Wisconsin Hospital Replaces All Anesthesiologists With CRNAs

[GassYous]

md only

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[Aheadbyacentury]

md only

Right.

 

[OneFellSwoop]

Sadly in most states, the opposite is the strategy. Typically CAA legislation is used as a pawn or threat in order to stave off a CRNA independent practice bill. It kind of reaches a point of trench warfare stalemate where the state Anesthesiologists don't aggressively push for an AA bill and the NAs don't aggressively push for an independent practice bill. In the end, physicians will be the suckers left holding the bag because the NAs aren't going to just sit back and not push for independent practice. It'll happen eventually, and if it happens in your state, wouldn't you want to be able to have the option to hire AAs instead? Unfortunately, in my experience, many states are going to be caught off guard when CRNA independent practice passes in their state and they didn't preemptively try to get AAs in--now there's no threat for the CRNAs and they can fully mobilize against a reactionary AA bill.

I agree with the overall sentiment, but just as a contrast, I already practice in a CRNA independent state without AAs. ACT is the predominant model here and there’s no decline in sight. There are CRNA-only hospitals in rural locations but that’s likely (hopefully) driven by the reimbursement scheme of rural pass through. The big AMCs have lost contracts and have almost no foothold. AAs would be great, however, at this point, it seems modifying the rural pass through would be the thing that really determines how likely it is for anesthesiologists to expand their presence in the state.

WI, OTOH, IS an AA state, and are losing hospitals to CRNAs with a fireman MD.

This issue is really state by state, but I agree that AAs should simply be legal across the country rather than a state decision. It’s weird to have an entire profession unable to practice in one state, but then freely in another. Off the top of my head I can’t think of many other professions like that.

 

[Endee]

I agree with the overall sentiment, but just as a contrast, I already practice in a CRNA independent state without AAs. ACT is the predominant model here and there’s no decline in sight. There are CRNA-only hospitals in rural locations but that’s likely (hopefully) driven by the reimbursement scheme of rural pass through. The big AMCs have lost contracts and have almost no foothold. AAs would be great, however, at this point, it seems modifying the rural pass through would be the thing that really determines how likely it is for anesthesiologists to expand their presence in the state.

WI, OTOH, IS an AA state, and are losing hospitals to CRNAs with a fireman MD.

This issue is really state by state, but I agree that AAs should simply be legal across the country rather than a state decision. It’s weird to have an entire profession unable to practice in one state, but then freely in another. Off the top of my head I can’t think of many other professions like that.

All professions are regulated at the state level, it's just that AAs have only been around since the late 60's, and didn't expand much outside of OH and GA until the 2000's. By then, the CRNA lobby had gotten very strong, and they've put up incredible resistance in each state where AA legislation is proposed.

In states like the one where you live, with CRNA independent practice or even with just CMS opt out, I don't know why the state components of the ASA don't go full force for passing AA legislation. Well, I do know, and the answer is there are a lot of cowardly physicians that are content with the status quo. Very few to no one willing to stick their neck out there and protect the profession if it means rocking the boat in their local group.

 

[OneFellSwoop]

All professions are regulated at the state level, it's just that AAs have only been around since the late 60's, and didn't expand much outside of OH and GA until the 2000's. By then, the CRNA lobby had gotten very strong, and they've put up incredible resistance in each state where AA legislation is proposed.

In states like the one where you live, with CRNA independent practice or even with just CMS opt out, I don't know why the state components of the ASA don't go full force for passing AA legislation. Well, I do know, and the answer is there are a lot of cowardly physicians that are content with the status quo. Very few to no one willing to stick their neck out there and protect the profession if it means rocking the boat in their local group.

It needs to come from the society without identifying individuals and would be nice if it was an anonymous vote within the society that forces the hands of the leadership to pursue AA legislation. It’s a big ask to risk losing a job or uprooting family for a potentially crappier job because you are the upsetter of apple carts. You aren’t just sacrificing yourself, but potentially your whole family. As an early career doc, that’s not being selfish or cowardly. Its instead a risk-benefit calculation tilted toward protecting family.

 

[Endee]

It needs to come from the society without identifying individuals and would be nice if it was an anonymous vote within the society that forces the hands of the leadership to pursue AA legislation. It’s a big ask to risk losing a job or uprooting family for a potentially crappier job because you are the upsetter of apple carts. You aren’t just sacrificing yourself, but potentially your whole family. As an early career doc, that’s not being selfish or cowardly. Its instead a risk-benefit calculation tilted toward protecting family.

I understand that perspective, I just think the threats made to people supporting AA hiring or AA legislation are almost always completely empty. No reasonably sized group has had a mass exodus of CRNAs because of reaction to AA support despite their threats. They just use those threats to control the physicians in their groups to do their bidding. Also there’s no reason why a physician can’t support AA practice and also still support the clinical staff in their group. Everyone seems to make it into an either or/all or none situation.

 

[Aheadbyacentury]

I understand that perspective, I just think the threats made to people supporting AA hiring or AA legislation are almost always completely empty. No reasonably sized group has had a mass exodus of CRNAs because of reaction to AA support despite their threats. They just use those threats to control the physicians in their groups to do their bidding. Also there’s no reason why a physician can’t support AA practice and also still support the clinical staff in their group. Everyone seems to make it into an either or/all or none situation.

CRNA bullies. "If you hire an AA, the entire CRNA group will leave."

This is why the people who need to spearhead this are ones in physician only groups who do not have CRNAs to have walk out.
Start an AA program at an Physician solo group.

 

[Endee]

CRNA bullies. "If you hire an AA, the entire CRNA group will leave."

This is why the people who need to spearhead this are ones in physician only groups who do not have CRNAs to have walk out.
Start an AA program at an Physician solo group.

Yeah, All MD conversion to ACT with only AAs has been done across the country and has been very successful. The physicians love a high performing team where members of the team aren’t colluding to betray you and replace you.

AAs can be introduced into hostile environments as well though and everything will be just fine. I was one of two AAs that started 10 years ago in a group of 30 MD/70 CRNA. The threats came, the docs called their bluff, and no one left. That group is now 50% AA 50% CRNA and everyone gets along well.

 

[Aheadbyacentury]

I was one of two AAs that started 10 years ago in a group of 30 MD/70 CRNA. The threats came, the docs called their bluff, and no one left. That group is now 50% AA 50% CRNA and everyone gets along well.

Wow!... It takes a strong AA to stand up to the bully CRNAs

 

[nimbus]

Posted this in another thread but meant to post it here.

Darwin’s Law of Natural Selection: Eliminating Medical Direction Anesthesia Delivery Models. – Excel Anesthesia

www.eakc.net

 

[Man o War]

CRNA bullies. "If you hire an AA, the entire CRNA group will leave."

This is why the people who need to spearhead this are ones in physician only groups who do not have CRNAs to have walk out.
Start an AA program at an Physician solo group.

That’s what they said when we brought in our first AA in my old group.
Guess how many left?
They refused to speak to the AAs, wouldn’t eat lunch with them, and tried to strong arm us and refuse to give them breaks(that didn’t go well for them), but nobody left. They stayed and acted like a bunch of middle schoolers.

 

[Status Sciaticus]

That’s what they said when we brought in our first AA in my old group.
Guess how many left?
They refused to speak to the AAs, wouldn’t eat lunch with them, and tried to strong arm us and refuse to give them breaks(that didn’t go well for them), but nobody left. They stayed and acted like a bunch of middle schoolers.

howd you react to that?

 

[coffeebythelake]

That’s what they said when we brought in our first AA in my old group.
Guess how many left?
They refused to speak to the AAs, wouldn’t eat lunch with them, and tried to strong arm us and refuse to give them breaks(that didn’t go well for them), but nobody left. They stayed and acted like a bunch of middle schoolers.

Is it legal for those crnas to make a threat like that?

 

[jwk]

Is it legal for those crnas to make a threat like that?

No - but same problem - rarely is anyone willing to call the bluff.

 

[Man o War]

howd you react to that?

Sent them home for insubordination, and they didn’t get paid for the rest of that day. Official write ups were done. We never ran super lean, so we pulled docs to finish cases and increased supervision ratios. Some docs had to work post call. We knew this would be temporary one way or another.
After several of them missed half their normal hours and realized we weren’t giving in they stopped.
People usually act right when their livelihood is affected.

 

[coffeebythelake]

No - but same problem - rarely is anyone willing to call the bluff.

My first thought would be do go after their nursing license for this, but then I rralize that the nursing organizations that are supposed to regulate them DGAF

 

[Man o War]

Is it legal for those crnas to make a threat like that?

I don’t know honestly. Didn’t matter to us because we had a 3 strikes and you’re out policy and they were written up every time they refused. So they would’ve been gone quickly if they had continued.

 

[Endee]

Sent them home for insubordination, and they didn’t get paid for the rest of that day. Official write ups were done. We never ran super lean, so we pulled docs to finish cases and increased supervision ratios. Some docs had to work post call. We knew this would be temporary one way or another.
After several of them missed half their normal hours and realized we weren’t giving in they stopped.
People usually act right when their livelihood is affected.

Strong work!!

 

[Man o War]

Strong work!!

Well I suppose we had the luxury of not really needing them. Our state allowed AAs, we had enough staff to run rooms without the troublemakers, and we had a pool to hire from if we needed new folks.
I realize not every group has that luxury.
What I know to be true is, if you show weakness they will take advantage of it. You cannot give them an inch.
This is why we need AA legislation in every state.

 

[chocomorsel]

Sent them home for insubordination, and they didn’t get paid for the rest of that day. Official write ups were done. We never ran super lean, so we pulled docs to finish cases and increased supervision ratios. Some docs had to work post call. We knew this would be temporary one way or another.
After several of them missed half their normal hours and realized we weren’t giving in they stopped.
People usually act right when their livelihood is affected.

My idol!! Mr. No Messing Around!!! Love it. Glad you and your partners stuck to your guns. We need more like you around. Strong work!!

 

[chocomorsel]

I don’t know honestly. Didn’t matter to us because we had a 3 strikes and you’re out policy and they were written up every time they refused. So they would’ve been gone quickly if they had continued.

And how do they get along these days?

 

[Man o War]

My idol!! Mr. No Messing Around!!! Love it. Glad you and your partners stuck to your guns. We need more like you around. Strong work!!

We need to reduce our dependence on CRNAs, when they lose their leverage groups don’t need to cow tow to the mob like behavior we see all too often. I have never seen that behavior from AAs, and I’ve worked with tons of them.

 

[Man o War]

And how do they get along these days?

I am not sure, last I heard the group was thriving and preferentially hiring AAs. They were about 50/50 CRNAs and AAs the last time I checked.

 

[Greenbayslacker]

Any updates out of Wisconsin?

 

[BLADEMDA]

Posted this in another thread but meant to post it here.

Darwin’s Law of Natural Selection: Eliminating Medical Direction Anesthesia Delivery Models. – Excel Anesthesia

www.eakc.net

 

[BLADEMDA]

So, based on the chart above why wouldn't any CEO/CFO/CMO keep the physician Anesthesiologist in the loop? When I analyze the graph above I come away with a different conclusion: CRNA ONLY model isn't worth it for the savings. You don't get a "supervisor" or physician involvement in the care of surgical patients.

Based on the acuity of the cases the graph above actually validates the 1:4 model as very cost effective if you actually care about patient quality.

 

[IMGASMD]

So, based on the chart above why wouldn't any CEO/CFO/CMO keep the physician Anesthesiologist in the loop? When I analyze the graph above I come away with a different conclusion: CRNA ONLY model isn't worth it for the savings. You don't get a "supervisor" or physician involvement in the care of surgical patients.

Based on the acuity of the cases the graph above actually validates the 1:4 model as very cost effective if you actually care about patient quality.

Can you explain why 1:6 generates less revenue?
Or why is 1:1 generates more revenues than MD alone?

 

[Status Sciaticus]

Can you explain why 1:6 generates less revenue?
Or why is 1:1 generates more revenues than MD alone?

So, based on the chart above why wouldn't any CEO/CFO/CMO keep the physician Anesthesiologist in the loop? When I analyze the graph above I come away with a different conclusion: CRNA ONLY model isn't worth it for the savings. You don't get a "supervisor" or physician involvement in the care of surgical patients.

Based on the acuity of the cases the graph above actually validates the 1:4 model as very cost effective if you actually care about patient quality.

Or also why the anesthesiologists costs 2million more per year compared to the CRNA?

 

[ambiturner]

Or also why the anesthesiologists costs 2million more per year compared to the CRNA?

“Table from The Lewin Group, prepared for American Association of Nurse Anesthetists” - that tells you everything you need to know!

A LOT of assumptions are baked into this. 1:6 presumably billing less due to supervision modifier. Why the solo MD isn’t billing more is unclear. Why more is billed for supervision also isn’t clear. And I am puzzled at the idea that solo CRNAs are going to work for less than half the hourly rate of the MDs. So basically this is garbage propaganda.

 

[Status Sciaticus]

“Table from The Lewin Group, prepared for American Association of Nurse Anesthetists” - that tells you everything you need to know!

A LOT of assumptions are baked into this. 1:6 presumably billing less due to supervision modifier. Why the solo MD isn’t billing more is unclear. Why more is billed for supervision also isn’t clear. And I am puzzled at the idea that solo CRNAs are going to work for less than half the hourly rate of the MDs. So basically this is garbage propaganda.

Right. So its a bullsh1t table that Blade posted.

 

[ambiturner]

Right. So its a bullsh1t table that Blade posted.

It came from the article nimbus posted so I don’t think he was necessarily endorsing it. While definitely bullsh1t, you better believe they show this sort of thing to legislators, administrators, AMCs…and it only takes one idiot buying it to cause headaches for everybody else.

 

[Endee]

The biggest con in the AANA’s playbook is that independent CRNAs are cheaper than physicians because of taking the average salaries of the two and comparing them. They know legislators have no idea how anesthesia billing works, and they’re fine with straight up lying to them.

 

[jwk]

The biggest con in the AANA’s playbook is that independent CRNAs are cheaper than physicians because of taking the average salaries of the two and comparing them. They know legislators have no idea how anesthesia billing works, and they’re fine with straight up lying to them.

They're absolute experts at lying to anyone who will listen.

 

[BLADEMDA]

They're absolute experts at lying to anyone who will listen.

That "table" is pure propaganda. I posted it because you all need to see what they present as fact. CRNA salaries are on the rise and the hourly rate is quickly approaching $140 per hour if not even higher. In addition, they expect a limited work week with set hours.

If a CFO/CEO falls for their sales pitch then the savings will be minimal with less accountability for poor outcomes. There are facilities where the case acuity is extremely low so a CRNA can deliver safe and effective care to patients. To deny this fact would be as hypocritical as the AANA claim of equivalency. But, overall the vast majority of medical centers are better served in terms of patient care by having a skilled, well-qualified Board Certified Anesthesiologist leading the perioperative team.

 

[BLADEMDA]

one study published by Economics, Education, and Health Systems Research used a wide variety of formulas to measure the cost-effectiveness of hiring an anesthesiologist.

This study compiled data that showed the added cost of hiring an anesthesiologist was worth the investment. The concluding paragraph of the publication sums the findings up succinctly.

“This study demonstrates that provider costs for physician-directed anesthesia are similar to provider costs for nonmedically directed nurse anesthesia and, when cost savings with reduced mortality are considered, physician anesthesia seems to decrease net health care costs. Even if all model assumptions are least favorable to physicians, these cost-effectiveness analyses suggest that incremental gains in life expectancy with a physician-directed versus nonmedically directed nurse model of care can be obtained at a cost deemed reasonable by society.”

It’s not just about how much money you can save, but the liability that would come with cutting these costs.

Hiring a CRNA: What to Expect

When it comes to the best fit for your medical practice, do you know who you should hire? Here are the pros of hiring a CRNA vs. an anesthesiologist.

physiciansthrive.com

 

[BLADEMDA]

 

[dabears505]

I'd be interested to see what percent of anesthesiologists are doing all those things. I know partners that can't do central lines. I've never met a crna that outright doesn't do spinals.

 

[deleted126335]

…I've never met a crna that outright doesn't do spinals.

Perhaps you should get out more.

 

[epidural man]

I have a question.

Are anesthesiologists better than CRNA's (as a group..obviously there are horrible anesthesiologists and great CRNA's)?

Because I believe - yes they bring something to the table that CRNA's can't bring. I could be wrong, but I believe it.

So IF that is the case - then when someone posts a news story that an entire hospital went 100% CRNA - instead of talking about what a travesty it is, and how we are screwed, or how we need to come up with another way to rape other human beings by scrapping tons of money of their hard labor (who will eventually turn around and do the same thing CRNA's do) -

instead of doing that - when we read of that hospital....the proper response is to laugh and laugh and say...."Ha. Good luck with that" and when that hospital comes back to an anesthesiologist....we have to band together...no matter how much they eventually offer...and say "F$%K YOU! Good luck."

But the way most of you talk is like you don't believe what I believe.

 

[GassYous]

I'd be interested to see what percent of anesthesiologists are doing all those things. I know partners that can't do central lines. I've never met a crna that outright doesn't do spinals.

In residency they would put a resident and a crna on at night with 2 attendings for ob. None of the crnas wanted to be there at night so they would put the new people there. A fair number of them were not comfortable and did not want to perform neuraxial so everything went to us. They were just biding their time until new people were hired and they could rotate out to days in the OR. It was kinda nice to do more procedures but also sucked to get up at night.

 

[sice4]

@epidural man could you try and describe what specifically you think an anesthesiologist brings to the table maybe in using specific situations?

 

[coffeebythelake]

@epidural man could you try and describe what specifically you think an anesthesiologist brings to the table maybe in using specific situations?

Do you need a specific instance to highlight the overarching fact that anesthesiologists have a lot more education and clinical training than a nurse anesthetist? In my daily practice (95% ACT with frequent 1:3 or 1:4 coverage) I'm there to plan safe anesthetics, problem solve issues when the people I direct struggle. That involves education and clinical training. And the cost to the patient and the insurance company is the same to have this extra layer of safety.

 

[epidural man]

@epidural man could you try and describe what specifically you think an anesthesiologist brings to the table maybe in using specific situations?

Not really.

I think the market should decide though. That Wisconsin hospital needs to be open and honest about what they have done - and patients should make the decision.

 

[OneFellSwoop]

@epidural man could you try and describe what specifically you think an anesthesiologist brings to the table maybe in using specific situations?

One of my partners diagnosed cardiac tamponade with TTE in PACU after pacemaker placement prior to arrest and then assisted in bedside ultrasound guided pericardiocentesis with the surgeon. Patient survived and did great went home POD1.

99%+ CRNAs can’t do this. In a crna only practice, there is high likelihood that patient would have either made it to the floor, arrested and died or arrested in PACU with standard ACLS led by crna with subsequent death.

 

[OneFellSwoop]

@epidural man could you try and describe what specifically you think an anesthesiologist brings to the table maybe in using specific situations?

Ultrasound PENG block in PACU to rescue hip scope that would have otherwise been transferred to hospital from ASC for overnight pain control but instead went home. Maybe a few more CRNAs would’ve done this, but still less than 5% would be my guess.

 

[IMGASMD]

I'd be interested to see what percent of anesthesiologists are doing all those things. I know partners that can't do central lines. I've never met a crna that outright doesn't do spinals.

Perhaps you should get out more.

I’ve met plenty…. Most of them are older and trained many moons ago. The ones insist on doing them, all have a chip on their shoulder. I’ve met a young/new grad recently, just won’t do them. Perhaps didn’t get enough “numbers” to be “comfortable”. Save me the hassle to ask and make sure they’re practicing within their f@king “scope”.

 

[undalay]

Not really.

I think the market should decide though. That Wisconsin hospital needs to be open and honest about what they have done - and patients should make the decision.

Dear Epidural
This is not a free market anymore particularly for anesthesiologists. AMC are colluding with nurse anesthetist to fire anesthesiologist only groups. The administrators want anesthesia service for free. There is no open bidding process for these jobs, secondly there is no advertisement by the hospital directly.

When the housing market declined in 2008, the sellers agent colluded with the buyer and buyers agent agains the seller of the home prices. That means 3 against one seller in order for the transaction to proceed. The sellers agent has a financial incentive to depress the sale price in favor of the buyer in a difficult 2008 recession.

if you take that analogy, the AMC, Hospital administrator and Militant CRNA groups are actively colluding to decrease the bargaining power of anesthesiologists. It’s only a matter of time before the law suits can prove the above

 

[nimbus]

When the housing market declined in 2008, the sellers agent colluded with the buyer and buyers agent agains the seller of the home prices. That means 3 against one seller in order for the transaction to proceed. The sellers agent has a financial incentive to depress the sale price in favor of the buyer in a difficult 2008 recession.

Since their commissions are a percentage of sale price, both sellers’ and buyers’ agents are generally incentivized to get the highest sales price. I supposed it’s possible that there can be collusion to get a lower sales price if it looks like the deal would otherwise fail.

 

[coffeebythelake]

Since their commissions are a percentage of sale price, both sellers’ and buyers’ agents are generally incentivized to get the highest sales price. I supposed it’s possible that there can be collusion to get a lower sales price if it looks like the deal would otherwise fail.

It makes more sense to go volume if they are able to move sales quickly even if it is lower.. Rqther than linger on for the best price. The agents best interest is not necessarily aligned with the sellers best interest.

 

[Zekchar]

I have a question.

Are anesthesiologists better than CRNA's (as a group..obviously there are horrible anesthesiologists and great CRNA's)?

Because I believe - yes they bring something to the table that CRNA's can't bring. I could be wrong, but I believe it.

So IF that is the case - then when someone posts a news story that an entire hospital went 100% CRNA - instead of talking about what a travesty it is, and how we are screwed, or how we need to come up with another way to rape other human beings by scrapping tons of money of their hard labor (who will eventually turn around and do the same thing CRNA's do) -

instead of doing that - when we read of that hospital....the proper response is to laugh and laugh and say...."Ha. Good luck with that" and when that hospital comes back to an anesthesiologist....we have to band together...no matter how much they eventually offer...and say "F$%K YOU! Good luck."

But the way most of you talk is like you don't believe what I believe.

The answer is actually our friends with a J.D. and father time. Once the bad outcomes happen, and they inevitably will in greater number when CRNAs are working on their own compared to anesthesiologists, it is the malpractice and sub-standard of care outcomes that will drive change. The CEO might think they are "saving" a small % of their budget by going with the cheaper (and inferior) option in straight CRNA care. In actuality, it only takes 1 successful lawsuit to undo multiple years of "savings." Yes that CEO/CFO/COO might not be there to take the brunt of it, but the med mal claims and thus insurance dues will go up for CRNA only care and eventually that will be the great mitigator.

Remember the attention Joan Rivers got? Right now many of these bad outcomes are in rural hospitals with poor people that do not have options to get elsewhere and dont have big tabloids like the NYTimes to highlight their tragedies. The cases are quietly settled, CRNAs are fired and the hospital or surgeons pays out due to no anesthesiologist "liability sponge." Eventually the surgeons and/or board of directors say no more and it goes back to medical direction or anesthesiologist only care. A few more years and we'll see this play out en masse.

I'm in academics with a SRNA training program and its unbelievable how terrible and basic the CRNA teaching of SRNAs is. Babysitting long cases with minimal modifications of intra-op plans is difficult for 50% of them. The slightest deviation from expected intra-op courses is met with a blank stare and I need you in the OR (while writing "MDA aware"). On top of that they get bitchey at me since they dont like a woman telling them their intra-op management is garbage. Little do they know that that wont save them since they're expected to have a level of competency as well. I digress.