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Won't CRNA's price themselves out of jobs?

Discussion in 'Anesthesiology' started by medicine2006, Mar 31, 2004.

  1. medicine2006

    medicine2006 Happy Pisces
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    Here's my simplistic logic. Right now CRNA's are cheaper than MDAs therefore it stands to reason people would rather hire the cheaper worker. This is essentially why we have outsourcing of jobs in other fields. Well as CRNAs demand and get more priviledges and are able to bill like physicians their salary will go up. But this has an asymptotic limit. So I guess when their salaries are about equal to physicians then they'll be the ones out of work. The reason is if I had to pay X dollars for an MDA or CRNA I'd ALWAYS go with the person with the MD because they can do more. Does this seem like a reasonable assumption? So screw all the CRNAs because MDs will ALWAYS be superior and when push comes to shove all the people would prefer us.
     
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  3. doc_strange2001

    doc_strange2001 Senior Member
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    zzzzzzzzzzzzzzzzzzzzzzz

    this topic is played out!
     
  4. InGasWeTrust

    InGasWeTrust Member
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    Enter MacGyver........
     
  5. MacGyver

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    It should be outrageous to MDAs. What does that say about a medical specialty when people who have no training in that specialty are allowed to supervise?

    You cant divorce those 2 issues from each other. The shorter training period is an inherent advantage to CRNA practice.

    there's no reason why thats a definitive thing. Its impossible to say one way or the other.

    Under the current system? Perhaps. If CRNAs get even more scope of practice concessions (and there is NO indication that their victories in scope of practice are going to suddenly stop), then all best are off.

    And the states they left will promptly change the rules to allow CRNAs to do 100% of what an MDA does. Once a few states do that, the remaining states will have precedent to change the rules in the MDA-heavy states. This plays right into the CRNAs hands.

    You are INCREDIBLY naive if you think the states will just sit back and watch MDAs leave teh state and do nothing. Indeed, they wont sit back and do nothing, they will change laws/regulations to allow CRNAs to take over completely if need be.

    Link, please.

    The ASA needs lots of these studies to make up for lost time.
     
  6. doc_strange2001

    doc_strange2001 Senior Member
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    OMG this is outta hand
     
  7. Skip Intro

    Skip Intro Registered User
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    Your logic is dizzying, MacGyver, I'll give you that. I'm not going to respond point-by-point to each counter-issue you raise (because frankly, I feel it won't be productive and I personally don't care enough to), but...

    Here you go:

    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10861159
     
  8. MacGyver

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    Well that study is a good start. They need to do mroe studies though. The CRNA lobby wont rest on this issue, and the only way MDAs have a prayer of beating them back is to publish many more studies showing bad outcomes for CRNAs.

    I still think the ASA is not being nearly active enough in this area. They need to have a special committee which deals only with the CRNA threat.

    They also need to make a serious critique of the pro-CRNA "studies." The only ASA response I've seen was poorly written, didnt address many key points, and was largely worthless.
     
  9. Skip Intro

    Skip Intro Registered User
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    You know, I'm getting the impression that someone else alluded to earlier in a separate post. I'm thinking that maybe, just maybe, you are or have been interested in anesthesiology and someone scared you off of it (maybe a family member or friend or whatever). You are looking for reasons, perhaps by playing devil's advocate, to see why that person(s) is(are) wrong.

    Am I right?

    Either that's is the apparent case, or you are - in fact - just a meddling troll.

    Either way, I think many people contributing in this forum category would wish you'd stop trying to hijack and monopolize threads with your underlying yet rampant speculation of the demise of anesthesiology as a legitimate field of medicine, whether it's truly your primary intent or not.

    Just some observations, dude.

    -Skip
     
  10. Platysma

    Platysma Junior Member
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    1. CRNAs do not cost less than MDAs, even though they make less. Medicare makes no distinction between an MDA and a CRNA for billing purposes. The reason why MDAs make more is 1. MDAs can supervise multiple cases and 2. many CRNAs are hired by MDA groups, and are paid less money that way. CRNAs cost less to train than doctors, but that is not the big driver behind increasing medical costs. And, I don't think CRNAs are pushing for decreased reimbursements based on their qualifications.


    2. Supervision is also not an issue. Legally, several cases have established that Nurse Anesthestists can perform anesthesia without the presence of an anesthesiologist. In such cases, they are considered to be supervised by a surgeon. This is legal in all fifty states. Basically, CRNAs do not want to be "under supervision" by a surgeon. This is so they can bill more for the same procedure. This does not change liability issues-- if surgeons can be sued for MDA mistakes, who are not supervised, certainly they can be sued for CRNA mistakes, even though the surgeon was not "supervising" anyone.
     
  11. juddson

    juddson 3K Member
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    I am the one who made this suggestion in a seperate thread. I am in no position to judge the truth of the charge or not. In any event, this is EXACTLY the reason that I engage in these threads. I am INTERESTED in gas, and that being the case, I am content (more than content) to play the devil's advocate on this issue. For that reason, i also support MacGyver's posts on these threads.

    Unfortunately, many of you are wont to dismiss him as a "troll", but he's clearly not. He makes genuine arguments and counter-arguments, and doesn't seem to fit the MO of a "troll".

    That said, if he is in the different field already. . .well, then I would have to wonder why he is interested in the issue. Personally, I think he is a premed.

    In any event, it pushes the bounds of incredulty (sp) to suggest that he has "hijacked" this thread. The OP presented a theory upon which you expanded. MacGyver merely responded to your post. That is the nature of the beast, no? Analytical arguments on these forums "invite" responses. As simple as that, don't you think.

    Now, to the merits, as it were. . .

    The Silber study is the ONLY study that I have been able to locate on this issue which seems to favor MDA supervision. As was made abundantly clear on a previous thread, the AANA response to that study is (arguably) compelling (though I set forth a critique of that response in another thread). Most damning, I think, is the 30 day post-operative study period, which is simply way too long to evaluate non-MDA supervised CRNA performance.


    Look, let's try to be analytical about this, can't we? Answer this question:

    IF the data suggests that unsupervised CRNA M&M rates are the same as MDA M&M rates, does that not suggest that MDA's are, at the very least, overtrained?

    Judd
     
  12. Skip Intro

    Skip Intro Registered User
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    Well, more "trollish" than really a troll, per se. But, that is only because he appears to respond to only the parts of threads that he wants to, either accidentally (or purposefully, carelessly) "misses the point" on many counterarguments, repeatedly comes back to make the same arguments over and over, and/or just outright interjects points into a thread that he knows will get people riled-up. Also, I've had previous interactions with MacGyver (notice I'm definitely NOT a newbie to this forum) on other topics where he used a lot of similar dubious debating techniques, ad hominem, missing the point, etc.... all hallmarks of a troll.

    My "trolldar" is up. Sorry if you disagree. That's what a forum is about.

    If and when such a study is done and such a conclusion is drawn (and is only speculation at this point), I still won't believe it will be safe to conclude that MDAs are overtrained. I believe an adequate and well-controlled prospective trial will support the Silber study, indicating more likely that CRNAs are actually undertrained and not well-equipped to fully handle the occasional "scary" cases and/or have the clinical background and training to do fully adequate pre-op work-ups for every patient. But, such a study has not been done yet. Silber, criticized or not, is currently the best we have. However, all fifty licensing boards support more study before any firm conclusions are drawn.

    Remember this whole issue (i.e., free practice) is born out of the artificial commodity concept - there simply aren't enough anesthesiologists to go around. Sadly, patient safety takes second fiddle here.

    -Skip
     
  13. MacGyver

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    Give me an example of a surgeon who has been successfully sued for a CRNA's mistake.

    As we all know, lawyers have a "sue everybody first and ask questions later" philosophy, so just having their name on a lawsuit only to be withdrawn later doesnt mean much.
     
  14. juddson

    juddson 3K Member
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    The AANA position on this is quite simple. They claim that under the traditional system (ie., surgeons "supervising" CRNA's in the OR), there was NO legal liability for the surgeon when the CRNA made a mistake DESPITE the "supervision". In fact, it is precisely THIS argument advanced by MDA's (that surgeons who "supervise" CRNA's will be liable for thier malpractice - and therefore they ought not use CRNA's) that the AANA objects to most. According to the AANA, they have fought for practice autonomy IN ORDER TO take the wind out of this argument advanced by "the enemies of Nurse Anesthesia". That is, the AANA is saying in effect "MDA's have been successful in convincing surgeons that if they supervise CRNA's, they take on legal liability for CRNA malpractice. While we don't think this is true, we can bury the issue in any event simply by doing away with supervision. And this is what we have done. Now there should be no 'liability related' reason for a surgeon not to hire a CRNA".

    In any event, I am unconvinced by this argument, despite what the AANA's position on this issue is. And it is here that MacGyver alsmot certainly has it wrong.

    First, there is no doubt in my mind that the mere act of "supervision" alone is enough to confer liability upon a surgeon for the mistakes of a CRNA. The AANA's arguments are this point are purely self-serving. The ability to direct the means and methods of an "agent" rather than merely the result is the sin quo non of vicarious liability. And this is precisely what "supervision" means in this context. HOW can a person LEGALLY charged with "supervision" (despite the medicare rules, most states STILL have mandatory supervision regulations on the books, never mind the hospital's own regulations themselves) escape liability when the person being supervised makes a mistake? The reality is that the AANA knows this all too well (despite the rhetoric to the contrary). As evidence of this, the AANA urges hospitals to abandon thier own internal regulations requiring "supervision" of CRNA's because, it says, this creates a needless exposure to liability based on that very supervision.

    So, on the one hand the AANA is urging that "supervision" does NOT expose the surgeon to liability for the mistakes of the CRNA. On the other hand, it is urging hospitals to abandon the supervision rules because these may expose the hospital to liability.

    The reality is somewhere inbetween. Supervision clearly DOES expose supervisors to liability, but hospitals almost certainly hang on to these regulations because, I imagine, supervision decreases mortality and morbidity, which goes quite a bit further in preventing liability.

    Secondly. . .

    Even so, the AANA's position might now be that in the abscence of "supervision" regulations, there will be NO surgeon or hospital liabilty for CRNA mistakes. Presumably, CRNA's might even practice as independant contractors. It's my position, in any event, that this will have no bearing on actual liability for the surgeon (or hospital) for the mistakes of the CRNA, but will merely change the theory upon which liability is based. No more will malpractice charges against a suregon be based on "supervision" or on a theory of vicarious liability, but instead they will be based on the negligence of the surgeon in choosing to use a less qualified provider in the first place. Again, the AANA is all too aware of this liability issue as well. For instance, the AANA urges that surgeons NOT use non-CRNA nurses to administer anesthetic. Why? The theory of liability is NOT based on "supervision" or some other form of vicarious liability, but rather because the surgeon (and hospital) commit negligence by choosing to use a less qualified practitioner when more qualified practitioners are available and willing. An aggravating factor is that the surgeon or hospital will have chosen the CRNA rather than the MDA in order to save money, a motivation that is never well received by a jury. Certainly IF there ate studies which suggest higher M&M rates for CRNA, a surgeon will have some difficulty explaining why he or she chose to use a CRNA.

    Anyway, just some rambling.

    Judd
     
  15. Skip Intro

    Skip Intro Registered User
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    Excellent summarization and grasping of the finer point of this issue.

    Eating their cake and having it to...

    The "decreases mortality and morbidity" may or may not be the case, depending on who you believe. If you trust that the Silber results are reproducible, this is probably true. But, I see it in simpler terms. Hospitals want to limit their exposure. If the federal ruling and a signature from the government permits them to do this, then liability is factored out of it. If the CRNA will take full legal responsibility for his/her actions, patient safety really becomes secondary. This is ultimately about money. And, no one party involved this issue/dispute is above that fact.

    Interesting. Could be. But, I doubt this will happen and/or I surmise that a judge would summarily dismiss a surgeon from a tort. If a CRNA is legally licensed and in good standing in the state he/she practices, there's no liability on the surgeon for choosing him/her. So, this is a bit of a reach of a scenario that some lawyers might try to argue (hell, lawyers will try anything to get to the deep pockets), but it's questionable whether or not they would be successful.

    Again, good point. But with the exemption in those states that allow it, the surgeon will always have the ability to say. "I was following the law and the CRNA I hired was in good standing with that state's nursing board... (etc.)" I think if the law is clear that they don't need supervision, the liability ends at the CRNA. This will be tested in court, though. We'll see then. I think the only certainty is that malpractice insurance rates for CRNAs are going to skyrocket.

    Good rambling. ("Hears Judd's 'gears' turning.")

    :)

    -Skip
     
  16. juddson

    juddson 3K Member
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    I can expand on this as well.

    Let's assume that in states that exercise the opt-out, the CRNA's begin to form thier own independant contracting companies, and the hospitals in those states also do away with any of thier own "supervision" regulations. This will STILL not insulate the surgeon or hospital from liability, even liability based on a "supervision" or vicarious liability theory. WHY? Because the courts of very clear that the relationship between two parties (a surgeon or Hospital and the CRNA, in this case) is determined by the "totally of the facts" and is NEVER determined by the formal agreement the parties may have.

    For instance, for purposes of tort liability and in the area of taxation (the two areas where the "independant contractor" doctrine most often comes up) courts HAVE held that independant contrator MDA's are "employees" of hospitals where the facts suggest that the hospital controls not just the "results" of the MDA's efforst, but also the "means" by which he acceives these results. Where the totally of the facts surrounding a relationship suggest an element of "control" by one party over another, the courts do not hesistate to ignore the "formal" relationship (whether by contract or otherwise) between the parties to find liability.

    The operating rooms is ripe with these sorts of facts, isn't it? For instance, on the one hand it can be argued that the surgeon (or hospital) exercises control over the "result" of the provision of anesthetic by a CRNA in that he is interested only that the patient be sedated (ie, sedation is the result). He does not control the "means" of sedation because he does not direct the CRNA to administer anesthetic A or anesthetic B. However, isn't this a too simplistic view of what goes on in the OR. For instance, from what I understand the anesthetic practioner is ordinarily response for the general "physiology" of the patient, and a surgeon participates ENORMOUSLY in dictating the direction of that physiology. Don't surgeons call for the administration of agents all the time (calcium, potasium, etc.)?

    Anyway - I have not looked at he caselaw on these issues (only that which the lawyer for the AANA posts on thier website- which I think is probably one-sided - though even much of that is ripe with interesting details which do not necessarily favor CRNA's). I don't have access to Lexis or Westlaw anymore, do that sucks.

    I'm sure that when and IF a case comes down with substantial liability for a surgeon for the actions of a CRNA, the ASA will plaster it all over the place. We'll see what happens.


    judd
     
  17. Gator05

    Gator05 Resident
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    Yes, this all comes down to money. And for an excellent review of why MDA's are cheaper in the long run even with the most pro-CRNA situations out there, please look to the March 2004 issue of Anesthesia and Analgesia.
     
  18. Skip Intro

    Skip Intro Registered User
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    Have a link?

    -Skip
     
  19. gaseous

    gaseous Senior Member
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  20. juddson

    juddson 3K Member
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    There's no link as you need a subscription to get to the article. I was able to get the abstract.

    The authors determined a marginal cost per year of extra life saved (cost/YLS) associated with MDA administration of anesthesia versus non-medically directed CRNA administration. Obviously, the assumption is that MDA administration leads to additional years of life compared to CRNA administration (would have liked to see the citations in the article showing this) and that in terms of the extra cost for those extra years of life, MDA's are actually cheaper than CRNA's. And in any event, what extra money they do cost is worth it from a societal standpoint.

    Judd
     
  21. Skip Intro

    Skip Intro Registered User
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    Thanks, Judd. Do you have the PubMed citation link and/or authors? I can look up the article when I'm back in the hospital on Monday (when this incredibly kick-butt Spring Break week is finally over... :( ).

    -Skip
     
  22. jjjez

    jjjez Junior Member
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    Why would the surgeon get sued over a nurses wrong actions.
    confused:
    the nurse is only supervized by the surgeon. the nurse has a license and doesn't work for the surgeon or anybody else except the hospital.
    Nurses have ACCOUNTABILITY.
    whatever they do wrong is their problem, how could it be the surgeons??? she doesn't answer to him professionally, she answers to her professional body.
    if doctors and surgeons are blamed for a nurses actions then something is seriously wrong with the judicial system.
    e.g. doctor tells nurse to give drug,
    nurse doesn't check dosage
    nurse gives patient drug, patient dies
    how is this the doctors fault????
    it is the nurses responsibility.
    she may lose her license, but how would a doctor be involved??
    yes he specified the wrong dose, but nurses are educated to check everything doctors say, based on their training, knowledge and good old fashioned gut instinct, just like doctors.
    If medical staff get blamed for nursing staff mistakes then i would question your legal system not the nurses.
    :confused: :
     
  23. juddson

    juddson 3K Member
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    You're kidding me, right???!!!

    If a doctor tells a nurse to give the patient 50 cc's of X, when only 5 was indicated, patient dies as a result, and you don't think the doctor is at fault???

    Judd
     
  24. jjjez

    jjjez Junior Member
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    Well in reality it's no one persons fault, each could blame each other for a wide variety of reasons, reasonably blame will lie with both of them.
    i'm not too sure really. this spreads nicely into how nurses train. i can only give the british system which is, never trust a prescription if you're not sure. we would expect our nurses (hopefully) to catch this mistake. if the drug is usually 5cc (don't use cc's in uk, we use gram milligrams and so on) and 50 is written then something has clearly gone wrong.
    It of course is partly the doctors fault, but if the nurse is blindly giving drugs left right and centre then anyone can see an error coming a mile off for this nurse.
    After a while (depending on where you work i guess) i think that most nurses become familiar with at least half of the drugs in their clinical area of have at least heard of them (even more likely in the US, because of the nursing education in pharmacology. so it is actually quite hard (theoretically) to write a wrong drug dose and the nurse to then give it.
    Also nurses are accountable for their own actions. so although any physician can write a wrong drug dosage and get blamed, if it's the nurse giving the drug responsibilty lies with her, not the doctor as the nurse is the one that is giving the drug.
    It's tricky because obviously no nurse can realistically check every drug in a book, hence where the familiarity with drugs and their usual dosages come in. I think part of it comes from gut instinct ofn the nurses behalf of whether it 'sounds' right aswell.
    I personally hacve had s/c heparin written for 50000 units.
    when it was supposed to be 5000, an easy extra 0 can be written by anyone at anytime. so really the last person to check the drug would be the nurse wouldn't it. therefore in real terms the buck stops there.
    Try to think of it more abstractly:
    A car factory, lets say the doctors are the builders and the nurses are the safety guys
    if there were no safety guysand the car falls apart it could be the builders fault for poor quality.
    If there are safety guys, then it could be their fault for not checking.
    You see :)
     
  25. PCOM_Rocks

    PCOM_Rocks Member
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    I hate CRNAs!
     
  26. jjjez

    jjjez Junior Member
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    Well i don't think they're rolling out the welcome wagon, so much as running you down with it.
    You really should let this go.
    It's all gettin g a bit territorial sounding eh?
    I've got bizarre images of MDA's and CRNA's patrolling their bit of turf around the Operating Theatres and urinating up against the walls to mark their territory.
    (mda)'IVAC'
    (crna)'MINE!'
    (mda)'YOU NOT HAVE 7 YEARS SCHOOL! YOU SEDATE BUTTOCK LESION MAN! ME DO OPEN HEART SURGERY!'

    I think a song to make us think about uniting together might be Stevie Wonder and Paul McCartneys' classic hit 'Ebony and Ivory'
    And a one, two, three, four!
     

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