The Ineffectiveness of our ASA Board

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Mman said:
that's why I like the idea of having both models available, but as a specialty if we advocate to get rid of ACT model we are by definition advancing the cause of independent CRNAs.
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But the ASA should not be calling the ACT model the standard. The best care is physician anesthesia. Not supervision.
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Mman said:
No offense, but as a med student I'm not sure you are qualified to weigh in on that topic. I mean do you complain about ICU physicians that cover 16-24 patients at a time? If not, what's wrong with an anesthesiologist covering 3-4 ORs at a time when they include ASA 1 patients and maybe 1 big case? I personally feel that ACT model is the best for me and it's not about money. I'd work for less money. Why? Because I get to do more. I manage more airways, I put in more lines, I put in more blocks. Sitting in a room during a long boring case is not what I trained for a long time to do.
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Not saying you should do all of your own cases, just that CRNAs shouldn't be welcomed in this field by anyone in any way. If you want to let AAs take the easier cases for you, then by all means.
Consigliere said:
I am and he/she is NOT qualified. Some starry eyed, idealistic med student's opinion goes right where I throw my ASA dues statement - directly in the garbage.

I just can't understand the holier-than-thou "I do my own cases" crowd that look down their noses on ACT model anesthesiologists. These group of anesthesiologists deem themselves so high and mighty simply because they sit on a stool, watching an intubated, paralyzed pt. while charting vitals q 5 minutes. They mock ACT anesthesiologists and refer to them in pejorative terms such as "lazy ass freeloaders." I guarantee you I work harder than ANY anesthesiologist who does their own cases. I'm the one putting in all the central lines, doing all the peripheral nerve blocks, seeing every pt. that is going to the OR and devising an anesthetic plan for them, bailing out CRNAs countless times, doing the difficult spinals and intubations, and numerous other activites I've lost the desire to list. A *****....a certifiable IQ-of-65 having ***** can do easy spinals and intubations. In most parts of the USA, the ACT model is the prevalent model and the choice is: ACT practice or unemployment.
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I am far from starry-eyed and idealistic, I assure you.
 
likeaboss said:
copyright 1993...
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My point of the post was that juries view the CRNA as a "nurse" and will look to the "physician" as the person in charge of the case. While there are cases where the CRNA took the entire judgement upon him/herself that is not a typical scenario.

The reasons patients die in the O.R. are usually related to the underlying medical conditions and not the failure of the CRNA to intubate or use Iso vs Sevo. The CRNA is more likely to "go along" and not recognize or properly address a serious co-morbidity which led to the bad outcome. The malpractice attorney will look for the "deep pocket" and the physician in charge of the case.


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Noyac said:
OK I may have started this banter and I apologize. Lazy ass freeloaders was uncalled for.

Please, can we discuss constructively and educate the students and residents without attacking everyone.

Btw, I have worked in both the ACT and the physician only model. I much prefer the physician only model.
Both can be easy and both can be difficult.
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As have I and as do I. Unfortunately, circumstances dictate my current ACT model practice. When you falsely characterized anesthesiologists such as myself as you did, it made me angry. Especially since I realize I am in this situation and can do nothing but make the best of it. Thanks for apologizing though.
 
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MD administered anesthesia is a rare bird that is getting rarer.
 
zero0 said:
Not saying you should do all of your own cases, just that CRNAs shouldn't be welcomed in this field by anyone in any way. If you want to let AAs take the easier cases for you, then by all means.
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Listen, you either support the ACT model or you don't. If you don't, you are furthering the cause of independent CRNA practice. And no, AAs don't "take the easier cases" and neither do CRNAs. We do everything in the ACT model, including pediatric hearts, with great outcomes. You just tailor the supervision ratio (and cases) to the case mix. It's hard/impossible for someone to argue they have a better outcome on a case in MD only when we can do the same case with an MD that never leaves the room and a CRNA/AA along side them. When does that happen? When it needs to. In a bad trauma, we might have 1 doc and 2 or 3 CRNAs/AAs in the room for most of it. There is zero chance that an MD by themselves could do better.
 
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Mman said:
the poster I replied to did not mention an attending preferring to work with a CRNA instead of a resident. They were preferring supervising a CRNA instead of doing MD only care. The word resident wasn't in there anywhere and I don't know how else you'd read it.

So yes, medical students can ask questions. They should. But they also don't have a basis to express shock and disgust that an anesthesiologist might prefer the ACT model to MD only care since they have no relevant experience with either.

I think you probably misread the post I replied to. As to your other point, yes administrators/MBAs can ask questions. Just like students. But if they don't know what they are talking about, they get the same quick correction.

As a profession and specialty, we are basically obligated to fight for the ACT model in this country regardless of your personal preference for that vs MD only care by the sheer math of number of anesthesiologists vs number of surgical procedures done in this country each year. I fully support the idea of groups providing MD only care. I personally don't want to do it as it bores me, but I think it's great that the option is there. We do, however, absolutely positively need the preservation of medical direction of CRNAs by anesthesiologists. There are a lot of bad CRNAs that will kill people if left to their own devices. There are also some good ones that would likely be just fine. But they are fine in the current model, too, whereas the bad ones are protected from hurting people.
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You are right, I did misread his post. However, I stand by my disagreement that he is not qualified to express shock/disgust/concern/whatever with how things are being done. As a medical student, he has invested time and money into the profession and he has not only the qualifications to question how things are done, but a duty to do so...whether he is right or wrong.

And let's not kid ourselves on why the ACT model proliferated. It was not out of a sense of duty to our patients.
 
GravelRider said:
And let's not kid ourselves on why the ACT model proliferated. It was not out of a sense of duty to our patients.
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Perhaps you could research the history for us and report back.
 
Mman said:
Listen, you either support the ACT model or you don't. If you don't, you are furthering the cause of independent CRNA practice. And no, AAs don't "take the easier cases" and neither do CRNAs. We do everything in the ACT model, including pediatric hearts, with great outcomes. You just tailor the supervision ratio (and cases) to the case mix. It's hard/impossible for someone to argue they have a better outcome on a case in MD only when we can do the same case with an MD that never leaves the room and a CRNA/AA along side them. When does that happen? When it needs to. In a bad trauma, we might have 1 doc and 2 or 3 CRNAs/AAs in the room for most of it. There is zero chance that an MD by themselves could do better.
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You just changed the terms.
We (I) were talking about 1:3 or 1:4 supervision.
More skilled hands in the cases you describe is a benefit at times. But tell me, what percent of all cases are in the ctgory you jut described (pedi hearts and massive trauma)?
And I do massive trauma by myself without any issue. Just had one a few nights ago. Maybe some extra hands would make it easier but the outcome was the same.
 
Mman said:
Listen, you either support the ACT model or you don't. If you don't, you are furthering the cause of independent CRNA practice. And no, AAs don't "take the easier cases" and neither do CRNAs. We do everything in the ACT model, including pediatric hearts, with great outcomes. You just tailor the supervision ratio (and cases) to the case mix. It's hard/impossible for someone to argue they have a better outcome on a case in MD only when we can do the same case with an MD that never leaves the room and a CRNA/AA along side them. When does that happen? When it needs to. In a bad trauma, we might have 1 doc and 2 or 3 CRNAs/AAs in the room for most of it. There is zero chance that an MD by themselves could do better.
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Allow me to clarify, I don't have anything against the ACT model. In a lot of ways it is more efficient and, more often than not, runs smoothly. My main issue with it is that it currently relies on a militant branch of midlevels who view themselves as being in direct competition with anesthesiologists. I would much rather prefer to employ midlevels whose exact position in the pecking order is unquestionable and right in their name, i.e. AAs. However, if you're implying that the battle has already been lost and CRNAs are here to stay, then yes, I would rather have them working for anesthesiologists than competing against them, without question.
 
Noyac said:
You just changed the terms.
We (I) were talking about 1:3 or 1:4 supervision.
More skilled hands in the cases you describe is a benefit at times. But tell me, what percent of all cases are in the ctgory you jut described (pedi hearts and massive trauma)?
And I do massive trauma by myself without any issue. Just had one a few nights ago. Maybe some extra hands would make it easier but the outcome was the same.
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ACT model supervision ratios change depending on the case, or at least they should. If you want to argue that you have a better outcome for your patients, surely you aren't arguing that the ASA 1 hernias or lap choles have a lower mortality rate with MD only vs ACT? I mean I assume you'd try to make that argument with the sickest patients, right? But the sickest patients send us to the lowest supervision ratios, 1:1 when necessary.

So you are either arguing you have better outcomes with healthy people having minor procedures when the supervision ratios are highest, or you are arguing you do best with the biggest cases and sickest patients when supervision ratios are the lowest. I'm not changing the terms, I'm pointing out that supervision ratios aren't fixed constants.
 
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zero0 said:
Allow me to clarify, I don't have anything against the ACT model. In a lot of ways it is more efficient and, more often than not, runs smoothly. My main issue with it is that it currently relies on a militant branch of midlevels who view themselves as being in direct competition with anesthesiologists. I would much rather prefer to employ midlevels whose exact position in the pecking order is unquestionable and right in their name, i.e. AAs. However, if you're implying that the battle has already been lost and CRNAs are here to stay, then yes, I would rather have them working for anesthesiologists than competing against them, without question.
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Not all CRNAs espouse the views you believe them to. There are more than a few that are quite happy to have an anesthesiologist around to help provide better care for the patient.
 
Mman said:
Perhaps you could research the history for us and report back.
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I'll get that report out to you right away.

We all agree the ACT model is the reality now and will be the reality going forward. Getting back to the original question of how the ASA is failing us is that there is no concrete definition of what the ACT model is. Much like the perioperative surgical home, they speak in ideals and vague terms. This allows organizations like the AANA or corporate anesthesia practices to bastardize the definition. Is the ideal ratio 2:1, 3:1, 4:1, 8:1, 20:1? Maybe we'll take your ICU example and make it 24:1? Maybe we'll just employ 1 anesthesiologist to "round" in all the ORs during the day and make sure the anesthetic plan is sound? Maybe we can have eORs like the eICUs? Maybe the anesthesiologist covering will review all the charts the night before the cases, lay out an anesthetic plan and then round in the ORs the next day? You see where I'm going with this and the problem people have with the ASA. I'm glad your practice has the ability and flexibility to decrease ratios when needed, but for every practice like yours there is another one like the Kansas City practice in the other thread that has an anesthesiologist around "because they have to." There is no standard put forth by the ASA that would put a stop to that.
 
Mman said:
So you are either arguing you have better outcomes with healthy people having minor procedures when the supervision ratios are highest, or you are arguing you do best with the biggest cases and sickest patients when supervision ratios are the lowest. I'm not changing the terms, I'm pointing out that supervision ratios aren't fixed constants.
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Yes.
 
horsebarn.jpg
 
Seems like some of the young hard-chargers could form an organization that stands for their values (as an ASA-alternative).

I'd pay in.
 
I like my current group because we have the best of both. The call attn will supervise 2 crnas during the day and then take over after the nurses leave. Meanwhile the other attns that are not on call are doing their own cases.
 
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Well the thing is, ASA is severely lacking in funds to do much. Anesthesiologists are barely donating to the pac. Like what the ASA president said during the PGA, if you want to make things better, start doing something. Run for an ASA position or something. the asa people are mostly doing it out of their own time. But yea i think one problem we have as a field is we are ALWAYS on the defensive. We do need to switch that around.

The asa is far from perfect and may not do many things you want them to do. But they do do something, like the recent VA nursing issue. However if people keep encouraging others to not donate to them just because they are 'ineffective' will only harm our field.
 
An ad like this would swiftly eliminate crnas from independent practice
 
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Arch Guillotti said:
Let alone getting them in a place with CRNA's; although it's possible.
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Certainly possible but they have to have the stones to actually do it. It should be like the "Michigan 68". "If you don't do this, we'll walk" followed by "See Ya!!!"
 
pgg said:
Not true.

"ASAPAC is the largest, medical specialty political action committee in the United States."

https://www.asahq.org/advocacy/asapac/faqs
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Except every nursing PAC and the American Hospital Association is on the side of the AANA. Add in the fact that every hospital administrator wants to buy the **** the AANA is selling. They just don't have enough cover. Throw in the fact that some academic anesthesiologists are trying to give it to them.
 
Consigliere said:
As have I and as do I. Unfortunately, circumstances dictate my current ACT model practice. When you falsely characterized anesthesiologists such as myself as you did, it made me angry. Especially since I realize I am in this situation and can do nothing but make the best of it. Thanks for apologizing though.
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As many times as you have sat in front of your computers and called physician only docs, "stool sitters" , and how you like running around supervising and prefer to be at home sleeping with the nurses doing your epidurals at night, and talked about taking advantage of your supervision situation as in more money in your pocket, and much more AND, NOW, NOW??? you wanna change your tune.

You are more than welcome to change your mind as we all grow over time. But don't come here now professing your love for doing your own cases when you have repeatedly bashed physician only models in the past. Please.
 
chocomorsel said:
As many times as you have sat in front of your computers and called physician only docs, "stool sitters" , and how you like running around supervising and prefer to be at home sleeping with the nurses doing your epidurals at night, and talked about taking advantage of your supervision situation as in more money in your pocket, and much more AND, NOW, NOW??? you wanna change your tune.

You are more than welcome to change your mind as we all grow over time. But don't come here now professing your love for doing your own cases when you have repeatedly bashed physician only models in the past. Please.
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I'll do whatever the f_uck I want, thank you very much. Maybe YOU should go back to nursing.
 
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GravelRider said:
Wrong. You won't do whatever the f_uck you want. You are still a pawn in a system that is a lot bigger and more powerful than you. You will only do what the system allows you to do.
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Ok Morpheus.
 
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GravelRider said:
Wrong. You won't do whatever the f_uck you want. You are still a pawn in a system that is a lot bigger and more powerful than you. You will only do what the system allows you to do.
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False. But when it does get to that point (and it will), I'm out.
 
Consigliere said:
I'll do whatever the f_uck I want, thank you very much. Maybe YOU should go back to nursing.
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What the f--- does my nursing background have to do with it? Gave that **** up a decade ago.

Point is, you are a complete sell out when it comes to this. You are all about the money, and YOU'VE repeatedly said so before. All about the supervision scam remember? Putting more money in your pocket. Now all of a sudden, you PREFER doing your own cases. Puhleeze!!! Maybe some AMC is lurking by trying to take over your practice or something. Someone must be coming after your money for you to sing this new tune.

You are a fraud and everyone on this board sees it. So whatever man!!
 
Consigliere said:
False. But when it does get to that point (and it will), I'm out.
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You think you are free to practice however you want, but that is a false sense freedom. Your ability to practice is still dictated by the healthcare economy, regulations, the lifestyle you created for yourself and the level of consumerism you have. Freedom is not inherent in the sense that the more money you have, the more freedom you have. Physicians as individuals or as a collective will never have as much money as the organizations that allow physicians to practice (hospitals, insurance companies, pharma, the gov't) and thus are never really free to practice how they wish. It's why we've seen deterioration of medical practice over the years and why organizations like the ASA seem useless and impotent. We can "win" small fights like the VA battle, but once hospitals, insurance companies, and the government decide that it is in their best interest to allow independent CRNA practice, no amount of donations to the ASAPAC will change their mind.

I won't even go into the ridiculous fact that state medical licenses do not offer universal reciprocity despite having fairly rigorous national standards for medical schools and residencies. And should we bring up MOCA and the nonsense of maintaining board certification? So no, free to practice as you wish is not the reality. You are right that it will only get worse and the older generation is lucky for having practiced with some level of autonomy that those entering medical school now will never experience.
 
dr doze said:
Except every nursing PAC and the American Hospital Association is on the side of the AANA. Add in the fact that every hospital administrator wants to buy the **** the AANA is selling. They just don't have enough cover. Throw in the fact that some academic anesthesiologists are trying to give it to them.
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Yup, they are by far the largest and most powerful minnow in a pool of sharks. My gut says more ASA involvement by current physicians would be a step in the right direction, assuming they are indeed opposed to AMC buyouts and represent our best interests. I can't say I've done the legwork to make sure they're on the up-and-up, but then again my annual fee is only $10 compared to the $1000+ you guys pay.
 
zero0 said:
Yup, they are by far the largest and most powerful minnow in a pool of sharks. My gut says more ASA involvement by current physicians would be a step in the right direction, assuming they are indeed opposed to AMC buyouts and represent our best interests. I can't say I've done the legwork to make sure they're on the up-and-up, but then again my annual fee is only $10 compared to the $1000+ you guys pay.
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I think we have the AANA all wrong. I believe the last time I looked at OpenSecrets.org, the ASAPAC spent more than double the money when compared to the AANA version. The AANA is like [insert small, weak, but vocal United States ally here]. They have some big boy friends like the American Hospital Association, but in the end they are just pawns in a bigger game.
 
chocomorsel said:
What the f--- does my nursing background have to do with it? Gave that **** up a decade ago.

Point is, you are a complete sell out when it comes to this. You are all about the money, and YOU'VE repeatedly said so before. All about the supervision scam remember? Putting more money in your pocket. Now all of a sudden, you PREFER doing your own cases. Puhleeze!!! Maybe some AMC is lurking by trying to take over your practice or something. Someone must be coming after your money for you to sing this new tune.

You are a fraud and everyone on this board sees it. So whatever man!!
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Nah. My practice is rock solid, baby. I would prefer doing my own cases but am in a situation where that is not feasible. Don't hate just cuz The Kid's making fat stacks, yo.
 
GravelRider said:
You think you are free to practice however you want, but that is a false sense freedom. Your ability to practice is still dictated by the healthcare economy, regulations, the lifestyle you created for yourself and the level of consumerism you have. Freedom is not inherent in the sense that the more money you have, the more freedom you have. Physicians as individuals or as a collective will never have as much money as the organizations that allow physicians to practice (hospitals, insurance companies, pharma, the gov't) and thus are never really free to practice how they wish. It's why we've seen deterioration of medical practice over the years and why organizations like the ASA seem useless and impotent. We can "win" small fights like the VA battle, but once hospitals, insurance companies, and the government decide that it is in their best interest to allow independent CRNA practice, no amount of donations to the ASAPAC will change their mind.

I won't even go into the ridiculous fact that state medical licenses do not offer universal reciprocity despite having fairly rigorous national standards for medical schools and residencies. And should we bring up MOCA and the nonsense of maintaining board certification? So no, free to practice as you wish is not the reality. You are right that it will only get worse and the older generation is lucky for having practiced with some level of autonomy that those entering medical school now will never experience.
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That you for that enlightening discourse, professor. It is what it is; better than being unemployed.
 
Consigliere said:
Nah. My practice is rock solid, baby. I would prefer doing my own cases but am in a situation where that is not feasible. Don't hate just cuz The Kid's making fat stacks, yo.
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Why is it not feasible?? You're a partner in a PP.right? What stops you guys from showing all your CRNA's the door and hiring MD's. I know that's not financially ideal but it's certainly feasible.
 
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SaltyDog said:
Why is it not feasible?? You're a partner in a PP.right? What stops you guys from showing all your CRNA's the door and hiring MD's. I know that's not financially ideal but it's certainly feasible.
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It's part inertia, but mostly money. I'd be interested to know if a reasonably sized practice has EVER gone from supervision to MD only.

I know Mman would jump down my throat in a nanosecond if I tried to say I provide better care in my MD only practice, so I won't go there. But I think over the length of a career, one certainly enjoys the day in, day out of the job much more by doing MD only. That's just the vibe I get here and from speaking with friends.
 
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Consigliere said:
Nah. My practice is rock solid, baby. I would prefer doing my own cases but am in a situation where that is not feasible. Don't hate just cuz The Kid's making fat stacks, yo.
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Alright. That's a lot more reasonable. Was that so difficult? I knew you could do it.
You just have never mentioned that you liked your own cases before and knocked us who did prefer it. And now in the course of a week you have said it twice. Just seems weird.

I don't hate on people who make money. Work the system. Cuz it is working you. Long as you ain't hurting no one but the insurance companies. Cuz we all know they want to scam physicians. More power, and make more hay. While you still can. All about those Benjamins man!!! Use those nurses to your advantage.

I wish could supervise and make more money. But I am a terrible supervisor, can't multitask like that. So I continue to do my own cases and not take call and am happier that way. Much happier than putting out other people's fires.
 
I agree with @Southpaw. I bet if you're not running a hardcore 4:1 ratio at all times the income differential would be less than people think too. Maybe the omniscient Blade has some real numbers on that??
 
Southpaw said:
It's part inertia, but mostly money. I'd be interested to know if a reasonably sized practice has EVER gone from supervision to MD only.

I know Mman would jump down my throat in a nanosecond if I tried to say I provide better care in my MD only practice, so I won't go there. But I think over the length of a career, one certainly enjoys the day in, day out of the job much more by doing MD only. That's just the vibe I get here and from speaking with friends.
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Mostly money is the truth. He might make a couple of hundred grand less than what he is now. Plus, most likely where he lives, that's what the practices look like. ACT.
 
For those of you who have been at this for more than 20 years; At what point did it become common for Anesthesia to be delivered in an ACT model? I can't understand this happening in a first world country. In a developing country, yes, but in a country with the resources we have?
 
chocomorsel said:
For those of you who have been at this for more than 20 years; At what point did it become common for Anesthesia to be delivered in an ACT model? I can't understand this happening in a first world country. In a developing country, yes, but in a country with the resources we have?
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The ACT really took off in the late 1970s /early 1980s in the Southern USA. CRNAs were cheap labor back then earning around $35,000 per year. In the early 1990s An Anesthesiologist could bill 150% of Medicare rates (for Medicare patients) for each room he/she supervised up to 4 rooms.
So, back then one could make a fortune covering multiple rooms even with Medicare rates (established in 1992)

One more thing was the fact that Medicare paid relatively well to Anesthesiology prior to 1992 and the RVU system. (the law was passed in 1989 but took effect in 1992).

https://www.nhpf.org/library/the-basics/Basics_RVUs_01-12-15.pdf

The Omnibus Budget Reconciliation Act of 1989 established a Medicare fee schedule for physicians that decoupled Medicare’s payment rates from the physicians’ charges for services. Rather than continuing to pursue a charge-based payment system, a resource-based relative value system was developed
http://www.larkinhospital.com/larki...an-Reimbursement-Past-Present-and-Future1.pdf
 
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chocomorsel said:
For those of you who have been at this for more than 20 years; At what point did it become common for Anesthesia to be delivered in an ACT model? I can't understand this happening in a first world country. In a developing country, yes, but in a country with the resources we have?
Click to expand...

This is a quote from 1988. Please note the Medicare Conversion factor for some areas in 2017 is the same amount as it was in 1988!

A ninety-minute gall bladder operation, for example, on a seventy year-old patient could be worth seven base units, with one extra unit for the patient’s age, plus six time units. Using a typical $20 conversion factor, the anesthesiologist would get paid $280, or $187 on an hourly basis, assuming no time with the patient before or after the operation (which we consider later)

http://content.healthaffairs.org/content/7/4/5.full.pdf
 
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