"Anesthesiologists are gaming the system"

Specialties CRNA

Published

http://thehill.com/blogs/congress-blog/healthcare/309183-anesthesiologists-are-gaming-the-system

To make this whole issue even more absurd are two recent studies published in the journal "Anesthesiology," the official publication of the ASA, and "Anesthesia & Analgesia." In one, communications with "supervising" anesthesiologists were evaluated revealing that less than 2 percent of such communications originated from those being "supervised" in the OR. In the other, the authors revealed significant lapses in the ability to meet the accountability rules as the number of "medically directed" CRNAs increased - lapses which occurred 99 percent of the time! The study also identified a 22-minute delay when anesthesiologists try to meet the guidelines in order to properly bill for medical direction. With Medicare anesthesia provider reimbursement at a rate of $1.43 per minute, and perhaps millions of such delays every year, the waste of Medicare dollars adds up very quickly, even when the criteria can be met. But this is only a small part of the inherent economic fiasco. While patients waits for an anesthesiologist, the standard Operating Room charges are also accumulating at a rate of $25-50 per minute!

The solution to this problem is exquisitely simple. The president, via his HHS Secretary, must eliminate reimbursement for medically directed anesthesia claims other than those incurred when teaching students or residents. All anesthesia professionals privileged to relieve pain and suffering should actually administer anesthetics. As a society we simply cannot afford to have highly trained anesthesiologists, whose residencies are financed by taxpayers, "supervising". If a procedure requires multiple anesthesia providers due to surgical acuity or complexity, the current regulations provide for full reimbursement. The system currently incentivizes inefficiency without any gain in quality or safety, and potentially pays for services not rendered. This change eliminates the waste of millions or even billions of taxpayer-supported health care dollars and the submission of fraudulent claims. This would force anesthesia departments to become more efficient and allow all Americans to receive the same high level of care as our military heroes.

Specializes in Anesthesia.
Your own article proves my point. Revenues (what the payor actually pays) are the same, whether done by MD only, CRNA only, or an ACT group. I think in our area, a Medicare unit is about $17. If it's a 10 unit case, that's $170. If a CRNA alone does the case, it costs Medicare $170. If an MD alone does the case, it costs Medicare $170. If it's done by a doc and anesthetist in an ACT practice, the cost to Medicare is $170. WHERE IS THE SAVINGS?????

4x17=68 vs. 5x17=85... I think that is pretty clear, and that doesn't even add in the difference in salaries.

Basic math as was depicted in the charts.

Let me break it down in an even more basic format.

MDA + crna (4 cases): cost 20(mda) 10(crna)=60, Cases pay 100. Profit is 40

CRNA solo(4 cases): cost 40, cases pay 100. Profit is 60.

This is very basic but should help you understand the math behind it. So if the CRNA is employed, the hospital either saves money or makes more money depending on variables of course.

If it is a group, the group either saves money or makes more money, again depending on the variables.

Very simplistic but basically the same concept.

BTW Revenue is NOT the same as profit.

I'm not talking about profit. That's for the hospital/group/practice to determine. It is not the function of Medicare or private insurors to determine the profit to a group or hospital. If the hospital employs the anesthetists, they're going to take their cut, no different than a private practice group would do, even in a private all-CRNA group. Unless you're totally independent and do your own billing, the employer is the one who has to deal with overhead.

The CHARGES to the insuror, Medicare in particular, are THE SAME. THAT is what is simple.

4x17=68 vs. 5x17=85... I think that is pretty clear, and that doesn't even add in the difference in salaries.
You guys are still dodging the issue. If we want to use a doc and 4 anesthetists to do 4 cases, that's fine. We're not going to be paid any more by the insurance company than we would if it was 4 anesthetist or 4 docs doing those cases.
Specializes in Anesthesia, Pain, Emergency Medicine.

Sometimes you just have to laugh, shake your head and move on.

Specializes in Anesthesia.
You guys are still dodging the issue. If we want to use a doc and 4 anesthetists to do 4 cases, that's fine. We're not going to be paid any more by the insurance company than we would if it was 4 anesthetist or 4 docs doing those cases.

The RVU is the same, but the costs are different. I think you are somehow trying to say that since Medicare pays the same then that makes the costs the same. That is like saying 2+2=10. It does not add up. In a mixed group you would have 5 anesthesia providers doing 5 cases, and billing for 5 cases at 100%. In ACT, at the maximum, you have 4 cases with 4 CRNAs and 1 supervising MDA spliting the billing for 4 cases. 4 does not equal 5 no matter how you slice it.

A lot of anesthesia groups are not owned or operated by the hospital.

"CRNAs acting independently provide anesthesia services at the lowest economic cost, and net revenue is likely to be positive under most circumstances. The supervisory model is the second lowest cost but reimbursement policies limit its profitability. In facilities where demand is high and relatively stable, the medical direction 1:4 model is better than the other medical direction models and can approach the net revenue benefits of the CRNA model. However, in areas of low demand, the medical direction models are inefficient. The medical direction 1:1 model is almost always the least efficient model.CRNAs acting independently is the only model likely to have positive net revenue in venues of low demand, such as may be found in rural areas. Other models, including medical direction models where one anesthesiologist directs two to four CRNAs, are likely to require subsidies in cases where overall demand is not consistent with full utilization of facilities. Finally, analysis of claims data suggests CRNAs acting independently are the lowest cost to the private payer."

http://www.medscape.com/viewarticle/726678_6

The RVU is the same, but the costs are different. I think you are somehow trying to say that since Medicare pays the same then that makes the costs the same. That is like saying 2+2=10. It does not add up. In a mixed group you would have 5 anesthesia providers doing 5 cases, and billing for 5 cases at 100%. In ACT, at the maximum, you have 4 cases with 4 CRNAs and 1 supervising MDA spliting the billing for 4 cases. 4 does not equal 5 no matter how you slice it.

A lot of anesthesia groups are not owned or operated by the hospital.

"CRNAs acting independently provide anesthesia services at the lowest economic cost, and net revenue is likely to be positive under most circumstances. The supervisory model is the second lowest cost but reimbursement policies limit its profitability. In facilities where demand is high and relatively stable, the medical direction 1:4 model is better than the other medical direction models and can approach the net revenue benefits of the CRNA model. However, in areas of low demand, the medical direction models are inefficient. The medical direction 1:1 model is almost always the least efficient model.CRNAs acting independently is the only model likely to have positive net revenue in venues of low demand, such as may be found in rural areas. Other models, including medical direction models where one anesthesiologist directs two to four CRNAs, are likely to require subsidies in cases where overall demand is not consistent with full utilization of facilities. Finally, analysis of claims data suggests CRNAs acting independently are the lowest cost to the private payer."

http://www.medscape.com/viewarticle/726678_6

The costs to the PRACTICE is different - the cost to the payor is the same. When you try and claim that CRNA's are the cheapest alternative for something like Medicare, it's simply not true. Y'all are trying to make the case that you're a less expensive alternative, when the fact is, what you are paid from Medicare and insurance companies is the same as what it would be if a doc or a doc/anesthetist did the case. A 10 unit case is a 10 unit case is a 10 unit case. What happens after the insurance payments are deposited in the bank is immaterial.

Specializes in critcal care, CRNA.

The costs to the PRACTICE is different - the cost to the payor is the same. When you try and claim that CRNA's are the cheapest alternative for something like Medicare, it's simply not true. Y'all are trying to make the case that you're a less expensive alternative, when the fact is, what you are paid from Medicare and insurance companies is the same as what it would be if a doc or a doc/anesthetist did the case. A 10 unit case is a 10 unit case is a 10 unit case. What happens after the insurance payments are deposited in the bank is immaterial.

Are costs to the PTs based on the costs of the hospital? I really don't know but I would think that if the hospital has to pay more to supply a provider then they would charge more.

Specializes in Anesthesia, Pain, Emergency Medicine.

Nice try at spin. Here is what got the discussion started. Not medicare.

WTB, no matter how much logic or science you use, some will be unable or unwilling to admit it. AA are really not needed, period. Especially from a cost standpoint.

The most expensive to least expensive types of practices are anesthesiologist only practice followed by ACT practices, and then CRNA only practices (mixed independent practices would fall between ACTs and CRNA only practices). This is a fact that is well documented.

https://www.aana.com/resources2/rese...j_10_hogan.pdf

That is why you do not see the ASA trying to refute this. This is simple math if you have 4 anesthesia providers doing cases instead of 5 (the 4 CRNAs and 1 MDA) then you are billing for 4 cases at one time instead of 5. There is no possible way that an ACT would ever be as cheap as CRNA only practice or an MDA/CRNA independent practice of comparable size.

Specializes in Anesthesia.
The costs to the PRACTICE is different - the cost to the payor is the same. When you try and claim that CRNA's are the cheapest alternative for something like Medicare, it's simply not true. Y'all are trying to make the case that you're a less expensive alternative, when the fact is, what you are paid from Medicare and insurance companies is the same as what it would be if a doc or a doc/anesthetist did the case. A 10 unit case is a 10 unit case is a 10 unit case. What happens after the insurance payments are deposited in the bank is immaterial.

The simple fact is ACTs cost more to run than either mixed independent practices or CRNA only practices. It is the one of the biggest reasons that the majority of rural practices are CRNA only practices.

The simple fact is ACTs cost more to run than either mixed independent practices or CRNA only practices. It is the one of the biggest reasons that the majority of rural practices are CRNA only practices.

Nice try - the charge to the patient is the same. The cost to the practice doesn't matter.

And you know as well as I do that the playing field isn't level for rural hospitals that are able to use Medicare Part A to help pay for their anesthesia services andthat those payments aren't available to anesthesiologists.

Specializes in Anesthesia.
Nice try - the charge to the patient is the same. The cost to the practice doesn't matter.

And you know as well as I do that the playing field isn't level for rural hospitals that are able to use Medicare Part A to help pay for their anesthesia services andthat those payments aren't available to anesthesiologists.

I am talking about costs and you are talking about billing. The last time I looked those are two different entities.

ACT practices cost more than any other type of practice besides MDA only shops.

I am talking about costs and you are talking about billing. The last time I looked those are two different entities.

ACT practices cost more than any other type of practice besides MDA only shops.

Do you think payors care what your costs are? They only care about what you charge them.

You're trying to convince us that CRNA's are cheaper - cheaper to WHOM? It's not the payor, and that's what matters. When you try and claim to CMS that you're a cheaper alternative than an MD or ACT practice, it's simply not true.

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