Learn The Law and Represent Yourself in Court
Share
-
American Society of Anesthesiologists Runs Terror Radio Ads In Colorado: Opt Out Of Medicare CRNA Supervision And Die
In a desperate attempt to protect their turf by preventing the governor of Colorado from joining 15 other states in opting out of Medicare reimbursement rules requiring Certified Registered Nurse Anesthetists (CRNA) to be supervised by a physician in order to be paid for their services, the American Society of Anesthesiologists (ASA) is running radio spots aimed at misleading and frightening the public. And they are doing it knowingly and purposefully.
‘Supervision’, as defined by Medicare, is the physical presence of a physician, any physician with or without any training in anesthesia (a psychiatrist will do), in the operating room with a CRNA for certain portions of the anesthetic including induction and emergence. The Medicare guidelines also require the physician to be available for emergencies and to participate in the preoperative and postoperative care of the patient.
A recent study has shown that solo CRNA practice in states who have opted out of the requirement has remained at its previous high level of quality and safety, with no difference in patient outcomes versus physician involvement. Rural hospitals which are more likely to employ CRNAs as the sole providers of anesthesia, benefit from being able to bill Medicare for anesthesia services regardless of the presence of an anesthesiologist or supervising physician. When a physician is present and supervising, the fee is reimbursed at a percentage split between the CRNA and the physician, depending on the number of cases the physician is supervising at the same time. Typically hospitals make up the shortfall created by splitting the fee between providers when it comes to paying salaries. When 100% of the already strained medicare reimbursement goes for the services of a single provider, health care costs are lowered.
Non-supervised CRNA anesthesia care has existed for over 100 years and resulted in an impressive record of safety and quality.
The radio ads would have the public beleive that independent CRNA practice will suddenly be created should the governor sign the opt out. This is absurd. At issue is an INSURANCE reimbursement rule. It does NOT regulate or change the current practice of anesthesia by CRNAs in any way shape or form. It simply states that in order for reimbursement to occur for Medicare and Medicaid patients, a physician of any specialty must be present for X, Y and Z during anesthesia. There is in fact no science behind the rule and no one can point to any evidence which supports having the rule in the first place.
And yet the ASA claims in their ads that people will die from “one wrong move” by a “nurse”, and that with a “stroke of a pen” the Colorado governor will allow CRNAs to practice without physician supervision. Such hyperbole is not only irresponsible, it is blatantly false. The quality of CRNA anesthesia care is well known, and the governor does not have the power to regulate whether CRNAs practice with supervision, only whether Medicare will pay them for it for a select group of patients.
Shame on a supposedly professional society for attempting to frighten the citizens of Colorado, particularly its senior citizens and most vulnerable who benefit from Medicare and Medicaid.
Listen below by clicking play button:
Related Posts
- KY 17th State To Opt Out Of Medicare CRNA Physician Supervision Requirement
- Calif Anesthesiologists Taking CRNA Supervision Issue To Supreme Court
- Anesthesiologist Misinformation Rampant In Medicare CRNA Opt Out
- Colorado Opts Out Of Federal Medicare CRNA Supervision Rule
- ASA Response To NY Times A-Bomb Editorial On CRNA Supervision: Paradigm Shift?
[...] previously reported on radio ads running in Colorado sponsored by the Colorado Society of Anesthesiologists (CSA) aimed [...]
Hello,
I have been reading many of the blogs on this site and wanted to send a comment, as the blogs are very one sided, pro CRNA.
Let me start by saying that I am an ICU trained physician, I interact with surgeons, anesthesiologists, and CRNAs on a daily basis.
The studies that you seem to quote does show no difference in “outcome” per se between Anesthesiologist and CRNA. But did you realize that Anesthesiologists are the ones that take care of the sickest patients? If CRNAs have equal “complication” rates to Anesthesiologist, who receives the sickest patient, then it’ll be scary to see what the rates will be when CRNA takes on the sick patients.
In these so called “opt” out states, you must realize that Anesthesiologist still practice in those states and anytime a surgeon or GI doctor has a sick patient, they aren’t going to risk their license by performing a procedure with a CRNA managing the patient, hence again, sick patient goes to the Anesthesiologist.
A study that truly studies Anesthesiologist care and CRNA would be unethical. You can’t tell a sick patient that a nurse will take care of them under anesthesia because you are doing a study to see what would happened without physician supervision.
Since I am in charged of post op ICU patients, I can tell you that Anesthesia is indeed “safe” from my point of view. You can have an extremely sick patient make it out of “anesthesia” and end up in the ICU.
The anesthesia team , whether it be a CRNA or Anesthesiologist usually “pats” their back and leave assuming their job is done. But most don’t realize that what happens to the patient in the OR significantly changes their ICU course. And I can tell you without a doubt that the Anesthesiologist manage their intra-op patients signficantly better, further, they come and see their post op patients with me and we are able to discuss in depth physiology on the patient’s management and for future OR visits.
One last thing to add is, I had an opportunity to meet 4 former “CRNAs” who went back to Medical school and retrained as Anesthesiologist and they all admit that they were overconfident as a CRNA and it was scary to think that they didn’t know a lot of things that they did now.
The future of medicine does require more mid level providers, and these providers, whether they are Nurse Practitioners to PAs to CRNAs, we all need to work in concert with others. Do not be confused by studies published by mid levels providers citing that there’s no difference in “outcome.” One can not truly perform this study ethically, much like performing a study on whether or not a parachute is life-saving.
my two cents.
Regards,
DocMike
DocMike,
Thank you for your comments.
I must take exception to a number of representations. You ask “But did you realize that Anesthesiologists are the ones that take care of the sickest patients?” Less there be some misunderstanding it must be pointed out that CRNAs care for the sickest of the sick in hospitals across this country every single day. This includes open heart surgery, organ transplantation, brain surgery, pediatric surgery, trauma, high risk OB, etc. Perhaps you meant to say that the majority of the sickest patients are cared for by an Anesthesia Care team which includes both CRNAs and anesthesiologists. It is NOT the case that anesthesiologists are assigned to sick patients in place of nurse anesthetists as a rule or standard of care. It must also be said that there are hospitals where CRNAs are the sole anesthesia providers for patients that are as ill as they can get.
“it’ll be scary to see what the rates will be when CRNA takes on the sick patients” is a statement without basis in fact. It is a personal opinion to which you are certainly entitled. Should one wish to do the work, there is a substantial amount of data which could be collected regarding this premise from existing CRNA practice.
“A study that truly studies Anesthesiologist care and CRNA would be unethical. You can’t tell a sick patient that a nurse will take care of them under anesthesia because you are doing a study to see what would happened without physician supervision.” This is debatable. Since institutional review boards for this type of study would necessarily have to be those in hospitals which use the Anesthesia Care Team model, the anesthesiologists would never allow study approval. However, a study which has informed consent from a patient agreeing to their anesthesia being administer by a CRNA without an anesthesiologist being involved is simply NOT unethical. Something which meets the current acceptable standard of care cannot be unethical. And solo anesthesia practice by a CRNA MEETS the standard of care…regardless of how sick a patient is.
“And I can tell you without a doubt that the Anesthesiologist manage their intra-op patients signficantly better, further, they come and see their post op patients with me and we are able to discuss in depth physiology”. I am confused. You are a critical care physician. You take care of ICU patients. Anesthesiologists take care of all of your sick patients. How exactly do you compare their care to that of a CRNA? None of your patients receive CRNA care. Your evaluation here appears lacking the most basic information to substantiate it.
“In these so called “opt” out states, you must realize that Anesthesiologist still practice in those states and anytime a surgeon or GI doctor has a sick patient, they aren’t going to risk their license by performing a procedure with a CRNA managing the patient, hence again, sick patient goes to the Anesthesiologist.” NO physician ‘risks their license’ by working with a CRNA. This is simply false and represents a complete lack of understanding regarding risk and liability whether an anesthesiologist is involved or not, under the law. First of all, I assume you perhaps meant to allude to malpractice liability rather than professional license risk. Risk of professional license is simply a non-starter….there is none. A concern which has been propagated by anesthesiologists to surgeons is that they take on additional liability when either supervising or working with a CRNA instead of having an anesthesiologist supervising.
From a legal standpoint this is incorrect. A CRNA does not practice based on the license of any physician. The CRNA alone is responsible and liable for their actions. This is true when they work with an anesthesiologist, surgeon or dentist. Liability in such circumstances has been well litigated and regardless of whom the surgeon is working with they are liable for acts of anesthesia only in which they were materially involved. If the surgeon demands that either the MDA or CRNA administer an inappropriate medication then the surgeon is liable for the consequences. They are NOT liable for the acts of a CRNA merely because they are ‘supervising’ the CRNA or they are in an opt-out state where the CRNA is practicing without supervision.
Hello LawMed,
Thanks for your follow up comments. Let me clarify a few things.
In your first paragraph, you wrote “Less there be some misunderstanding it must be pointed out that CRNAs care for the sickest of the sick in hospitals across this country every single day. This includes open heart surgery, organ transplantation, brain surgery, pediatric surgery, trauma, high risk OB, etc.”
While it is true that CRNAs do take care of open heart surgery, organ transplantation, brain surgery, etc; BUT this statement does NOT mean that they take care of sick patients. This explanation is commonly used by mid level providers to represent how experienced they are, an argument for the lay public to support their cause. For instance, open heart surgery can mean open coronary bypass in a patient with just a history of hypertension and preserved ejection fraction. These cases are typically “straight forward.” But if you have a patient with a ejection fraction of 20%, paced for arrythmias, diabetes with autonomic dysfunction, hypertension, COPD, that requires bypass surgery, that’s completely different. These patients come in on a laundry list of meds for each disease process that requires a strong understanding of how they work. Residents spend years of training just to master how these drugs work, nurses prior to CRNA training administers them under doctor orders but they don’t learn WHY they are administered. Any of the areas you listed above can be considered an “ASA I or II” class patient, a classification used to determine a patient’s medical risks/conditions prior to surgery. Further, CRNA has MINIMAL Anatomy training. Medical students spend years of medical school memorizing every part of the human body. This is important for the various types of surgery and diagnosing intra-op emergencies. I have well experienced ICU nurses and PAs that are very good, able to diagnose problems and come up with treatments, but they base it on “reflex” experience. They see “A” and they immediately think “B” and only “B.” Much like a new medical intern basing his/her diagnosis on “reflex” based on a set number of symptoms, thats why most people call medical interns “confident and most dangerous” by the end of their first year, much like what I feel about mid level providers. Most people in this position just don’t know how much they don’t know. I’ve been practicing for a long time, my M.D. colleagues and I still don’t feel like we know enough.
In your 4th paragraph, you mention “I am confused. You are a critical care physician. You take care of ICU patients. Anesthesiologists take care of all of your sick patients. How exactly do you compare their care to that of a CRNA? None of your patients receive CRNA care. Your evaluation here appears lacking the most basic information to substantiate it.”
I’m sorry that I did not clarify this earlier. I live in a so called “opt” out state. My hospital has two anesthesia providers to save money. One is a solo anethesia M.D. group with 4 doctors that are fellowship trained. The other is a CRNA group with 1 M.D. anesthesiologist on “standby”. Although the later have anesthesiologist on standby, they are considered solo and the anesthesiologist is there for support if needed but rarely intervenes with case management. For this reason, I am able to see the outcome of “solo” anesthesiologist and “solo” CRNA treating my patients. Typically the “sicker” patients will go to the solo M.D. and the “healthier” patients goes to the CRNAs. This is decided by the M.D. Anesthesia and surgical team. While it’s true that the sickest patients come to the ICU, this is not the exception. We get many many admits for many different reasons. An otherwise healthy 30 year old breast flap may come to the ICU for “flap” checks, or a mouth cancer removal in an otherwise healthy smoker can come for “airway” monitoring post op wise – both cases of which will be managed by the CRNA group 10 out of 10 times. Whereas the M.D. Anesthesiologist sends me the 80 year old diabetic, copd, heart failure patients after abdominal aortic aneurysm repair. Although one can say it may be difficult to monitor the different outcomes of each case, there are things that usually goes wrong with the CRNA groups more often than the M.D. groups. For instance, one is fluid management. There’s no reason why I should get otherwise healthy patients going into pre-renal failure because a CRNA did not give enough fluids for “fears” of issues for extubation or get healthy patients who comes to my ICU with untreated hypertension from sympathetic release from surgery. Explanations that I typically hear from them is “oh, he or she is otherwise healthy, they should get better.” Unacceptable. Yes, the majority of the time they will get better, but long term wise their kidneys have undergone damage and their heart was strained by the outrageous blood pressure. Post op complications like these are NEVER reported in our hospital. Cases like these illustrates the many different reasons why CRNAs are able to do studies and say “hey we have the same outcomes as anesthesiologist.”
Healthcare is pushing for more and more mid level providers to take a larger role in medicine. Although its true that we need to optimize our care costs, we should be careful of doing it at the expense of patient health. I agree that mid level providers are critical for health care, but I don’t agree that they should become the sole provider. You’ll find many “prior” R.N.s or CRNAs now M.D. trained who admit that they were over confident and not knowing how much they didn’t know prior to their M.D. training. There are hundres of prior R.N.s and CRNAs that are now M.D. trained, I have yet to come across one that said M.D. training did not change their care or made them humble. If you find one, let me know, would love to pick their brain.
Regards,
DocMike
p.s. to avoid this from becoming a 20 page debate as these topics are truly a matter of personal opinion, I won’t post another comment but would love to hear your thoughts of my reply. Thank you.
DocMike,
Thank you for your thoughtful comments and your gentlemanly post script. Should you wish to comment further I have no objections…we have plenty of bandwith and the discussion is productive!
I must stand by my statement that CRNAs care for the sickest of the sick every single day in major academic medical centers across this country. There simply is NO prevailing standard in the anesthesia community that CRNAs are assigned to ASA I or II cases and more complex procedures or medically complicated patients, or ASA III or IV patients are assigned to physician providers rather than CRNAs.
Certainly not every open heart, for example, is ‘difficult’ or medically complicated from an anesthesia prospective, and this is true of all surgeries. Yet the “ejection fraction of 20%, paced for arrythmias, diabetes with autonomic dysfunction, hypertension, COPD, that requires bypass surgery” on a host of medications is quite frankly the very patients some CRNAs, just like some MDs, specialize in.
At the Cleveland Clinic, arguably in the top three of cardiac hospitals in this country if not the world, utilizes CRNAs in their Cardiothoracic Anesthesia Department (as well as all other anesthesia sections). Carol Ratcliff, CRNA is the Chief CRNA in the cardiothoracic section. Her biography on the department website states: “In 1996 she began assuming some supervisory responsibilities for the CRNAs in the Cardiothoracic department, and in 2000 she became the department’s first Chief CRNA. As a CRNA in the Cardiothoracic department she participates in the anesthesia care for all cardiac and thoracic procedures including transplants, aneurysms, complex redo operations, and esophageal and thoracic procedures”.
At the world renowned University of Maryland Shock Trauma Center, the world’s only freestanding trauma hospital, CRNAs have been a backbone of the patient care and provider training since its inception. Whether a massive blood loss, severe brain or spinal cord injury, or complex multiple trauma, the CRNAs provide advanced trauma airway management, large bore central venous access and monitoring, and rapid infusion complex massive blood component resuscitation, and are expected to do so based on their clinical judgment…no ‘mother may I’. Shock Trauma has the highest trauma survival rate in the world.
Something is wrong with the best hospitals in the world if they are allowing their most complicated surgical cases to be managed in most part by CRNAs if physician providers result in better outcomes.
I must completely disagree with your characterization that CRNAs graduate with an understanding of pharmacology that is inferior to graduating medical students. In fact in many CRNA training programs the student anesthetists are in the same pharmacology classes as the medical students.
Regarding the example of training in anatomy, I would cite this as a prime example of more not necessarily meaning better. While I would most strenuously challenge any argument that CRNAs have not been trained in anatomy to the point that they were required to be able to name every bone, muscle and tendon origination and insertion, every major blood vessel and blood supply major and minor to every organ, particular specialized components of every organ from microscopic to macroscopic, etc., etc., it is far more likely that a medical student was provided a human cadaver during all of their training. The CRNA likely dissected comparative animals for general anatomy but more than likely had human cadavers for their ‘anatomy for anesthesia’ courses.
Training CRNAs are expected to know the detailed anatomy and physiology relevant to each and every case they participate in while in school and are challenged on their knowledge while participating in the anesthetic. They place their completion of training at great risk should they fall short in these areas. In other words, if you are doing a cerebral aneurysm, you had better be able to draw and label the circle of Willis from memory.
Thank you for clarifying the ICU/CRNA involvement at your institution. You are absolutely correct when you say “There’s no reason why I should get otherwise healthy patients going into pre-renal failure because a CRNA did not give enough fluids for “fears” of issues for extubation or get healthy patients who comes to my ICU with untreated hypertension from sympathetic release from surgery”. I would suggest that this is a specific provider(s) issue, not a class of provider issue. The examples you mention are “simple” clinical issues for the average CRNA. The CRNA who cannot manage them has no business working outside of an Anesthesia Care Team setting and likely had their formative years strongly influenced by a restrictive one.
But this is the exception rather than the rule. Just as there are physician anesthesiologists who should only be allowed to participate in bread and butter outpatient procedures on low BMI patients who jog every day, all CRNAs are not created equal. But their training is no joke and their anesthesia care, even for the near dead and horrifically, hopelessly ill is the highest quality. It is said that CRNAs attract the best and brightest in nursing. CRNAs most often request other CRNAs specifically for the anesthesia care of their families, children and selves…even for the most complex situations.
Yet, either they ARE the brightest and their care as a profession is above claims of danger to the medicare community, or they are tragically stupid, mistakenly believing that their CRNA colleagues provide the best care available having witnessed it day in and day out. Indeed this would make them beyond stupid…they would have to be delusional to the point of placing their loved ones at risk because of a fantasy.
There can be no argument that physicians receive more in depth, more intense, longer and wider breath of training in treatment of the ailing human. At what point the law of diminishing returns sets in in the practice of anesthesia is the question. What is the incidence of physician involvement impacting morbidity and mortality in anesthesia? The extremes of each side of the argument say no physician is needed ever and no CRNA should practice with out constant close supervision. Neither are correct, and neither can draw the definitive line. What we do know is that the entire debate is a victim of the anesthesia professions success in the end. It is the safest medical/nursing specialty there is no matter who is in the room when.
Respectfully,
LawMed