"opt out" commonly misunderstood

[Surfer]

I see this misunderstood in academia all over the place. "Opt out" states for CRNA's only applies to medicare reimbursement.

To be clear, CRNA's can and DO practice independently in every state already. They are usually picking the low-lying and lucrative fruit at surgery centers, plastic surgery offices, and Labor and Delivery hospitals. Usually, they are employed by other doctors who skim off the top of their services.

They are more than happy to continue to do the easy, 7-3pm office-based, lucrative anesthesia, while we fight over medicare/medicaid scraps on AAA and and SBO patients. Many of them make well over 200k and havent' worked a night/weekend/holiday since school.

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[Consigliere]

Thank you Captain Obvious.

 

[BuzzPhreed]

Yeah, really. What was the point of the OP? To tell us what we already know?

How about we argue about "captain of the ship" (respondeat superior) doctrine instead and try to figure out who's really liable for those "independently practicing" CRNAs? That'll be a lot more fun.

I'll start:

http://www.vawd.uscourts.gov/OPINIONS/JONES/202CV00043OPN.PDF

 

[Surfer]

sorry didn't realize yall were so smart. i've probably seen half a dozen posts this week alone saying "17 states now allow crna's to practice independently." so not everybody gets it.

 

[Precedex]

Yeah, really. What was the point of the OP? To tell us what we already know?

How about we argue about "captain of the ship" (respondeat superior) doctrine instead and try to figure out who's really liable for those "independently practicing" CRNAs? That'll be a lot more fun.

I'll start:

http://www.vawd.uscourts.gov/OPINIONS/JONES/202CV00043OPN.PDF

Thanks for posting! That was a pretty fascinating read. I wonder what ended up happening. He was not able to get summary judgement so maybe it went to court or more likely got settled out of court. The CRNA evidently died. I love the quote from the anesthesiologist expert witness :

"Well, I didn’t say that. I will say that somewhere along the way, and I may as well just make this statement, maybe this will satisfy everything. The law says the CRNA has got to be supervised. Somebody has to have been supervising this CRNA. I have no clue who was supervising that CRNA. The facts as I understand them are that the anaesthesiologist at this hospital was not even on the premises at the time that this case was performed. I don’t know how you can say that he was supervising this CRNA. Dr. Sheshadri was in the operating room, but he was doing his urology thing, and I don’t know that you could say that he was supervising the CRNA. I think its going to take a bunch of legal minds to figure out who was responsible here because I don’t know. All I know is the law says somebody had to supervise, and as far as I can see nobody was." ​

 

[BuzzPhreed]

sorry didn't realize yall were so smart. i've probably seen half a dozen posts this week alone saying "17 states now allow crna's to practice independently." so not everybody gets it.

They mean in addition to the other states that have already opted-out for a long time now. Hasn't changed much in the big cities. It has in the rural areas. New Mexico for one is a state that is basically run by CRNAs.

 

[BuzzPhreed]

Thanks for posting! That was a pretty fascinating read. I wonder what ended up happening. He was not able to get summary judgement so maybe it went to court or more likely got settled out of court. The CRNA evidently died. I love the quote from the anesthesiologist expert witness :

"Well, I didn’t say that. I will say that somewhere along the way, and I may as well just make this statement, maybe this will satisfy everything. The law says the CRNA has got to be supervised. Somebody has to have been supervising this CRNA. I have no clue who was supervising that CRNA. The facts as I understand them are that the anaesthesiologist at this hospital was not even on the premises at the time that this case was performed. I don’t know how you can say that he was supervising this CRNA. Dr. Sheshadri was in the operating room, but he was doing his urology thing, and I don’t know that you could say that he was supervising the CRNA. I think its going to take a bunch of legal minds to figure out who was responsible here because I don’t know. All I know is the law says somebody had to supervise, and as far as I can see nobody was." ​

Well what makes this interesting is that you'll hear a bunch of CRNAs say that no one else is responsible for their work. Yeah. Right. It doesn't matter what the ultimate outcome was. Getting sued is bad (and costly) enough. And even if this urologist won it doesn't mean that the next guy will get a summary judgment either. Good lawyers will argue each case and each situation are different.

 

[Surfer]

Hospitals have very deep pockets and are thus the biggest buffer for our own job security. Honestly CRNA"s don't care about being sued anymore than we do. We do a good job and understand we might get sued once or twice in our careers and that's just a cost of doing business. But hopsitals don't want to get sued for "not having a board certified anesthesiologist" doing that complicated procedure which ended in catastrophe. This is why so many crna's end up in small office/outpatient settings. Those centers don't have deep pockets and have much less to lose relatively. Not to mention the docs there are skimming off the CRNA's (but then again, so do the anesthesiologists who "supervise.")

 

[Deanmonster]

How exactly does the plastic surgery thing work? Since it's a cash business, I assume the plastic surgeon charges a flat fee and then sends the anesthesiologist or CRNA a check. So he is skimming off the top in a way, but the patient is not being billed for anesthesia separately so there are no "kickbacks." This seems like a more reasonable way to bill to me.

 

[Monty Python]

"Opt out" states for CRNA's only applies to medicare reimbursement.

To be clear, CRNA's can and DO practice independently in every state already. .

Not correct.

CRNAs practice under their particular state's Nurse Practice Act. Approximately 50% of states require CRNAs to work under the supervision and direction (or similar verbiage) of an MD/DO/DDS. CRNAs have independent practice in the other ~50% of states. Local facility bylaws can always be more restrictive than state law, but not less so.

Opt out pertains just to medicare reimbursement, and only in the ~50% of states which already allow independent CRNA practice. It requires the governor to "opt-out." I believe the number of states which has opted-out is in the upper teens. The other ~33 states haven't (or can't) opt-out. Opt-out is not a choice for the governor in states which require MD/DO/DDS supervision of CRNA practice.

 

[BuzzPhreed]

^^^^ This is right.

 

[Baller MD]

So why haven't hospitals in states that have opted out and have nurse independence shifted towards to an all CRNA model since it supposedly saves money? Why do they even have MDs at all? Is it just for liability purposes?

 

[jwk]

So why haven't hospitals in states that have opted out and have nurse independence shifted towards to an all CRNA model since it supposedly saves money? Why do they even have MDs at all? Is it just for liability purposes?

You're assuming the hospital is paying for anesthesia professional services, which they are not in many facilities. If the hospital doesn't employ them, they save nothing since they're not paying in the first place. Subsidies are a different matter, but please - don't think for a second that CRNAs in CRNA-only facilities don't take subsidies.

 

[Baller MD]

You're assuming the hospital is paying for anesthesia professional services, which they are not in many facilities. If the hospital doesn't employ them, they save nothing since they're not paying in the first place. Subsidies are a different matter, but please - don't think for a second that CRNAs in CRNA-only facilities don't take subsidies.

Newb question: what do you mean by this?

 

[Mman]

So why haven't hospitals in states that have opted out and have nurse independence shifted towards to an all CRNA model since it supposedly saves money? Why do they even have MDs at all? Is it just for liability purposes?

Because having anesthesiologists around provides better care for the patients. That's why. You won't find a major medical center that doesn't have anesthesiologists, even in opt out states. I have plenty of friends that work in opt out states providing medical direction.

 

[BuzzPhreed]

Newb question: what do you mean by this?

They expect to be paid to cover OB 24/7/365 just like docs, for example. Doubly-true in a small town or region where these types of groups predominate.

 

[Sirach38]

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