Why don't you use AA's, the PA of anesthesia

[Maverikk]

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I want to get some feedback, why doesn't your practice use AAs. With the right training they're just as competent as CRNAs without the attitude and militancy from what I've seen. I'm in training, my goal is to have an independent practice, I figure a MD+AA model is cheaper and offers the same things as an MD+CRNA model. For those who utilize AAs, what's the learning curve like, I'd be happy with a practice where it required more MDs hands on training/work hours of AAs rather than the negative attitude I get from CRNAs. I think the new generation of MDs who are sick of the militia would take a slightly less pay if meant training people who were on their team (I know I would)

 

[deleted126335]

Too few out there. Got like one inquiry from an AA in ten years. If I were an AA, I would prefer to be in a practice that already had a few.

 

[deleted171991]

Plus they are not licensed to work in 2/3 of the states (yet!).

 

[IlDestriero]

Proper hiring of CRNAs will help a militancy problem. Make sure at the interview, or pre interview, that the position is for a care team member and that they are expected to be part of a team and not work, or hope to work independently any time in the future.: That should keep away the independent minded dreamers.
If you screen for it, put it in the contract, and council in writing any issues you have, firing someone FOR CAUSE should not be a problem.
Our CRNAs are fine, they knew what they were getting into and were happy to get the job here.
The issues we have had were with overall attitude and whining, not militancy.

 

[kazuma]

Proper hiring of CRNAs will help a militancy problem. Make sure at the interview, or pre interview, that the position is for a care team member and that they are expected to be part of a team and not work, or hope to work independently any time in the future.: That should keep away the independent minded dreamers.
If you screen for it, put it in the contract, and council in writing any issues you have, firing someone FOR CAUSE should not be a problem.
Our CRNAs are fine, they knew what they were getting into and were happy to get the job here.
The issues we have had were with overall attitude and whining, not militancy.

This is definitely helpful as the vast majority of CRNA's, especially newly minted ones from shady programs, do not want to work independently and are woefully prepared to do so. However, I would prefer to do my own cases for at least my first five years out.

With the AANA flooding the market with new grads, it will drive down salaries. But eventually I could see nurses not wanting to take on med-school-like debt for diminished returns on their investment. Perhaps I'm naive, but I have a difficult time imagining a hospital/administrator/CEO wanting to hire a CRNA over an anesthesiologist if the salaries are somewhat comparable. Anesthesiologists will likely not have any problems obtaining employment in the future, but it will depend on how hungry you are and how low of a salary you are willing to accept for this line of work. Kind of depressing to think about it that way, but at least we can hope for relative job security. I like anesthesiology, so even though the golden days over, I can still wake up every morning and do something I enjoy.

 

[jwk]

I want to get some feedback, why doesn't your practice use AAs. With the right training they're just as competent as CRNAs without the attitude and militancy from what I've seen. I'm in training, my goal is to have an independent practice, I figure a MD+AA model is cheaper and offers the same things as an MD+CRNA model. For those who utilize AAs, what's the learning curve like, I'd be happy with a practice where it required more MDs hands on training/work hours of AAs rather than the negative attitude I get from CRNAs. I think the new generation of MDs who are sick of the militia would take a slightly less pay if meant training people who were on their team (I know I would)

Not sure what the concern is about a learning curve with AA's. It's no longer than our new CRNA's. We hire newly minted AA's and CRNA's. They all get the same orientation period and start taking call at the same time. At least at our place, orientation is primarily a way for the new folks to get used to us and the way we practice, and starting to get a handle of how private practice works compared to an academic center. Learning surgeon personalities and demands, and how to move things along in a fast-paced practice comprises much of our orientation.

If you need any information about AA's or how to integrate them into your current practice, please don't hesitate to PM me.

 

[deansrv72]

This is definitely helpful as the vast majority of CRNA's, especially newly minted ones from shady programs, do not want to work independently and are woefully prepared to do so. However, I would prefer to do my own cases for at least my first five years out.

With the AANA flooding the market with new grads, it will drive down salaries. But eventually I could see nurses not wanting to take on med-school-like debt for diminished returns on their investment. Perhaps I'm naive, but I have a difficult time imagining a hospital/administrator/CEO wanting to hire a CRNA over an anesthesiologist if the salaries are somewhat comparable. Anesthesiologists will likely not have any problems obtaining employment in the future, but it will depend on how hungry you are and how low of a salary you are willing to accept for this line of work. Kind of depressing to think about it that way, but at least we can hope for relative job security. I like anesthesiology, so even though the golden days over, I can still wake up every morning and do something I enjoy.

Hey kazuma,
The AANA has nothing to do with the number, or quality of SRNA/CRNA graduates. It has all to do with the program(s) itself, the higher-ups of said program(s), and the COA. And what JWK has said, is pretty much on point.

 

[jwk]

The AANA has nothing to do with the number, or quality of SRNA/CRNA graduates. It has all to do with the program(s) itself, the higher-ups of said program(s), and the COA.

There's a lot of debate about that, even among CRNA's, even though technically the AANA, COA, and NBCRNA are separate organizations. Two of the three still operate under the same roof - if I remember correctly, all three did until recently.

 

[BLADEMDA]

There's a lot of debate about that, even among CRNA's, even though technically the AANA, COA, and NBCRNA are separate organizations. Two of the three still operate under the same roof - if I remember correctly, all three did until recently.

AANA membership recently voted to provide "guidance and suggestions" to the NBCRNA. The NBCRNA was told "do what we want" or we will replace you. The COA is next on the agenda.

 

[BLADEMDA]

If a CRNA and MD work for a hospital, AMC or private group (everyone has the same employer) then TEFRA doesn't have to be followed completely.
But, if an AA has the same employer TEFRA must be followed 100% of the time all of the time.

This gives the typical CRNA from the local mill a big advantage over the AA in many practice situations.

 

[chmd]

I friends practice interviewed an AA and all the CRNAs at his practice threatened to quit.

I think most anesthesia resideny programs should train AAs as well. How hard could it be to work them into the curriculum?

 

[IlDestriero]

I friends practice interviewed an AA and all the CRNAs at his practice threatened to quit.

I think most anesthesia resideny programs should train AAs as well. How hard could it be to work them into the curriculum?

Conspiring against the physicians sounds like good grounds for dismissal of the whole group. That's a BAD sign for the future.

 

[Consigliere]

I friends practice interviewed an AA and all the CRNAs at his practice threatened to quit.

I would have fired every one of those motherfu_ckers. Our CRNAs know better than to make idle threats or to complain for that matter.

 

[jwk]

I friends practice interviewed an AA and all the CRNAs at his practice threatened to quit.

I think most anesthesia resideny programs should train AAs as well. How hard could it be to work them into the curriculum?

By all means - let them quit. This threat is quite common and is rarely acted upon. Most CRNA's aren't that dumb that they would leave a good paying job and uproot their families just to make a political statement, although there are of course exceptions. It's funny - for all their claims about wanting to practice independently, they sure as hell want to remain part of a group or hospital with anesthesiologists and keep AA's out. Scared sh*tless of the competition I guess.

 

[IDBasco]

I would have fired every one of those motherfu_ckers. Our CRNAs know better than to make idle threats or to complain for that matter.

You only need to fire one. The rest figure it out.
If it were me I would just tell them you accept their resignation, effective immediately. Same result.

 

[chmd]

It doesn't seem like a good idea to test them. You have 20 crnas walk out, the OR shuts down and you lose your contract. It's a big enough city that they could probably find jobs that would work for them, meanwhile I can easily se no CRNA working for your group.

Maybe you could get by with locums MDs for a while, but I dont think so.

 

[deansrv72]

If a CRNA and MD work for a hospital, AMC or private group (everyone has the same employer) then TEFRA doesn't have to be followed completely.

Can you clarify? I wasn't aware that only part of TEFRA needs to be followed. Unless it's hospital policy where it's a collaborative (or non-medically directed environment), it's my understanding that in order to bill, appropriately, CMS, when medically directing, all seven points have to be met, with emergence being the broadest definition of the bunch.

 

[BLADEMDA]

Can you clarify? I wasn't aware that only part of TEFRA needs to be followed. Unless it's hospital policy where it's a collaborative (or non-medically directed environment), it's my understanding that in order to bill, appropriately, CMS, when medically directing, all seven points have to be met, with emergence being the broadest definition of the bunch.

http://www.nurse-anesthesia.org/archive/index.php/t-10519.html

TEFRA doesn't result in any additional monies to the group or employer.
It would really surprise you to know some famous hospitals and medical centers don't always follow TEFRA completely.

 

[jwk]

http://www.nurse-anesthesia.org/archive/index.php/t-10519.html

TEFRA doesn't result in any additional monies to the group or employer.
It would really surprise you to know some famous hospitals and medical centers don't always follow TEFRA completely.

And likewise, there are some groups who have figured out that it can be done. All it takes is some reasonable organizational skills and a willingness to staff appropriately. There are even software packages available to help keep everything straight.

 

[HenryH]

http://www.nurse-anesthesia.org/archive/index.php/t-10519.html

TEFRA doesn't result in any additional monies to the group or employer.
It would really surprise you to know some famous hospitals and medical centers don't always follow TEFRA completely.

I'm not really familiar with this topic, but why would a practice comprised of anesthesiologists and CRNAs not be required to follow TEFRA, while a practice staffed with anesthesiologists and AAs would have to follow it? What potential implications does this requirement have for a group that is interested in hiring AAs?

 

[jwk]

I'm not really familiar with this topic, but why would a practice comprised of anesthesiologists and CRNAs not be required to follow TEFRA, while a practice staffed with anesthesiologists and AAs would have to follow it? What potential implications does this requirement have for a group that is interested in hiring AAs?

CRNA's, in some cases, can function independently, in which case an anesthesiologist wouldn't be involved at all, on any level. In some practices, there is "medical supervision" where an anesthesiologist can supervise any number of CRNA's, and the tightest is "medical direction" which can be 1:4 at the most. AA practices are generally done with medical direction, in which case the TEFRA requirements apply ( anesthesiologists provides pre-op evaluation, anesthesia plan, present for induction, emergence and at intervals during case, PACU care, and discharge).

 

[BLADEMDA]

Medical supervision generates more revenue per Group than medical direction because strict adherence to TEFRA isn't required. For those groups with a poor payer mix medical supervision may make better fiscal sense.

 

[goosegas]

I'm not really familiar with this topic, but why would a practice comprised of anesthesiologists and CRNAs not be required to follow TEFRA, ...

Because its not actually a requirement. When it comes to TEFRA, we are talking about a billing issue, not a practice issue. If you choose to bill for medical direction, then there are 7 steps that must be met by the anesthesiologist in order to get paid. If you don't bill for medical direction, then you do not have to perform the 7 steps.

Medical supervision generates more revenue per Group than medical direction because strict adherence to TEFRA isn't required. For those groups with a poor payer mix medical supervision may make better fiscal sense.

This would result in lower revenue than medical direction. In medical "direction", each provider receives 50% of the allowable amount so that 100% of the allowable amount is received by the group. With medical "supervision", the CRNA would bill for and receive 50% of the allowable amount. The anesthesiologist would get 3 units for the case (4 if they are present for induction). So this would likely result in lost revenue but there are no requirements to be met.
The method of billing that allows for the maximum revenue generation for the group with the least amount of required steps is to submit only one bill for the CRNA with the QZ modifier for CRNA without medical directions. This allows for the CRNA to bill for 100% of the allowable amount. So the group has received the maximum allowed billing with no "required" steps. The anesthesiologists in the group are free to perform as much or as little supervision as they like with no requirement to document it.

 

[BLADEMDA]

Because its not actually a requirement. When it comes to TEFRA, we are talking about a billing issue, not a practice issue. If you choose to bill for medical direction, then there are 7 steps that must be met by the anesthesiologist in order to get paid. If you don't bill for medical direction, then you do not have to perform the 7 steps.


This would result in lower revenue than medical direction. In medical "direction", each provider receives 50% of the allowable amount so that 100% of the allowable amount is received by the group. With medical "supervision", the CRNA would bill for and receive 50% of the allowable amount. The anesthesiologist would get 3 units for the case (4 if they are present for induction). So this would likely result in lost revenue but there are no requirements to be met.
The method of billing that allows for the maximum revenue generation for the group with the least amount of required steps is to submit only one bill for the CRNA with the QZ modifier for CRNA without medical directions. This allows for the CRNA to bill for 100% of the allowable amount. So the group has received the maximum allowed billing with no "required" steps. The anesthesiologists in the group are free to perform as much or as little supervision as they like with no requirement to document it.

It's all B.S. anyway. I use the term "medical supervision" as a descriptive term and not a billing term. Many Groups bill "QZ" while providing medical "supervision" of their CRNAs. Utilization of CRNAs permits "QZ Billing" while maintaining quality control over midlevel providers. Billing 'QZ" does not mean CRNAs are necessarily functioning independently bur rather the terms of Medical Direction (TEFRA) were not met.

 

[goosegas]

Agree 100% Blade. I just wanted to make it clear for some of the others that thought medical direction was a requirement for CRNA's. As you stated, billing for medical direction does not result in additional income to the group and it does burden you with its required steps that MUST be performed (and documented). If not, its fraud. By billing QZ (CRNA not medically directed), the same amount of revenue is generated for the group but there are no steps that are required to be met by the anesthesiologist. The anesthesiologist is free to provide as much or as little oversight/supervision as they feel is required.
Also, billing QZ has nothing to do with a states opt out status. QZ can be billed regardless of the states opt out status.