What happens if...

[Gator05]

...the governor of your state/President of the United States allows CRNA's to be reimbursed by Medicare?

Loathed topic, yes, but a lot of my classmates keep running into SRNA's at our satellite facility. SRNA's (in the typical ignorance) keep spouting the ever-so-loved line, "we can do anything an anesthesiologist can". Spent 20 minutes tonight explaining the studies, the high salaries of CRNA's, TEE, neuromonitoring, peri-operative care, pain management, fellowship training, differences in clinical/educational experience, etc etc etc.

Spent another 10 minutes explaining mid-level practitioners "entry" into medical practice across nearly all fields of medicine (haven't heard about rads or path yet, but I'm sure it'll come shortly). Jaws were gaping. Eyes were wide-open. Heads were shaking.

Currently, 12 states have opted-out. Looking at Gasnet, there is no major disparity in the number of jobs in Iowa, Washington, or other opted-out states.
To come back to the point, what happens if CRNA's are thus financially and legally permitted to function independently?

My guess is the following:
CRNA salaries are already quite high. I can't imagine them coming down for any reason after such a ruling would be made. MDA salaries would "plummet" to that of CRNAs, perhaps a bit higher. Hospitals then have a choice; they can contract with CRNA's, or with MDA's. From here, it gets murky:
1. It becomes a no-brainer for hospitals to contract with MDA's, since they can market the "increased training" and "safer experience". The MDA's can also provide ICU care, allowing marketing for "decreased ICU mortalities" per the Leapfrog group. (As of now, the billing isn't the same, but it's not too shabby either.) Negotiations can be made with insurance companies to decrease pre-op testing/consults, since this is part of "peri-operative care" inherent to MDA's. Surgeons are happy, because they can spend more time in surgery rather than peri-operative care (see #2 for comparison). The hospital also gets a contract with the MDA's interventional pain management branch. CRNA's invited to work for the MDA's on ASA I/II patients undergoing lower-risk surgery; MDA would "coordinate" up to 4-6 rooms of CRNA's, focusing on pre/post-op care and providing an extra set of hands should something, er, unplanned happen.

2. Dream come true for CRNA's: MDA's are out of the picture completely. CRNA's contract for exclusive care with hospitals, and do so with a vengence. CRNA's market their ability/willingness to do anything the surgeon wants, and their increased numbers. Slightly lower salaries than MDA's. Surgeons assume responsibility, and liability, for CRNA's. Pitfalls ensue during major cases, pre/post-op planning, or whenever things "just don't go right" and another pair of hands is needed. One month of OB wasn't enough to prepare them for ultra-obese pregnant women w/ fetal decels; trial-lawyers salivate. Graduating MDA's beg for sub-100k jobs, usually for positions requiring a fellowship-trained person. Anesthesiologists regret tort reform.

3. CRNA's and MDA's collaborate. MDA's no longer supervise, but coordinate several rooms to smooth turnover/pre/post-op care. CRNA's salaries increase, MDA's decrease to a middle-ground. MDA's take less call while earning less as well, as call can be EQUITABLY distributed. CRNA's work ASA I/II, while MDA's do higher-level cases. Competition for fellowships skyrockets. Conflicts still occur between CRNA/MDA, now about case-asignment. Jobs are harder to find for MDA's, as the "shortage" ends abrubtly. CRNA's now state they can be fellowship-trained, ensuing yet another round of SDN debates. Thankfully for those in the specialty, less than 500 MD's enter into anesthesiology each year due to falling reimbursement/job offers. MDA's gradually go the way of the MD PCP; swallowed up by the US healthcare system.


I'm NOT aiming to debate the benefits/detractors of CRNA's, or whether they will practice with complete independence. Simply a discussion on economic scenarios.

---

Members don't see this ad.

 

[Gator05]

Disclaimer: I have worked with a number of excellent CRNA's, and do marvel at their skills sometimes. These are the older, wiser, more experienced anesthetists, usually military-trained.

The immature, ignorant ones "empowered" by successful, easy cases who brag about "nothing bad ever happening" to them are the ones who leave me shaking my head...

 

[apma77]

ive met surgical PAs who claim they could easily do lap choles, manage ICU patients
ive met NP's who claim they can do everything a family dr can do
ive met CRNAs who dont know why anesthesia needs an MD degree

so on and so on...........


if you are so worried bout CRNA's taking over then do a fellowship in pain or cardiac..that way they are likely not to impinge on your turf

otherwise this is a never ending debate

 

[Leukocyte]

The only way to cut the CRNA supply, is by shuting down their demand. If patients start demanding an Anesthesiologist (THE DIAMOND), instead of a CRNA (CUBIC ZERCONIUM (sp?), then we have won this turf battle.

And yes, ECONOMICALY/practically speaking, there is a competition. People (mostly residents) who say that MDAs are more skilled/knowledgable than CRNA are correct. But in the real world, it is the bread and butter "procedures" that mostly count. Fellowship trained MDAs are still in demand, but are more expensive to hire, and positions that require fellowship trained MDAs are fewer, in comparison, to positions that only need a general Anesthetist. If I was an office based general surgery group that needs 5 anesthetists, I will not hire 5 MDAs, nor will I hire fellowship trained MDAs. I will only hire one general MDA, and 4 CRNAs. Not too long ago, similar businesses were infact hiring 5 MDAs if they needed 5 anesthetists. This means that 4 MDAs who could have gotten the job, did not because the business chose to hire 4 CRNAs I-N-S-T-E-A-D. Yes, a MDA is not equal to a CRNAs, but a competition does exist. Highly specialized anesthesiology does not realy count in the real world of business, since the demand is less in comparison to "beard and butter" anesthesiology.

However, I am still SERIOUSLY considering going into Anesthesia. Turf battles aside, it is a fun field. If I do become a MDA, I will however be an active participant in the "war against CRNA pactice rights expansion".

 

[juddson]

ive met surgical PAs who claim they could easily do lap choles, manage ICU patients
ive met NP's who claim they can do everything a family dr can do
ive met CRNAs who dont know why anesthesia needs an MD degree

Are they wrong?

Judd

 

[InGasWeTrust]

I'll chime in my .02$

I think we(future MD's), are missing the point completely.

The "taking" over by mid level practioners is happening in all fields, not just in anesthesiology.

The real difference is simple, they have a powerful and well funded political lobby. Money talks and bull**** walks, instead of everyone becoming so hype over who is better and who is not, that is not the real issue, the real issue is what happens in D.C. and in state capitols.

Why do you think trial lawyers get the fees and money they do? I will tell you why, their lobby is well funded and well connected.

I think the real solution, and hopefully it will not be too late is to unite across all of medicine through the AMA. One voice people! We need to change our mindset, and say instead of buying this or that I am going to give 3k+ a year to AMA, ASA, and my local PAC.

So until such a time happens, they i.e ALL midlevels have us divided, and easily vulnerable to failure.

This case is not failure of our profession, our incomes, our egos but ultimately our patients.

 

[thegasman]

Ingaswetrust is right. The CRNA lobby fights for their expansion while we are complacent. They use questionable studies and say that "they can do anything an anesthesiologist can" and we do nothing. If we are not there to argue the point and stand up for ourselves, no one else will. Many already believe what the CRNA lobby is preaching.

 

[IsoGirl2707]

So besides giving money to the ASA, AMA, etc, I have been wondering what else we as residents and anesthesiologists can do to get more involved with the pro-anesthesiologist movement?

Well, first of all the AMA has a website that discusses advocacy called the AMA grassroots action center:
http://www.ama-assn.org/ama/pub/category/8659.html

There is also a really good pdf file put out by the ASA on legislative involvement:
http://www.asahq.org/Washington/2003LegislativeInvolvementGuide.pdf

There is also the ASA political action committee (you have to be a member of the ASA to have access but most of us are members anyway):
http://www.asahq.org/government.htm

And there is the resident component of the ASA:
http://www.asahq.org/asarc/index.html

Granted, it is hard to get out and lobby when you are a busy resident or a practicing physician but it can be done. And I guarantee the CRNA's are doing it.

 

[UTSouthwestern]

While rotating at a private hospital, I asked a patient the routine pre-op questions about previous surgeries and complications with anesthesia. Severe PONV, pain, and a brief ICU transfer to a larger hospital for suspected myocardial ischemia were noted separately on two out of four previous trips to the OR. Out of curiosity, I then asked if she knew if her anesthetist was a physician or CRNA and she looked confused: She had assumed that all anesthetics were provided by physicians and none of her previous anesthetists had identified themselves as physicians or CRNA's at the outpatient surgical center she had been to (which I knew employed only CRNA's at that time but has recently changed to provide MDA physician oversight). Out of further curiosity, I asked if knowing which type of provider was to provide her anesthetic was available, would she have had second thoughts about proceeding with her surgery or requested a physician to provide her anesthetic? The answer was yes to both questions.

Are CRNA's a necessary component of anesthesia? At this time yes as there are simply not enough MDA's to cover all cases. Does this mean that CRNA's should be allowed to operate independently and if not what should we as anesthesiologists do about the situation?

This is an issue that has been and will continue to be hotly discussed. At the chief residents' council in Seattle, I spoke with the president of the ASA at length about these concerns.

To keep a LONG conversation short, two things stand out about his response:
1. Our membership and involvement with the ASA is incredibly low and needs to improve both to provide more weight to our arguments and provide more funding to our legal team. (I personally think our legal team needs to be replaced or augmented).
2. Anesthesiologists' reimbursements have yet to be significantly affected in those states that have opted out, however, this is based only on a single year's data.

In other words, we haven't felt a pinch yet, therefore we have not given the ASA enough support to pitch our positions.

Ironically, what was said earlier about midlevel practitioners across the health care spectrum has led the AMA to become more actively involved in these issues and that can only help our position should we ever decide to pool data and support between these two organizations.

The bottom line is that everyone, EVERYONE should become a contributing member of the ASA. $20 is a small price to donate as a resident. A few hundred dollars as a private practitioner even less when you look at the amount of reimbursement you can expect at this time.

There are several initiatives being undertaken by the resident component of the ASA and if you would like to participate or would like to help better organize your state's physicians, please contact the the ASA resident component chair or myself to help us better organize resident efforts. This will translate into better education among current and future residents on these important issues and allow us to present to the public a more organized front on these issues. All of these efforts will give us the opportunity to elucidate our education and training and minimize any attempts to blur the distinction between physician and nurse provider in any field of medicine.

 

[Gator05]

There have been some great posts to this thread. However, the original question concerned scenarios WHEN CRNA's are able to effectively practice with no oversight.

Why WHEN? Because US Healthcare is dominated by politics and money, not sound medical practice. Even with effective lobbying and financing, riders will be slipped through, CRNA-friendly governors/presidents elected, etc etc. It's just a matter of time. Most legislation takes decades to pass through the government; our system is designed this way, to temper any and all changes to government.

UTSW, thanks for the info about not feeling the pinch yet. I think it'll be 5+ years perhaps before a pinch is felt, due to the shortage.

By the by, Pennsylvania has a new "declaration" law which sounds like a great idea. Patients must be told who will be performing their X, their training background, etc. I had thought this to be a standard component of informed consent, but this seems to go a little bit further.