Opt-out

[Monty Python]

VolatileAgent wrote elsewhere: (i think it was you, trin, who not that long ago said that crna's could practice independently in 28 states. there are only 14 opt-out states. i meant to clear that up in my own mind. am i mis-remembering a statement you made? or, is that recollection correct?)

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This is a very common question, thanks to our wonderful mix of rules from federal and state levels of government (which, of course, never communicate with each other).

The 28 states refers to those areas which essentially give free rein to CRNAs per State Nurse Practice Acts. They are still bound by federal Medicare rules of CRNA supervision to receive federal reimbursement. So in these 28 states you have the BON saying CRNAs may practice independently, yet Uncle Sam says "no way" if you wish to receive Medicare reimbursement. This has no bearing on private pay or charity work.

The 14 states refers to a completely different topic. The 14 opt-out states are a sub-set of the 28 states which give CRNAs independent practice via State Nurse Practice Act, and also have declared themselves by gubernatorial edict to "opt-out" of the supervision requirement. Thus a governor in one of the 28 states which allow independent CRNA practice (by state law) can supercede the Medicare supervision rule which is otherwise required in order to get federal reimbursement. Generally this is found in the boonie states.

None of the above has any bearing nor applicability in the states where state law requires CRNA practice to have supervision. Opt-out is not an option in those states.

These rules are made by the same people who have conjured up the 50,000 pages of the tax code.

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[VolatileAgent]

i think there was a link to the aana website (you posted it one time too) that outlines this.

the confusion is whether or not this represents "de facto" independent practice. i think it is important to understand what this means because of the situation currently occurring in louisiana.

there was also a court case a few years ago in florida where a crna successfully argued in court that he should be able to give general anesthesia in a surgicenter. initially this was upheld, but then overturned on appeal secondary to the case law that appeared to be changing scope of practice dictated by a professional board, which it can't do.

if you have a link to this "28 state" list, i'd like to see it. thanks in advance.

 

[Monty Python]

i think there was a link to the aana website (you posted it one time too) that outlines this.

the confusion is whether or not this represents "de facto" independent practice. i think it is important to understand what this means because of the situation currently occurring in louisiana.

there was also a court case a few years ago in florida where a crna successfully argued in court that he should be able to give general anesthesia in a surgicenter. initially this was upheld, but then overturned on appeal secondary to the case law that appeared to be changing scope of practice dictated by a professional board, which it can't do.

if you have a link to this "28 state" list, i'd like to see it. thanks in advance.

This was emailed to me as an attachment from AANA. I'll try to find a direct link but may take some time. It was 24 states, not 28, sorry.


No Supervision or Direction Requirement (including hospital statutes/regulations)

The following 24 states, and the District of Columbia, have no supervision or direction requirement concerning nurse anesthetists in nurse practice acts, board of nursing rules/regulations, medical practice acts, board of medicine rules/regulations, hospital licensing statutes, hospital licensing rules/regulations, or their generic equivalents:

Alaska Nebraska
California New Hampshire
Colorado New Mexico
Delaware North Carolina
District of Columbia North Dakota
Hawaii Oregon
Idaho South Carolina
Illinois Tennessee
Iowa Texas
Maryland Vermont
Minnesota Washington
Mississippi Wisconsin
Montana

 

[VolatileAgent]

okay, 24. that's ten more than the cms ruling at the federal level.

still begs the question...

what actual impact does this have?

here's why i ask. by virtue of my medical degree, i can perform surgery. that's right. if i went to a private office and decided to cut a lump out of someone's back under a local, nothing's stopping me. i'm perfectly capable of exercising my license (and, i do already have a full, unrestricted license to practice medicine along with my own dea number already despite being a few months from finishing residency) and excising that growth.

however... the real question is would i do this and can i do this? the "would i" is based on the fact that i run the risk of HUGE liability if something goes wrong. chances are i'm not going to be covered by malpractice insurance as it doesn't fall within the scope of my professional training or responsibility.

the "can i" part is a little trickier. this is dependent on whether or not i can get someone to let me do this at their facility, as well as getting some insurance company to pay me for doing it. both huge, if not insurmountable, problems.

so, while i think this makes for some amusing legalese at the state nursing board level, i don't think it amounts to much. in other words, the practicality of "practicing independently" is probably not real. therefore, it seems this is just a moderately interesting regulatory sidenote and not really an area for hotly challeged or contested wrangling with potential practice implications.

or, perhaps you disagree?

i say this because, not only is louisiana not on your list, it's also somewhat of a fluke that, in my estimation, has a narrow chance of clearing the hurdles of the often underestimated levelheadedness of most legislators. just look at what happened in florida.

 

[EtherMD]

okay, 24. that's ten more than the cms ruling at the federal level.

still begs the question...

what actual impact does this have?

here's why i ask. by virtue of my medical degree, i can perform surgery. that's right. if i went to a private office and decided to cut a lump out of someone's back under a local, nothing's stopping me. i'm perfectly capable of exercising my license (and, i do already have a full, unrestricted license to practice medicine along with my own dea number already despite being a few months from finishing residency) and excising that growth.

however... the real question is would i do this and can i do this? the "would i" is based on the fact that i run the risk of HUGE liability if something goes wrong. chances are i'm not going to be covered by malpractice insurance as it doesn't fall within the scope of my professional training or responsibility.

the "can i" part is a little trickier. this is dependent on whether or not i can get someone to let me do this at their facility, as well as getting some insurance company to pay me for doing it. both huge, if not insurmountable, problems.

so, while i think this makes for some amusing legalese at the state nursing board level, i don't think it amounts to much. in other words, the practicality of "practicing independently" is probably not real. therefore, it seems this is just a moderately interesting regulatory sidenote and not really an area for hotly challeged or contested wrangling with potential practice implications.

or, perhaps you disagree?

i say this because, not only is louisiana not on your list, it's also somewhat of a fluke that, in my estimation, has a narrow chance of clearing the hurdles of the often underestimated levelheadedness of most legislators. just look at what happened in florida.

Volatile,

CRNA's are practicing solo in Florida at surgi-centers. I know this for a fact. The AANA is working hard to make this a reality in every state. Is the Specialty of Anesthesiology a field of Medicine? You say "yes" but the AANA and most States view it as "Nursing" as well thus the right of Nursing Boards to stipulate practice parameters for CRNA's.

Do I believe this is correct? No. But, this what the fight between the ASA and the AANA is all about these days . The control of the market place. Despite all the rhetoric, MDA's control the market place currently. The AANA is working hard to change that permanently. First, rural USA and then simple cases at offices and surgi-centers. Next, control of hospitals and medical centers. Ludicrous? We shall soon find out. Does the USA know who is in charge of their Anesthesia? Do they care? Your job and future depends on it.

 

[VolatileAgent]

if crna's are "practicing solo" in florida, then they are violating the law. pure and simple.

http://www.flrules.org/gateway/ruleno.asp?id=64B8-9.009&Section=0

 

[Monty Python]

okay, 24. that's ten more than the cms ruling at the federal level.

still begs the question...

what actual impact does this have?

(snip)

so, while i think this makes for some amusing legalese at the state nursing board level, i don't think it amounts to much. in other words, the practicality of "practicing independently" is probably not real. therefore, it seems this is just a moderately interesting regulatory sidenote and not really an area for hotly challeged or contested wrangling with potential practice implications.

or, perhaps you disagree?

We could probably get 10 people from all walks of life together in a room, and get 10 different answers to that question.

My personal reply is that (a) I'm not a lawyer, (b) despite what others say, I'm essentially laissez-faire when it comes to political activism, (c) I enjoy working with fully-qualified anesthesiologists, and (d) the rules and regs from the various BOMs, BONs, etc say xyz and I just read xyz at face value and carry forth doing xyz. Nothing less, nothing more. I'm certainly not qualified to go around interpreting rules promulgated by my licensing body.

Physicians (not sure if it was specifically anesthesiologists) have been trying to shut down CRNAs since the 1910s-1920s. A handful of court cases said anesthesia was the practice of medicine when performed by a physician, and was the practice of nursing when performed by a CRNA. There was some additional verbage which muddied the waters and has been a source of confusion ever since. I'd bet a six-pack that these waters will still be muddied, with never-ending debate still raging, long after we're all pushing up daisies.

i say this because, not only is louisiana not on your list, it's also somewhat of a fluke that, in my estimation, has a narrow chance of clearing the hurdles of the often underestimated levelheadedness of most legislators. just look at what happened in florida.

Section 9:30 of the Louisiana Nurse Practice Act requires CRNAs to practice under the supervision and direction of an MD/DO or DDS.

My jaundiced view of legislators is that level-headedness takes a back seat (usually) to doing/saying/voting whatever is needed to reassure reelection, with palms greased, paid for, and bought by the biggest spender. My wife is a direct descendant of Huey P. Long's immediate family. Some stories I could tell about politics ...........

 

[VolatileAgent]

My jaundiced view of legislators is that level-headedness takes a back seat (usually) to doing/saying/voting whatever is needed to reassure reelection, with palms greased, paid for, and bought by the biggest spender. My wife is a direct descendant of Huey P. Long's immediate family. Some stories I could tell about politics ...........

in some folks minds, that is the definition of level-headedness. do you think, for example, john edwards has either of our profession's best interest in mind? glad we can agree, at least implicitly and in principle, that it's always about the almighty dollar. screw everything else. right?

 

[EtherMD]

if crna's are "practicing solo" in florida, then they are violating the law. pure and simple.

http://www.flrules.org/gateway/ruleno.asp?id=64B8-9.009&Section=0

Volatile,

Florida law requires MD/DO supervision of CRNA Anesthesia. CRNA's can work without an Anesthesiologist at a surgi-center or office. Florida allows CRNA's to administer 'Mac' Anesthesia in a surgeon's or Gastroenterologist's office.
Of course, the Physician assumes "legal" responsibility for the Medical Care of the patient. The "Anesthesia" is left up to the CRNA.

 

[Monty Python]

Volatile,

Florida law requires MD/DO supervision of CRNA Anesthesia. CRNA's can work without an Anesthesiologist at a surgi-center or office. Florida allows CRNA's to administer 'Mac' Anesthesia in a surgeon's or Gastroenterologist's office.
Of course, the Physician assumes "legal" responsibility for the Medical Care of the patient. The "Anesthesia" is left up to the CRNA.

This brings up another point, which when overlooked can add to the confusion of CRNA supervision/direction/independence (partly to blame is 50 separate and different codes of state law).

Previously posted:

a. 24 states allow (essentially) independent CRNA practice by state law.
b. in those 24 states, Uncle Sam still mandates anesthesiologist supervision of CRNA practice for Medicare reimbursement.
c. governors in those states can opt-out of that requirement.
d. the other 26 states require MD/DO/DDS supervision of CRNA practice

And now, the additional confusing points:

e. no state law anywhere specifically requires CRNA supervision by an anesthesiologist
f. hospital by-laws can (and do) mandate CRNA supervision by an anesthesthesiologist in any state, irregardless of state law.

 

[SleepIsGood]

Trinity-

We're all still waiting for the full name of the Anesthesiologist, and anesthesia group name (with hospital affliation) of the person you accussed didnt know what a LMA was.

Or were you just trying to pull a fast one on all of us again...?

 

[Stimulate]

Anyone else getting sick of CRNA vs MD/DO threads? Doesn't seem like much gets accomplished by these posts. Everyone gets fired up but nothing changes.

I would encourage those of us who are physician anesthesiologists to put our money and efforts where our mouths are. Make appointments with your legislators and explain to them the differences between CRNAs and physicians, explain to them that we only get $60 an hour to anesthetize Medicare patients and that these patients will lose access if cuts continue, educate them on the teaching rule that hurts academic anesthesiology programs, and lastly contribute to your speciality PACs.

If none of these sound appealing call your state society and ask for other ways you can help. We are all very busy but we owe it the specialty and to our patients to ensure that they will have access to safe anesthesia care and that there is funding available to not only pay our salaries but to make further advances in patient safety.

 

[VA Hopeful Dr]

Trinity-

We're all still waiting for the full name of the Anesthesiologist, and anesthesia group name (with hospital affliation) of the person you accussed didnt know what a LMA was.

Or were you just trying to pull a fast one on all of us again...?

Thanks for attemping to derail this thread. I was actually enjoying the discussion of practice laws in the various states.

 

[jwk]

Trinity-

We're all still waiting for the full name of the Anesthesiologist, and anesthesia group name (with hospital affliation) of the person you accussed didnt know what a LMA was.

Or were you just trying to pull a fast one on all of us again...?

Let it go.

 

[opa beleza?]

Acually I think there is some great info comming out here RE: CRNA practice laws that I have not had the chance to learn yet. Thanks, please continue posting.

 

[dhb]

Trinity-

We're all still waiting for the full name of the Anesthesiologist, and anesthesia group name (with hospital affliation) of the person you accussed didnt know what a LMA was.

Or were you just trying to pull a fast one on all of us again...?

He corrected saying it was in fact a supervising MD that didn't know about the LMA (not an anesthesiologist) which is possible but a bit sneaky i agree..

 

[Monty Python]

Anyone else getting sick of CRNA vs MD/DO threads? .

1. My intent with this thread was simply to provide factual regulatory information in direct response to an inquiry from a forum member. No anthill kicking intended.

2. Sleep Is Good, the incident occured at an away hospital where I was working locums for a brief period (on vacation from fulltime job). I was subpoenaed and deposed once. I do not know the current legal status of the litigation. I've not been in further contact with that away hospital. Therefore I will simply say the event happened and I don't know if I have legal liberty to say more. The incident could be in pre-trial settlement talks, pre-trial planning, etc. I just don't know and I don't want to risk violating a gag order which potentially exists.


3. I've received several PMs advising me that I'm not contributing to productive exchange of information. So, I'll respect those folks' opinions as a guest here. Lurk mode on.

 

[VolatileAgent]

well, i don't think you need to just lurk, trinity. you are one of the few even-keeled crna's who actually participates in this forum.

but... i'll still have to disagree, in principle, with a lot of the discussion around the "facts", as confusing as they are, and stick to the following statement:

so, while i think this makes for some amusing legalese at the state nursing board level, i don't think it amounts to much. in other words, the practicality of "practicing independently" is probably not real. therefore, it seems this is just a moderately interesting regulatory sidenote and not really an area for hotly challeged or contested wrangling with potential practice implications.

in other words, what is written and what really happens are, much more importantly, dictated by who's actually willing to pay. and, a large part of that goes hand-in-hand with the potential for litigation, which is the ever present wildcard within the "administrative" part of our screwed-up profession.