Michigan CRNA's set up Go Fund Me page to raise money for lawyers!

[deleted480308]

also, the legislature has no reasonable way to judge. The hospital/surgeons are in a better position to make judgments about (individual) providers.

We're in full agreement on that much, but I'd go one step farther and say the ultimate responsibility for determining capability for a scheduled surgery (both for surgery and anesthesia) is the patient. I won't choose an independent CRNA based on risk assessment and I wouldn't choose a surgeon who insisted on CRNA independently running my anesthesia.

Lots of people may choose differently but I think it's too risky for me and my family. Even if the states all go CRNA independent and most the hospitals go with them, I'll keep looking for more conservative surgical groups that demand a physician supervising the anesthesia.

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[Aralc]

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[deleted480308]

I agree with you for the most part (and I don't see independent CRNA practice becoming the standard in tertiary care or affluent hospitals). But consider these two points:

The law disagrees that the burden is on the patient to choose competent providers. If the patient makes a mistake in their choice, and it can be proven that the provider was not competent, then the patient has a legitimate claim against that provider. Again, the patient is even less capable than the law (which sets requirements for licensure) in determining medical competence.

My other point is about access. I think the CRNAs make a reasonable point that not every patient and not every hospital can afford "the best." And maybe by limiting practice we are doing those folks a disservice.

I understand your philosophy is the norm, but the idea that the patient isn't ultimately responsible for choices is one of the largest flaws in our system.

And while I understand the concept that CRNAs might make some more people capable of getting some level of care (if only by supply/demand because God knows they don't expect less pay once they go independent) the flaw in this is in not recognizing that the real disservice is in passing off differing levels of skill/education as comparable....it's a lie. And worse still, a lie that leads people to make life and death risks under false pretenses.

 

[deleted480308]

I'll go further and state that if legislators were personally financially/criminally liable for malpractice suits due to which trades were granted practice rights that we would have never heard the phrase "midlevel independence"

 

[Aralc]

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[Aralc]

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[deleted480308]

Haha. Well, honestly, I think an independent CRNA is worth more than a supervised or directed one. They need more clinical skills.

My point was that they will demand the same pay as a physician. It will be just like the NPs did to the FM docs. They'll argue for full practice by claiming cost savings and increased access, then when they get it, the new cry will be "equal pay for equal work"....despite not offering equal work

Anyways, don't think doctors aren't complaining either about salaries. It's just life. Like someone said earlier in the thread- complaining that someone else has found a way to do your job cheaper isn't a negotiating stance. It's just whining.

It's not whining to point out they aren't doing the same work.

 

[Aralc]

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[deleted480308]

In an ideal world the free market would determine salaries (although we know sometimes it takes a while to get there).

We found an agreement!

 

[Man o War]

Correct! So convince the decision makers (which really are hospitals, and by proxy- surgeons) that you are worth more.

As much as I hate to stir the pot again, that is what happened in this case.

Oh, I realized that one thing I forgot in my economic comparisons was that a subsidized solo MD > solo MD. So if an MD wants to be paid more than a CRNA, the solo MD needs to convince the payor that s/he is worth more.

In an ideal world the free market would determine salaries (although we know sometimes it takes a while to get there).

This has always puzzled me, am I flawed in the following thinking? I think independent practice is such a dumb approach for them and I don't get the strategy. Let's say tomorrow someone makes us all equal- meaning you can get a doc or CRNA for the same price. A hospital will choose the doc, all other things being equal. So the docs take the prime jobs at the prime locations and leave the rest for the CRNAs. This displaces a ton of them from "desirable" locations and hospitals.

 

[Aralc]

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[Aralc]

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[pgg]

We're in full agreement on that much, but I'd go one step farther and say the ultimate responsibility for determining capability for a scheduled surgery (both for surgery and anesthesia) is the patient. I won't choose an independent CRNA based on risk assessment and I wouldn't choose a surgeon who insisted on CRNA independently running my anesthesia.

I disagree ... it's not appropriate for us to abdicate that responsibility and delegate it to patients. It may sound paternalistic of me, but patients just don't have the knowledge to make judgments in that regard. They rely on government regulatory bodies, hospitals, and physicians to not set them up for unnecessary risk.

Especially for selfish economic reasons.

Protecting patients from snake oil is the reason we have things like the FDA, licensing boards, and credentialing committees in the first place. You and I are trained and educated in this area and have the sense to insist that physicians are involved in our care. Most patients aren't ... and worse, we have groups like the AANA deliberately trying to blur lines and deceive patients. Many patients aren't even aware that they're not getting doctors. How many times have you seen CRNAs obfuscate their training with a "Hi I'm John from anesthesia" style introduction? If they're lucky, John from anesthesia is at least working in an environment where physicians have screened patients, triaged the schedule, and are available to assist when needed.

To almost all patients, "good" medical care is ease of appointment scheduling, polite receptionists, and the subjective feeling of getting what they wanted or thought they needed. They're completely unable to make objective judgments of whether or not their kid's asthma is being managed optimally, or if they got the correct antibiotic, if the physician's recommendation for no treatment at all / watchful waiting is really better than a more aggressive plan, and so on.

This is why hospital administrators' push to reclassify patients as "customers" and their focus on "customer service" is harmful, and it's why the AANA is so dangerous. The hospitals' sin is excusable; they need to keep the lights on and the doors open, and tying payment to patient satisfaction isn't their idea. The AANA on the other hand has a systematic plan involving outright lies, reasonable sounding half-truths, and calculated omissions to their propaganda that puts their members' economic gain first and patient safety second. They hide behind lip service to patient autonomy and respect, but lobbying to remove physicians from patient care is about the most disrespectful thing a person or organization can do to patients. That really is the long and short of it.

We shouldn't just shrug and throw our patients to the wolves at the AANA.

 

[deleted480308]

I disagree ... it's not appropriate for us to abdicate that responsibility and delegate it to patients. It may sound paternalistic of me, but patients just don't have the knowledge to make judgments in that regard. They rely on government regulatory bodies, hospitals, and physicians to not set them up for unnecessary risk.

Especially for selfish economic reasons.

Protecting patients from snake oil is the reason we have things like the FDA, licensing boards, and credentialing committees in the first place. You and I are trained and educated in this area and have the sense to insist that physicians are involved in our care. Most patients aren't ... and worse, we have groups like the AANA deliberately trying to blur lines and deceive patients. Many patients aren't even aware that they're not getting doctors. How many times have you seen CRNAs obfuscate their training with a "Hi I'm John from anesthesia" style introduction? If they're lucky, John from anesthesia is at least working in an environment where physicians have screened patients, triaged the schedule, and are available to assist when needed.

To almost all patients, "good" medical care is ease of appointment scheduling, polite receptionists, and the subjective feeling of getting what they wanted or thought they needed. They're completely unable to make objective judgments of whether or not their kid's asthma is being managed optimally, or if they got the correct antibiotic, if the physician's recommendation for no treatment at all / watchful waiting is really better than a more aggressive plan, and so on.

This is why hospital administrators' push to reclassify patients as "customers" and their focus on "customer service" is harmful, and it's why the AANA is so dangerous. The hospitals' sin is excusable; they need to keep the lights on and the doors open, and tying payment to patient satisfaction isn't their idea. The AANA on the other hand has a systematic plan involving outright lies, reasonable sounding half-truths, and calculated omissions to their propaganda that puts their members' economic gain first and patient safety second. They hide behind lip service to patient autonomy and respect, but lobbying to remove physicians from patient care is about the most disrespectful thing a person or organization can do to patients. That really is the long and short of it.

We shouldn't just shrug and throw our patients to the wolves at the AANA.

It is paternalistic and while I disagree with you, I completely understand the impulse...

 

[Man o War]

An individual CRNA will get paid more than either a directed or a supervised CRNA.

They are worth more if they are clinically competent in their roles.

And not all hospitals have the luxury of paying premiums for docs.

And frankly, not all cases or anesthesia services need docs and you know it.

I don't know...I've seen more than enough perfectly healthy and "routine" patients/procedures go left and fast. That's why I really can't get to that place where I think it's ok for them to just go ahead and take the ASA 1 and 2s. What about the healthy woman delivering a baby and has an embolus? No way would I want a CRNA calling the shots on that solo.

 

[Aralc]

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[Aralc]

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[Aralc]

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[Man o War]

This is about risk management and resource allocation. The decision makers need to look at how frequently this happens, look at their resources, and decide whether or not it is a good allocation of their resources to spend on an anesthesiologist. The decision makers include surgeons, hospitals, legislators, payors, and to some degree, patients.

This calculation may depend on the resources one has at one's disposal.

Everyone on this board has the resources to afford the "best" and the knowledge regarding where to find it. That is a luxury.

For others, it may not make economic sense, and even may not result in the best health outcomes, to always demand the "best." (If you need an example- if a hospital demands all MDs for anesthesia, they may need to cut something else that could have a bigger health impact).

Do I wish that all my patients could get the $100k latest and greatest treatments available for a two month benefit in survival? Of course I do. But the reality is that someone has to pay for it and sometimes it's just not worth it.

I can't disagree with the cost/benefit analysis, but their claim that their outcomes are the same/will be the same is ludicrous. That's more the rub I have than anything.

 

[Man o War]

Anyways, if docs think it's so important for everyone to have access to an MD, they should take a position in a rural or poor access hospital at the same salary as the solo CRNA.



And this explains your confusion - you assume that a doc and CRNA salary will automatically become equivalent if CRNAs are granted independence.

Why wouldn't it be the same? The doc isn't supervising in that scenario.

 

[Aralc]

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[Aralc]

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[CopaceticOne]

We all know that there are flaws in retrospective analyses, but I think one can reasonably conclude that as long as the hospital is prudent in credentialing, and providers practice within their competency level, that outcomes are not so horrible as to devastate a hospital that chooses to go solo CRNA.

Your arguments are combinations of base rate fallacies, arguments from silence and false equivalence.

 

[Man o War]

We all know that there are flaws in retrospective analyses, but I think one can reasonably conclude that as long as the hospital is prudent in credentialing, and providers practice within their competency level, that outcomes are not so horrible as to devastate a hospital that chooses to go solo CRNA.

I made the point elsewhere that selection bias influences your opinion of competency. A CRNA in a medically directed practice is likely to be less competent than one who is in a successful independent practice.

Now, do I think a freshly graduated CRNA from an average training background is capable of independent practice? No, and likely neither will most credentialing boards.

Ps - I will offer the same advice that I did to Salerme. If you know that you are more clinically competent than a CRNA, the opinion of someone who either is lying or doesn't know any better shouldn't bother you.

That sounds good in theory, but when you spend years watching mid level provider bailing out and then listen to them collectively claim equivalence, it's not quite that cut and dry. I care that patients get competent care as well. Are you a doctor? I'm starting to wonder.

 

[Man o War]

It wouldn't be the same because the doc has an option of going to a supervising or medically directing practice.

Upper limit of doc salary is 2x upper limit of independent CRNA. Approximately.

The CRNA doesn't have the option of that 1:4 supervision model.

So it has to do with market forces. A doc who is really worth more than a CRNA will be able to command a bigger salary. The hospital will either have to pay the doc a premium or the doc will choose a practice where they supervise CRNAs.

I can do the math here and see if I get any better response than I did on Disqus... Say that per unit anesthesia reimbursement is 2X.

For directed anesthesia, CRNA entitled to X and doc entitled to 4X

For solo MD or solo CRNA - both entitled to 2X. MD may be subsidized to some degree because of payor preference (essentially hospital).

I figure that supervised anesthesia falls somewhere in the middle, governed by market forces.

So lower limit of CRNA is X, upper limit is 2X.

Lower limit of MD is 2X and upper limit is 4X.

Just let them go free.

Equivalence means no supervision. Stool sitting to stool sitting. CRNAs aren't cheaper.

 

[Aralc]

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[Aralc]

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[Aralc]

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[CopaceticOne]

Never did I make the argument that a CRNA was equivalent to an MD.

I am making the argument that outcomes with solo CRNA practice can be acceptable. Why?

I think because of case and provider selection bias.

For a hospital without adequate resources, and referring cases beyond the competence available at that hospital, hiring well trained CRNAs who would accept a lower salary than an MD may be an acceptable balance between risk and benefit.

Opinions aren't facts. Since you've conceded that the existing studies are flawed, do the studies between attending level physicians and CRNAs. Let the results be used to practice EVIDENCE BASED MEDICINE.

 

[Man o War]

Look, CRNAs aren't cheaper because those who know enough and can afford to pay will choose the well qualified MD.

Don't be afraid of the solo CRNA- if you are better, you will be paid more.

It's really not about money for me, just pointing out they often claim to be cheaper and they're not. More about never wanting to be emergently shipped to a hospital without docs at all if I have no say because I've been in a car wreck for example. I've known plenty of CRNAs from work who moonlight independently and it frightens me for those patients. So the idea that the hospital will ensure they are safe is absolutely not a reliable safeguard to fall back on.

 

[Aralc]

Opinions aren't facts. Since you've conceded that the existing studies are flawed, do the studies between attending level physicians and CRNAs. Let the results be used to practice EVIDENCE BASED MEDICINE.

You know nobody will ever do that study.

 

[CopaceticOne]

Look, CRNAs are cheaper because those who know enough and can afford to pay will choose the well qualified MD.

Don't be afraid of the solo CRNA- if you are better, you will be paid more.

What you are stating here is that the standard of care, well qualified MD, should not be followed if people don't know better or can't afford it.

 

[Aralc]

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[CopaceticOne]

You know nobody will ever do that study.

If they get grants they will.

 

[Aralc]

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[Aralc]

If they get grants they will.

Maybe we should help fund it.

 

[Man o War]

Medical ethics would never allow the sort of study we need and they know it, so they publish and tout poorly designed retrospective studies that are worthless to anyone who knows anything about study design, power, and statistical significance.

 

[Aralc]

Medical ethics would never allow the sort of study we need and they know it, so they publish and tout poorly designed retrospective studies that are worthless to anyone who knows anything about study design, power, and statistical significance.

I think we were both joking.

 

[Man o War]

I think we were both joking.

But they aren't! Frightening.

 

[Aralc]

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[Aralc]

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[deleted480308]

I was trying to think about this fear.

Yes, I might have an emergency and need to be cared for by a lesser hospital.

But I think I would be glad the hospital was there, and wouldn't want to live my life in general captive to that fear.

Not that we shouldn't try to do everything possible to make outcomes as optimal as possible, but perhaps it's just the realist in me.

And if the nurses came up with a certification that made them legal (not equally skilled, just legal) to work in your specialty, would you be so cavalier with the health of your patient population?

 

[Aralc]

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[GA8314]

Let me put this another way. For anyone who hasn't looked at all my posts and figured out what I do - I am a medical oncologist.

Where do I think the best cancer care happens? Probably at places like MSKCC, MD Anderson, Boston, etc.

But do I think it's possible for the majority of cancer care to be delivered that way? Clearly not- you need the community oncologist for routine cases and for those who don't have the resources to travel cross country for the latest and greatest clinical trials.

Seriously, for people who are truly interested in the best public health outcomes- invest in training the CRNAs.

Seriously, for people who are truly interested in the best public health outcomes-invest in training DNP's in medical oncology.

 

[Aralc]

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[deleted480308]

I don't understand why well trained APPs are such a threat to you.

Yes we train APPs in oncology because it increases access.

They don't get paid as much as physicians, and neither do CRNAs.

A well trained APP improves care all around.

(ignore the online format of this request) look me in the eye and tell me you would support independent nurse oncology with a straight face

 

[Aralc]

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[Man o War]

Well trained mid level providers I don't have an issue with, non supervised independent providers are what I have an issue with.
They aren't a threat to me, they're a threat to patients.

 

[CopaceticOne]

(ignore the online format of this request) look me in the eye and tell me you would support independent nurse oncology with a straight face

Because really... being an oncologist is just following the NCCN guidelines plus some clinical knowledge for symptom management, right? Also, I suppose they would need the ability to search for ongoing clinical trials.
This sort of thinking is the point of most discussions about midlevel providers. It is easy to say that they independently can do the majority of tasks on paper, but in practice is can be a drastically different picture.

 

[Man o War]

Pgg maybe you should just do me a favor and ban me. Clearly I have touched a nerve here.

You know that I don't think MDs and APPs are equivalent.

But a better trained midlevel is better for patient care. That includes having the humility that Man O War referenced when referring cases beyond one's level of competence.

But if the options are nobody or a well trained APP, I'll take the APP.

Don't go away, take this opportunity to learn from docs on the front lines in anesthesiology and advocate for supervision of CRNAs. If you as an oncologist told me it was unsafe for nurses to practice independently in oncology, I would tend to believe that since that isn't my specialty.