. Like the mafia. The health industry will kill people before they let go of that cash.

Physician income make up less than 9% of total health expenditures. When I was in med school in mid late 90s that number was 17%.

Even accointing for physician own practices and surgery centers physician income (total) probably accounts for less than 20% of total health care spending. But those physicians have overhead like leases, staff and equipment to pay for.

So the real adjusted physician income in 2013 is probably anywhere between 13-15% of total health care spending.

Its big hospital. Big pharma. Devices makers and insurance who make up the vast majority of the 75% of bloated cost. Management companies make up the other 10% (my guess).

 

[BLADEMDA]

Tell that to AANA. We all know that.

Like I said. There are young folks who going into college wanting to be Crna and knowing the system. They will be CRNAs by time they are 26 years old.

In my State of Florida you can graduate high school with an AA degree. This means when you are 18 years old the State grants you a high school diploma and then the community college your AA degree. By the time you are 20 some are RNs. I have worked with a 24 year old CRNA. Quite a few more are only 25 years old.

So, all this talk of experienced critical care nurses is B.S. in my State. Most have just a year or two of critical care experience and are not CCRNS.

 

[BLADEMDA]

Crabs in a barrel

Why dont you guys see the forest from the trees, where almost 3 trillion in healthcare expenditures end up?

Labor with healthcare utility shouldnt be arguing, or fighting over scraps like a pair of wild dogs.

Take a step out of your egocentric situation and look critically at the greater healthcare economic scheme, 3 trill is bankrupting society and its not going to docs or nurses. Labor has no cost in so far that it provides its own ongoing capital. Yet capital alone cannot because it needs labor to turn into something with utility and adds productive value to the intial capital through human ingenuity and sweat.

passive investors and those who provide no labor utility in our healthcare system suck both of you dry as well as society.

Healthcare is a societal need like a fire department, you allow it to be monetized and private investors in and what do u expect?

There was a short period in american history when this was done with fire departments, but it lasted a minute cause when the guy on one end of the block couldnt foot the bill the guy at the other end lost his house too because of the spread. Healthcare is the same, but it just isnt such an immediate and violent cause & effect like a fire.

Why is society reimbursing the CRNA the same as an Anesthesiologist? How can the AANA/CRNA claim to be saving the system money while charging almost identical anesthesia fees for their services? When you get an Advanced Practice Nurse the costs should be significantly less than a Physician. This is simply not the case.

Medicare needs to cut CRNA fees to 1/2 the usual amount if an Anesthesiologist is not performing medical direction. Then and only then can the author of this letter claim he is saving the system money.
Hence, the AANA needs to put up or shut up on this topic. It is time to expose the AANA power and money grab to the public and legislators.

If Society believes Anesthesia is a nursing level profession not requiring medical supervision by a Board Certified Anesthesiologist Physician then the fee structure should reflect it. Nursing level duty deserves nursing level pay. This is exactly how our military handles it and CMS should follow their example.

 

[ferning]

Easier said than done. Way too many interested parties. Like the mafia. The health industry will kill people before they let go of that cash.

Physician income make up less than 9% of total health expenditures. When I was in med school in mid late 90s that number was 17%.

Even accointing for physician own practices and surgery centers physician income (total) probably accounts for less than 20% of total health care spending. But those physicians have overhead like leases, staff and equipment to pay for.

So the real adjusted physician income in 2013 is probably anywhere between 13-15% of total health care spending.

Its big hospital. Big pharma. Devices makers and insurance who make up the vast majority of the 75% of bloated cost. Management companies make up the other 10% (my guess).

Dude its less like 5-6%, less than any other modern healthcare system in the world. Plus docs pay things like SS, medicare, and income tax which goes back into their pot. Now factor in a new doc with 250k in debt being paid to the fed with interest on top of all those taxes.

A passive investor only pays the 15-20% capital gains tax when they take it out of the market and when they do you can be sure its in a way the gains are offset to zero

And its not "easier said than done", you just do it if you got a problem with it or make some constructive moves. These complaints dont address root causes of your issues. Most CRNAs like most conscientious people dont want more responsibility than they can handle, and this is just a puppet union leader. Corps want to farm out them without the doc if they can.

Whining about the crna does nothing, form a union like they have and maybe you cries will actually be heard. Docs were banned from forming unions based on antitrust acts but now that crna's and other apns are paid the same as well as act independently then there is no basis for saying docs have a monopoly on medicine. In australia, a labor oriented country, docs have unions and dont can put there money where there mouth is. They make more and work less at this point in time compared to us, residents make almost 100k there.

 

[Mman]

In contrast with the above, and with a philosophy similar to the IOM report, the United States Air Force recently updated its policies for the provision of anesthesia services. The policy states that collaboration among anesthesia providers, independent of specific training background, is the preferred practice model. Unlike the civilian market, there is no financial incentive or profit motive involved in providing anesthesia services to our military heroes and their families, just the desire to provide safe and efficient care.

I'm calling BS on that one. The military has huge financial incentives to provide cheap care. They have no money. They get cuts left and right all the time. They try to get by with the bare minimum for everything including their own medical care.

You can't say there is "no financial incentive or profit motive" for military medical care. There is huge incentive. Even more than in private practice because they are footing their own bill. Bold faced lie just like the rest of the article. The fact that things can get printed in media without any sort of fact checking is amusing to say the least.

 

[aneftp]

Dude its less like 5-6%, less than any other modern healthcare system in the world. Plus docs pay things like SS, medicare, and income tax which goes back into their pot. Now factor in a new doc with 250k in debt being paid to the fed with interest on top of all those taxes.

A passive investor only pays the 15-20% capital gains tax when they take it out of the market and when they do you can be sure its in a way the gains are offset to zero

And its not "easier said than done", you just do it if you got a problem with it or make some constructive moves. These complaints dont address root causes of your issues. Most CRNAs like most conscientious people dont want more responsibility than they can handle, and this is just a puppet union leader. Corps want to farm out them without the doc if they can.

Whining about the crna does nothing, form a union like they have and maybe you cries will actually be heard. Docs were banned from forming unions based on antitrust acts but now that crna's and other apns are paid the same as well as act independently then there is no basis for saying docs have a monopoly on medicine. In australia, a labor oriented country, docs have unions and dont can put there money where there mouth is. They make more and work less at this point in time compared to us, residents make almost 100k there.

U can't compare the us to other systems.

It's very well known they have morning "tea breaks" in the Australian operating rooms. What US hospital allows tea breaks in the Am that slows down the schedule?

Many US docs own their own facility and surgery centers. They collect profit from these facilities unlike foreign practices where its very hard to set up your own shop.

US docs will screw each other. Groups compete within group practices. Their is no solidarity within ones group. And companies know this and take advantage of it

 

[deleted126335]

Why is society reimbursing the CRNA the same as an Anesthesiologist? How can the AANA/CRNA claim to be saving the system money while charging almost identical anesthesia fees for their services? When you get an Advanced Practice Nurse the costs should be significantly less than a Physician. This is simply not the case.

Medicare needs to cut CRNA fees to 1/2 the usual amount if an Anesthesiologist is not performing medical direction. Then and only then can the author of this letter claim he is saving the system money.
Hence, the AANA needs to put up or shut up on this topic. It is time to expose the AANA power and money grab to the public and legislators.

If Society believes Anesthesia is a nursing level profession not requiring medical supervision by a Board Certified Anesthesiologist Physician then the fee structure should reflect it. Nursing level duty deserves nursing level pay. This is exactly how our military handles it and CMS should follow their example.

Very few CRNAs actually bill as independent contractors. Most of the time they sign away their billing rights to their employer. Be it a doc controlled anesthesia group, a hospital, an AMC, a GI center. This is true even when they practice without an anesthesiologist.

The model will be to employ all the anesthesia providers, collect all the fees, and then figure out the cheapest relatively safe staffing model.
A.K.A. "How few Anesthesiologists can we get away with?"

How much hamburger helper can we get away with in the meat before people really start to notice?
How much water can you add to light beer before people really balk at drinking it?

 

[Mman]

Very few CRNAs actually bill as independent contractors. Most of the time they sign away their billing rights to their employer. Be it a doc controlled anesthesia group, a hospital, an AMC, a GI center. This is true even when they practice without an anesthesiologist.

The model will be to employ all the anesthesia providers, collect all the fees, and then figure out the cheapest relatively safe staffing model.
A.K.A. "How few Anesthesiologists can we get away with?"

How much hamburger helper can we get away with in the meat before people really start to notice?
How much water can you add to light beer before people really balk at drinking it?

I agree. I think the system we are heading toward is a system with higher and higher supervision ratios to the point where the MD is just around to bail out the CRNA screwups. How high of a ratio could you be and still be safe? Not sure. Depends on the people. If I can pick out who does what case and have a quality stable of CRNAs I could probably do 6:1 without much safety dropoff. 8:1 would be pushing the limits of sanity and I have no desire to just be a fireman fixing other people's f-ups. Other of my colleagues can barely scrap by at 3:1.

 

[Baller MD]

I keep holding on to this (false?) hope that anesthesia will change with regards to the CRNA problem since I am seriously considering going into it. But threads like these just keep putting the nail on the coffin. =(

 

[BLADEMDA]

Very few CRNAs actually bill as independent contractors. Most of the time they sign away their billing rights to their employer. Be it a doc controlled anesthesia group, a hospital, an AMC, a GI center. This is true even when they practice without an anesthesiologist.

The model will be to employ all the anesthesia providers, collect all the fees, and then figure out the cheapest relatively safe staffing model.
A.K.A. "How few Anesthesiologists can we get away with?"

How much hamburger helper can we get away with in the meat before people really start to notice?
How much water can you add to light beer before people really balk at drinking it?

That is not the model the author was advocating in his Article. Instead, he was advocating the military collaborative model where CRNAs are not supervised by an Anesthesiologist. Instead, each provider does his/her own case. This means some patients get an Anesthesiologist while others get a CRNA. The author states there is no difference in the care being delivered to the patient.

If the CRNA needs help the author may be willing to allow one Anesthesiologist to serve as a "fireman" for all the anesthettics in that facility. The author states this will save money for the government. However, increased morbidity and additional consults will likely eat up any cost savings in such a model.

Again, if this field is indeed an advanced nursing level duty not requiring the expertise of a Board Certified Anesthesiologist then society should reimburse it as such. However, I know that more patients will die and suffer under such a non physician based model and the additional costs of Solo CRNA care for our ASA 3 and 4 patients will end up costing society even more money.

 

[BLADEMDA]

Here is the Author's exact wording:

All anesthesia professionals privileged to relieve pain and suffering should actually administer anesthetics. As a society we simply cannot afford to have highly trained anesthesiologists, whose residencies are financed by taxpayers, “supervising."

 

[Silent Cool]

That is not the model the author was advocating in his Article. Instead, he was advocating the military collaborative model where CRNAs are not supervised by an Anesthesiologist. Instead, each provider does his/her own case. This means some patients get an Anesthesiologist while others get a CRNA. The author states there is no difference in the care being delivered to the patient.

If the CRNA needs help the author may be willing to allow one Anesthesiologist to serve as a "fireman" for all the anesthettics in that facility. The author states this will save money for the government. However, increased morbidity and additional consults will likely eat up any cost savings in such a model.

Again, if this field is indeed an advanced nursing level duty not requiring the expertise of a Board Certified Anesthesiologist then society should reimburse it as such. However, I know that more patients will die and suffer under such a non physician based model and the additional costs of Solo CRNA care for our ASA 3 and 4 patients will end up costing society even more money.

So med students shouldn't go into anesthesia then. Or am I missing something.

 

[BLADEMDA]

So med students shouldn't go into anesthesia then. Or am I missing something.

Where did I say you shouldn't go into anesthesia? All of medicine is headed towards socialized medicine circa 2018-2020. Obamacare is so expensive and will increase health insurance so much that the public will demand another system in just a few short years.

 

[deleted126335]

Here is the Author's exact wording:

All anesthesia professionals privileged to relieve pain and suffering should actually administer anesthetics. As a society we simply cannot afford to have highly trained anesthesiologists, whose residencies are financed by taxpayers, “supervising."

That may be the author's vision. But absent major federal no-fault tort reform, I think that it is far less likely than the "how few docs can we get away with" model.

 

[BLADEMDA]

So med students shouldn't go into anesthesia then. Or am I missing something.

Med Students choosing "Gas" need to understand the anesthesia problem. We are the front lines against the militant nurses who want the pay and prestige of being a doctor without going to medical school or doing a residency.

If you enter anesthesia be prepared for 25 year old nurses to claim equivalency with you. Be prepared for DNAP CRNAs claiming nurses deliver equal care to a board certified Anesthesiologist. You must also understand that the majority of anesthettics are performed by CRNAs or AAs who are supervised by Anesthesiologists.

More and more outpatient centers are hiring their own anesthesia staff and keeping the anesthesia revenue leaving the providers only a fraction of their collections. More AMCs are going the CRNA supervision model (minimal supervision) to keep costs down. These AMCs are also keeping a significant portion of the anesthesia revenue or charging the hospitals a large stipend.

Many older Anesthesiologists are selling their companies and bailing out of the business. This means there will be fewer and fewer good private practice jobs in the future. They will exist but most likely in isolated areas or smaller markets.

Now add to all our current problems the issue of Obamacare. I believe Obamacare was a Trojan horse leading us towards Medicare for all. Research what Medicare for all means to anesthesia and you will realize this means your future job is a hospital employed doctor or working for an academic center.

There are other specialties with equal or worse problems than anesthesia. But, there are others which will likely fare much better. So, look long and hard before jumping into bed with the specialty.

 

[BLADEMDA]

That may be the author's vision. But absent major federal no-fault tort reform, I think that it is far less likely than the "how few docs can we get away with" model.

We agree here. The trend will be 5:1 or 6:1 supervision with more CRNA autonomy as you can't supervise well at 6:1.

 

[bigeyedfish]

Blah blah blah. Ill tell you the same thing i tell my residents. I wish we would all be seen as equals and let the chips fall where they may. It would be the worst thing possible for the crna profession. With equal reimbursement from the payers is the hospital going to fire the mds and keep the nurses? Hell no! You're going to have a ton of out if work crnas. Nurses will see that and stop wanting to pay the 50k a year tuition for crna school. That will make a lot of people unhappy.

Some mds will make less money. But pay is going down anyway!

I work at a facility with about 80 crnas. Some of them would love for us to be equivilent but I think most want no part of it. Out if the 80 about 5 could think their way out of a paper bag. The vast majority neither want to nor are they capable of making their own decisions.

 

[Spinach Dip]

My (overly-simplistic) solution:

1. Allow CNAs to provide care without MD supervision.

2. Allow CNAs to be sued for malpractice.

3. Let the chips fall.

 

[pgg]

My (overly-simplistic) solution:

1. Allow CNAs to provide care without MD supervision.

2. Allow CNAs to be sued for malpractice.

3. Let the chips fall.

Here's the problem with that. When the SHTF and the call goes out for 'available anesthesia to room 12 stat' is the MD in the lounge going to go help, or pick up the other half of his bagel and let the patient die?


I work and have worked in a number of settings where the CRNAs do their cases without direction or supervision, and the anesthesiologists do their cases: multiple military hospitals, and a couple of rural hospitals in an opt-out state.

And here's what happens in the real world. An anesthesiologist makes the schedule and triages the low risk cases to the CRNAs, which goes a long way toward keeping events rare ... and when complications or crises arise in a CRNA room, whoever's available goes to help, because as doctors we don't like it when patients die.

The AANA can publish crappy studies in crappy journals showing "no difference" because even in these "independent" practice environments, they're really not independent and they really don't take care of all comers, from the 20-year-old skinny appy in the ER to the 80-year-old septic SBO with pulmonary hypertension in the ICU.

To "let the chips fall" as you put it, you'd need a scheduling anesthesiologist willing to give the appy to the physician and the SBO to the CRNA, and then keep his feet up in the lounge when the mayday call goes out, and that won't ever happen because no anesthesiologist is going to start letting patients die to make a rhetorical point.


You'd have better luck getting your IRB to sign off on a well designed prospective study randomizing unsupervised no-backup anesthesia care to CRNA vs physician. Except you'd never get any CRNAs to participate, and you'd never get any patients to consent.

 

[jjoo915]

.

 

[ferning]

U can't compare the us to other systems.

It's very well known they have morning "tea breaks" in the Australian operating rooms. What US hospital allows tea breaks in the Am that slows down the schedule?

Many US docs own their own facility and surgery centers. They collect profit from these facilities unlike foreign practices where its very hard to set up your own shop.

US docs will screw each other. Groups compete within group practices. Their is no solidarity within ones group. And companies know this and take advantage of it

You can and should compare the US to other systems, on this issue at least. If not you can still compare the US now to the US 10-20 years ago when this doc % was not as low and healthcare as a % of gdp was not as high. That increase is due to private passive investors sucking money out of patients and our society.

And isnt there a moratorium on new surgery centers? Meaning New ones cant be built. Excessively lucrative surgery center owners already makes up a small minority of physicians as it is, so I dont see how that in anyway lessens my point.

And why is it so horrible a doc have a "tea break" or any other type of "break" at work? High patient load and limited patient contact is clearly detrimental as it is. A break for reflection could do the following patients a world of good.

 

[BLADEMDA]

You can and should compare the US to other systems, on this issue at least. If not you can still compare the US now to the US 10-20 years ago when this doc % was not as low and healthcare as a % of gdp was not as high. That increase is due to private passive investors sucking money out of patients and our society.

And isnt there a moratorium on new surgery centers? Meaning New ones cant be built. Excessively lucrative surgery center owners already makes up a small minority of physicians as it is, so I dont see how that in anyway lessens my point.

And why is it so horrible a doc have a "tea break" or any other type of "break" at work? High patient load and limited patient contact is clearly detrimental as it is. A break for reflection could do the following patients a world of good.

Perhaps a Glass of Wine like the French would help many of us get through the day?😀

 

[jwk]

My (overly-simplistic) solution:

1. Allow CNAs to provide care without MD supervision.

2. Allow CNAs to be sued for malpractice.

3. Let the chips fall.

Dude - I think you're on our side - at least learn some facts.

CRNA's (not CNA's) already administer anesthetics without MD supervision.

They can be sued for malpractice.

 

[BLADEMDA]

Physician anesthesiologists are fighting for quality care and patient safety

By John M. Zerwas, M.D. and Jane C.K. Fitch, M.D. - 07/08/13 12:00 PM ET





The fight for the physician-led anesthesia care team is not about a turf battle, reimbursement or gaming a system. It’s a commitment to protect quality care and patient safety. The stories of two patients and our personal experience illustrate why when seconds count, physician anesthesiologists save lives.

Some have suggested we move to a model removing the physician-led team and have cited the Air Force as the paradigm. We disagree. Consider the tragic case of Air Force Staff Sgt. Dean Witt. He was hospitalized for what should have been a routine appendectomy at Travis Air Force Base. Following his surgery, Witt experienced breathing difficulties. The nurse anesthetist overseeing his anesthesia care made “mistake after mistake after mistake” (Stars and Stripes, Is the Feres Doctrine Fair?, June 19, 2011), including inserting a breathing tube into his stomach instead of his airway depriving his brain of oxygen and using resuscitation equipment designed for children. Left in a permanent vegetative state, the 25-year-old Witt died three months later when his family removed him from life support.

Or consider the system in place for most patients. When a young woman experienced cardiac arrest during childbirth due to an amniotic embolism -- a rare, but often deadly condition where amniotic fluid enters the mother’s bloodstream -- physician anesthesiologist Patrick Allaire, M.D., of Ames, Iowa, saved her life. He immediately placed a breathing tube, administered medication to restart her heart and instructed the care team to begin chest compressions. The mother had an emergency Cesarean section and Dr. Allaire cared for her throughout the day and night. Dr. Allaire’s quick response saved both mother and child and the mother has called him her daughter's guardian angel.


We know many physician anesthesiologists who are former nurse anesthetists, including one of us, and can speak to this issue firsthand. Beginning my career as a nurse anesthetist, I, Dr. Fitch, recognized the limitations of my training when it came to providing comprehensive care for my patients. I chose to attend medical school to complete my education and became a physician anesthesiologist.

Despite the significant improvements in the safety of anesthesia, every surgery and procedure carries risks, and there is no way to predict when a routine case will turn bad. When seconds count, when medical emergencies or complications occur, physician anesthesiologists draw upon their extensive medical education, years of clinical training and experience to make critical decisions that can and do save lives.

We recognize and appreciate that nurses are an integral part of the anesthesia care team. And when physician anesthesiologists and nurses work together, patients receive the high-quality and safe anesthesia care they deserve. Nursing skills are important and nurses are trained to administer anesthesia, but their education does not come close to the advanced medical education, training and clinical experience of physicians.

Physician anesthesiologists have 12,000 to 16,000 hours of education compared to nurse anesthetists' self-reported median of 1,651 hours. The difference goes beyond hours to the depth of training provided.

A physician anesthesiologist's education covers the medical management of the entire human body and all of its systems as well as pain medicine, critical care medicine and, of course, every aspect of the administration of anesthesia, before, during and after surgery.

A scientific study published in Anesthesiology on behalf of the Agency for Healthcare Research and Quality (AHRQ) – the nation’s leading federal agency for research on health care quality, costs, outcomes and patient safety – found that the presence of a physician anesthesiologist prevented 6.9 excess deaths per 1,000 cases in which an anesthesia or surgical complication occurred.

Nurse anesthetists often advocate cost and quality of care issues, but there are no definitive, independent studies that indicate they can ensure the same quality of care, patient safety and outcomes when working alone.

In fact, the cost to Medicare of physician anesthesiologists and nurse anesthetists are no different with payments the same regardless of who performs the procedure. If anything, eliminating the physician anesthesiologist can actually increase costs as other physicians may be needed to consult or provide the services a physician anesthesiologist would.

Quality of care and patient safety matter above all. Because of nurses’ limited education and training, it’s too risky to allow nurse anesthetists to administer anesthesia without the supervision of a physician.

We became physician anesthesiologists to obtain the skills needed to provide patients with the best possible care. All patients deserve no less. We’re certain the Witt family and Dr. Allaire’s patient would agree.

Zerwas is president of the American Society of Anesthesiologists. Fitch is president-elect of the American Society of Anesthesiologists and a former CRNA

Read more: http://thehill.com/blogs/congress-b...quality-care-and-patient-safety#ixzz2YVRwG9HG
Follow us: @thehill on Twitter | TheHill on Facebook

 

[aneftp]

The issue is the AANA is promoting "cheaper cost, safe care"

That's all the public hears.

The ASA needs to get off their high horse and slam the AANA for wanting to push 25-26 year old new Crnas into independent practice.

They need to inform public Medicare pays the same and Crnas who are in independent practice working same hours make the same money as their MDs.

 

[Spinach Dip]

Here's the problem with that. When the SHTF and the call goes out for 'available anesthesia to room 12 stat' is the MD in the lounge going to go help, or pick up the other half of his bagel and let the patient die?


I work and have worked in a number of settings where the CRNAs do their cases without direction or supervision, and the anesthesiologists do their cases: multiple military hospitals, and a couple of rural hospitals in an opt-out state.

And here's what happens in the real world. An anesthesiologist makes the schedule and triages the low risk cases to the CRNAs, which goes a long way toward keeping events rare ... and when complications or crises arise in a CRNA room, whoever's available goes to help, because as doctors we don't like it when patients die.

The AANA can publish crappy studies in crappy journals showing "no difference" because even in these "independent" practice environments, they're really not independent and they really don't take care of all comers, from the 20-year-old skinny appy in the ER to the 80-year-old septic SBO with pulmonary hypertension in the ICU.

To "let the chips fall" as you put it, you'd need a scheduling anesthesiologist willing to give the appy to the physician and the SBO to the CRNA, and then keep his feet up in the lounge when the mayday call goes out, and that won't ever happen because no anesthesiologist is going to start letting patients die to make a rhetorical point.


You'd have better luck getting your IRB to sign off on a well designed prospective study randomizing unsupervised no-backup anesthesia care to CRNA vs physician. Except you'd never get any CRNAs to participate, and you'd never get any patients to consent.

Of course, no provider should choose a bagel over saving a life (even one with cream cheese!). As I said, it was overly-simplistic.

My point was, if we make CRNAs and MD/DO anesthesiologists equivalent (which is what CRNAs CLAIM to want), no one would pick CRNAs because of the massive increase in liability.

(Heck, even the CRNAs would probably take one look at their malpractice insurance premiums and have a sudden change of heart.)

Dude - I think you're on our side - at least learn some facts.

CRNA's (not CNA's) already administer anesthetics without MD supervision.

They can be sued for malpractice.

OF COURSE I meant CRNA. Stupid typo on my part.

I'm also aware that there are different laws state-by-state. Unfortunately, I can't keep track of them all.

 

[pgg]

My point was, if we make CRNAs and MD/DO anesthesiologists equivalent (which is what CRNAs CLAIM to want), no one would pick CRNAs because of the massive increase in liability.

Well sure, but that can't and won't happen.

And if wishes were horses, we'd all be eating steak. 🙂

 

[Stank811]

Many of the comments illustrate that the graduating CRNA from mills all across the country are young and weak. The are not being trained to do anything except the most basic of cases and procedures...there are just not enough resources to give all the graduating anesthesiologist and CRNAs the number of cases and procedures needed to be independent. And of course the physician resident get priority so until they change something in regards to the volume CRNAs graduating every year this will continue to be their weak point.

 

[BLADEMDA]

The Hypocrisy of the militant CRNA becomes crystal clear when one compares the surgicenter vs the hospital.

1. AANA claims the CRNA saves the "system" money if the government allows the Advanced Management practice Anesthesia Nurse to practice Independently. Even though the govt reimburses at the same fee rate as a Board Certified Anesthesiologist most private payers only reimburse 70-80% of the usual medical direction rate. The AANA plan is to place all Anesthesiologists in rooms alongside their CRNA equals. This will save the hospital money by reducing or eliminating the stipend. The AANA seems very concerned about the $1-1.5 millon million stipend (on average across the USA) that the poor hospital CEOs must pay to keep all the services they demand. But, by eliminating medical supervision the AANA thinks the stipends would go away. However, there would be a big price to pay for this elimination of supervision in terms of lost revenue from private payers and increased morbidity/mortality. Hospital CEOs know that is true as do many Surgeons.

2. The majority of CRNAs at surgicenters are employees of an Anesthesiology Group or the center itself (W-2, 1099). If the CRNA is employed at the GI center or Surgicenter then those Physicians are making huge sums of money off the anesthesia reimbursement. I know of several centers where the Physician owners are making over $1 million in profit (that is after paying the CRNAs) from the anesthesia services. These CRNAs are paid $85-$100 per hour while generating $600-$900 per hour in collections. The Physician owners keep the difference. Where is the AANA on this issue of "ripping off the system"? Now, when you calculate the number of surgicenters vs hospitals across the USA one quickly realizes that all the stipends for anesthesia could be completely ELIMINATED if the AANA supported a law where the anesthesia profits from the surgicenter went to the local hospital and NOT into the pockets of non anesthesia providers. Why is it that the AANA has been silent on this issue?
Why is it "independent practice" only refers to the administration of anesthesia and NOT the revenue of the field?


You already know the answer.

 

[Pooh & Annie]

I wonder what the mistake/adverse outcome self-report rate is for CRNAs. For anesthesiologists the rate is relatively high and contributes to global quality improvement. Does the AANA encourage these reports or do they like to keep that info under wraps to avoid criticism of their policies?

 

[Mman]

we all know how they feel about saving the system money when the topic of the rural pass-through comes up. Essentially subsidizing CRNA salaries in random locations so they can be hired instead of MDs.

 

[epidural man]

Crabs in a barrel

Why dont you guys see the forest from the trees, where almost 3 trillion in healthcare expenditures end up?

Labor with healthcare utility shouldnt be arguing, or fighting over scraps like a pair of wild dogs.

Take a step out of your egocentric situation and look critically at the greater healthcare economic scheme, 3 trill is bankrupting society and its not going to docs or nurses. Labor has no cost in so far that it provides its own ongoing capital. Yet capital alone cannot because it needs labor to turn into something with utility and adds productive value to the intial capital through human ingenuity and sweat.

passive investors and those who provide no labor utility in our healthcare system suck both of you dry as well as society.

Healthcare is a societal need like a fire department, you allow it to be monetized and private investors in and what do u expect?

There was a short period in american history when this was done with fire departments, but it lasted a minute cause when the guy on one end of the block couldnt foot the bill the guy at the other end lost his house too because of the spread. Healthcare is the same, but it just isnt such an immediate and violent cause & effect like a fire.

👍

 

[jwk]

The Hypocrisy of the militant CRNA becomes crystal clear when one compares the surgicenter vs the hospital.

1. AANA claims the CRNA saves the "system" money if the government allows the Advanced Management practice Anesthesia Nurse to practice Independently. Even though the govt reimburses at the same fee rate as a Board Certified Anesthesiologist most private payers only reimburse 70-80% of the usual medical direction rate. The AANA plan is to place all Anesthesiologists in rooms alongside their CRNA equals. This will save the hospital money by reducing or eliminating the stipend. The AANA seems very concerned about the $1-1.5 millon million stipend (on average across the USA) that the poor hospital CEOs must pay to keep all the services they demand. But, by eliminating medical supervision the AANA thinks the stipends would go away. However, there would be a big price to pay for this elimination of supervision in terms of lost revenue from private payers and increased morbidity/mortality. Hospital CEOs know that is true as do many Surgeons.

2. The majority of CRNAs at surgicenters are employees of an Anesthesiology Group or the center itself (W-2, 1099). If the CRNA is employed at the GI center or Surgicenter then those Physicians are making huge sums of money off the anesthesia reimbursement. I know of several centers where the Physician owners are making over $1 million in profit (that is after paying the CRNAs) from the anesthesia services. These CRNAs are paid $85-$100 per hour while generating $600-$900 per hour in collections. The Physician owners keep the difference. Where is the AANA on this issue of "ripping off the system"? Now, when you calculate the number of surgicenters vs hospitals across the USA one quickly realizes that all the stipends for anesthesia could be completely ELIMINATED if the AANA supported a law where the anesthesia profits from the surgicenter went to the local hospital and NOT into the pockets of non anesthesia providers. Why is it that the AANA has been silent on this issue?
Why is it "independent practice" only refers to the administration of anesthesia and NOT the revenue of the field?


You already know the answer.

Facts simply are not the concern of these malignant CRNA's. I'm trying to point this out currently on one of the nursing forums - it's a simple fact that if you personally do a Medicare case, or a CRNA personally does a Medicare case, the payment from Medicare would be identical. Where is the savings when using a CRNA alone? There is none.

 

[BLADEMDA]

Facts simply are not the concern of these malignant CRNA's. I'm trying to point this out currently on one of the nursing forums - it's a simple fact that if you personally do a Medicare case, or a CRNA personally does a Medicare case, the payment from Medicare would be identical. Where is the savings when using a CRNA alone? There is none.

Emperor Has No Clothes Award. Mr. Horowitz, author of the propaganda piece, deserves the award.

 

[ferning]

Not disagreeing with point that healthcare professionals should clearly identify themselves so as to not portray their training as more or different than it is

But I have to ask about your experience with interns or residents who I've gauged are encouraged to portray themselves as an attending, or at least not a physician in training at some academic institutions. I think I might have a skewed view, but many places have pt care for all practical purposes governed by residents/interns with nominal oversight. And im not talking a highly knowledgable senior resident, who sometimes can have a better knowledge base than some attendings.

Have any of you as a resident at least have an opinion? As this is kind of the pot calling the kettle black, if you require crnas clearly define their eduational background through their title but not interns or resident physicians.

You may have a license after 1 yr but you are not board certified and if you werent in a training program you wouldnt have the hospital priveleges to engage in the pts care. Plus most people will assume you say doctor, you mean you are done training. Which is really what dictates these things, people assumptions

And I bring up cause my school is already propagandizing students in standardized patient encounters to call themselves "student doctor" rather than "medical student" with your grade penalized for not doing so. An ambiguous, imprecise title is encouraged to be used for what reason I can only speculate.

In these exercises students are encouraged (in plain language and gradewise) to speak to the patient and explain treatment plans, work up as if they were the attending. If you are uncertain (because it is outside your knowledge base and are still early in training where you should be uncertain) speaking as if you are yields a better overall grade for the encounter.

being ok with uncertainty is discouraged and being honest takes a back seat in these exercises, although its a pretend situation why should you be any less honest?

The most frightening thing about medicine to me is how confident many attendings are about dx, workup, tx, prognosis when they shouldnt after I read up on cases and supporting research.

I know basically all formal education lacks a critical thinking component and medicine is no exception, but encouraging the practice of medicine without its application is social hazard.

 

[deleted126335]

Not disagreeing with point that healthcare professionals should clearly identify themselves so as to not portray their training as more or different than it is

But I have to ask about your experience with interns or residents who I've gauged are encouraged to portray themselves as an attending, or at least not a physician in training at some academic institutions. I think I might have a skewed view, but many places have pt care for all practical purposes governed by residents/interns with nominal oversight. And im not talking a highly knowledgable senior resident, who sometimes can have a better knowledge base than some attendings.

Have any of you as a resident at least have an opinion? As this is kind of the pot calling the kettle black, if you require crnas clearly define their eduational background through their title but not interns or resident physicians.

You may have a license after 1 yr but you are not board certified and if you werent in a training program you wouldnt have the hospital priveleges to engage in the pts care. Plus most people will assume you say doctor, you mean you are done training. Which is really what dictates these things, people assumptions

Never thought about it, but it is a completely valid point. What's good for the goose is good for the gander. Housestaff should identify their level of training on their ID, PGY1, 2, etc. As long as the same goes for doctor, excuse me, physician wannabees.

 

[ferning]

ID's arent really the main mode of discommunication, just identifying yourself as Dr. So and so (like being a DNP and doing it) carries the assumption by patients you are done training. Most times, and its probably institution dependent as i rotate through several,its explained to the patient whats going on and that their attending will confer before follow through. But sometimes theres no mention of an attending (because the attending may only confer from a distance)

So it should be in my opinion resident physician or intern, and Dr for full fledged attendings as thats what patients assume when you say that. And of course nurse anesthesia. Phd degrees have no clinical bearing in a hospital and DNPs which is based basically a social science curriculum, need to clearly identify themselves as something other than " Dr." or add an addenum while patients still assume that means physician. Patients dictate these rules, they are already afforded the right to know who their healthcare providers are and their training. Or else we are back to quacks and snack venom salesman

But I suspect some academic attendings who depend heavily on the academic portion of their salary to subsidize the clinical component through residents may let crnas call themselves board certified dr so and so if it means they will have to do more work if the resident identification portion of this change requires it

 

[BLADEMDA]

Examination of the Horowitz hit piece:

1. Horowitz advocates for a collaborative practice of CRNAs and Anesthesiologists. But, how many of each would be needed for each facility? What is the proper ratio of CRNA to MD in such a model?
How many Anesthesiologists would be needed to deal with emergencies and what is their exact role in the care of patients?

2. Do you have any evidence in tertiary hospitals that switching to a non supervisory role would maintain patient safety and care as it currently exists? With most independent CRNAs practicing in rural USA or surgicenters there isn't a lot of data to make statements of safety and quality in our aging surgical population.

3. How do we know the system would save money by not having a supervising Anesthesiologist available to help with unplanned emergencies, line placement, difficult intubations, etc. Perhaps, in some institutions (like mine) morbidity and mortality would increase as a result of such a system. Is the risk of a longer ICU stay or a dead patient worth the supposed cost savings?

An honest discussion entails examining our entire health care system including how anesthesia revenue is used to line the pockets of non anesthesia providers. In addition, an advanced practice nurse should not be reimbursed the same as a Physician as that defeats the benefit of utilizing midevel providers.

I have no doubt that some experienced CRNAs can practice independently with excellent results. That said, I also have no doubt that the majority of CRNAs can not and should not be allowed to practice without Anesthesiologist supervision. Until the AANA recognizes and formally differentiates amongst its membership the most prudent course of action is to maintain supervision for all CRNAs. Fortunately, the majority of hospitals have such bylaws on its books.

 

[deleted126335]

ID's arent really the main mode of discommunication, just identifying yourself as Dr. So and so (like being a DNP and doing it) carries the assumption by patients you are done training. Most times, and its probably institution dependent as i rotate through several,its explained to the patient whats going on and that their attending will confer before follow through. But sometimes theres no mention of an attending (because the attending may only confer from a distance)

So it should be in my opinion resident physician or intern, and Dr for full fledged attendings as thats what patients assume when you say that. And of course nurse anesthesia. Phd degrees have no clinical bearing in a hospital and DNPs which is based basically a social science curriculum, need to clearly identify themselves as something other than " Dr." or add an addenum while patients still assume that means physician. Patients dictate these rules, they are already afforded the right to know who their healthcare providers are and their training. Or else we are back to quacks and snack venom salesman

But I suspect some academic attendings who depend heavily on the academic portion of their salary to subsidize the clinical component through residents may let crnas call themselves board certified dr so and so if it means they will have to do more work if the resident identification portion of this change requires it

Patients do not dictate these rules. Patients certainly have the right to know the credentials of those taking care of them, but that usually takes an affirmative step of inquiry. It has only become an issue as doctors (real ones) have recently pushed back agianst mid level misrepresentation. Note the language usage by AANA: physician anesthetist, MDA, referring to CRNA trainees as "residents" I just recently heard the term nurse anesthesiologist thrown out. The whole CRNA-PhD, or DNAP is about (mis)representing equivalence. Legislative efforts in individual states and at the local hospital level are underway to prevent non MD or DO or DDS or DPM from using the term "doctor". These efforts are virulently opposed by advanced practice nursing organizations who wish to confuse the public.

Keep fighting.

 

[jwk]

Nice rebuttal by Drs. Zerwas and Fitch...

http://thehill.com/blogs/congress-b...-fighting-for-quality-care-and-patient-safety

 

[sevoflurane]

Nice rebuttal by Drs. Zerwas and Fitch...

http://thehill.com/blogs/congress-b...-fighting-for-quality-care-and-patient-safety

👍

Yep. Just found it in my inbox. Very true.