"Anesthesiologists are gaming the system"

[wtbcrna]

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.

[manusko]

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.

Cheaper to the hospital?

[nomadcrna, DNP, CRNA, NP]

Spin, spin and more spin. Some here should be politicians.

[wtbcrna, MSN, DNP, CRNA]

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.

So, you agree that ACTs cost more. Now that that is settled we can move on.

Again, the costs are important to everyone if the same exact care can be provided at a cheaper cost then everyone benefits.

MDAs cost around a million dollars to train and a significant portion of that comes from CMS. Less MDAs less taxpayers money. That is just a drops in the taxpayers bucket you will probably say. I would have to agree we have expected shortage of anesthesia providers which AAs cannot fill because AAs require medical supervision.

Simply, if all MDAs and CRNAs do their own cases then more cases can be done, and quality of care has been shown by state department of health and numerous studies to not decline with independent CRNA care. With OR time costing between 20-120 dollars a minute a large hospital with the additional availabity of having extra anesthesia providers available to do cases could add millions of dollars a year. That additional income would decrease overall operating costs for the hospitals. The only persons that would lose out in this scenario would be MDAs bottom line and some of their egos, and AAs would essentially be jobless if there were no ACT practices.

[wtbcrna, MSN, DNP, CRNA]

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.

CMS cares a lot if costs were cheaper. There would be little argument for the anesthesia Medicare cuts/cost containment. No ACTs...No need CMS workers that have to do anesthesia TEFRA audits...no ACTs decrease legal fees for CMS. All those lawsuits aren't cheap for either side.

I am still waiting to hear what the great benefit to anyone is for having ACTs....

[PMFB-RN, RN]

But a LOT of places won't hire them without anesthesiologists. If they exist at all, hospitals routinely doing big cases - and I mean open heart, major vascular, major peds, major neuro - are going to have anesthesiologists. Surgeons and patients demand it.

*** My hospital does lots of emergency "big cases" at nigh and on the weekend. All of them are done by solo CRNAs regardless of the kind of case being done. We only have one anesthesia provider physically in house on off hours and they do whatever kind of case needs to be done. Speaking as one who often recovers these cases I can say those CRNAs do a great job.

I VERY much doubt the patient's demand it. They seem completely unaware of who is providing their care.

[PMFB-RN, RN]

I am still waiting to hear what the great benefit to anyone is for having ACTs....

*** I'll tell you, ME! I benefit greatly from my hospital's ACT. You see we have an MDA or two hanging around drinking coffee and flirting during the week days while they are supposedly "supervising" the CRNAs. They get paid a lot of money and one of them has used some of that money to buy a super nice big lake fishing boat. Now in order to get a tax write off on his super nice boat he runs a few charters at a loss each year. He offers those charters to my CRNA friends who always include me. Me and a couple friends get a great Lake Michigan salmon charter for like $100 each summer.

Long live the ACT!

[wtbcrna, MSN, DNP, CRNA]

*** I'll tell you, ME! I benefit greatly from my hospital's ACT. You see we have an MDA or two hanging around drinking coffee and flirting during the week days while they are supposedly "supervising" the CRNAs. They get paid a lot of money and one of them has used some of that money to buy a super nice big lake fishing boat. Now in order to get a tax write off on his super nice boat he runs a few charters at a loss each year. He offers those charters to my CRNA friends who always include me. Me and a couple friends get a great Lake Michigan salmon charter for like $100 each summer.

Long live the ACT!

Well yes in that case "long live the ACT".

[mcvcrna]

Interesting discussion. However, I think it's missing to the key elements as to why CRNA's are more cost-effective than our MDA counterparts. A little long but its a complex issue.

1. MDAs demand higher salaries than CRNA's. Unfortunately, the current reimbursement from commercial insurance carriers and CMS are not substantial enough to cover the MDA salary requirements. Thus, facilities must make up the difference. The range of stipends across the country can vary from $100,000 to even in the millions of dollars annually. However, most CRNA's in business for themselves, are able to sufficiently realize their salary requirements exclusively from third-party payers and CMS reimbursement.
   

The cost-effectiveness is realized when stipend money necessary to sustain MDA only and MDA/CRNA groups is no longer required by the majority of CRNA practices. While I realize that this does not save the insurance carriers or CMS any money, the savings are realized by the facility by not having to pay for the stipend. Ideally, these savings should be passed on to the patient. But that's another discussion. In situations where the CRNA is employed by the facility, the lower salary requirements further enhances the cost savings by the facility employing those CRNA's.

1. The number anesthesia providers required to staff the ACT model is greater than that needed to staff the ACT model. Commonsense dictates that if it takes five providers (MDA/CRNA) to accomplish the same service as four providers (CRNAs) can accomplish, then more money will be required to meet the same need. If the reimbursement is the same for both providers, which in most instances it is, one could argue that the same amount of money is just split between providers and no increased cost. However this thought process undermines the most essential consideration - it cost more money to employ five providers than four providers and thus 20 providers versus 16 providers. The additional four providers (MDAs), in the latter scenario, would result on an increased salary demand of about $1-$2 million annually. This money has to come from somewhere. If the reimbursement stays the same regardless of the number providers then the money has to be made up somewhere, once again this typically this is made up by the facility in the form of a stipend. Since MDA only model typically also requires increased reimbursement, the short fall again needs to be made up. CRNA only models rarely need stipend monies - a CRNA billing for themselves with a reasonable case load can easily generate $200 - $300/annually.
   

Please keep in mind that the working premise is predicated on the current blending of model practices across the country, M.D. only, MD/CRNA (Directed model), and CRNA only billing for themselves or being salaried by a facility. If all practices billed solely for themselves and did not rely on stipends from the facilities the disparity in cost-effectiveness between providers would be diminished. However, this would also result in MDA's realizing less money for their services and thus leveling the playing field for anesthesia provider income - something the MDAs are none to happy about - which I am sure most of wouldn't be.

[Terpole]

Interesting discussion. However, I think it’s missing to the key elements as to why CRNA’s are more cost-effective than our MDA counterparts. A little long but its a complex issue.

1. MDAs demand higher salaries than CRNA’s. Unfortunately, the current reimbursement from commercial insurance carriers and CMS are not substantial enough to cover the MDA salary requirements. Thus, facilities must make up the difference. The range of stipends across the country can vary from $100,000 to even in the millions of dollars annually. However, most CRNA’s in business for themselves, are able to sufficiently realize their salary requirements exclusively from third-party payers and CMS reimbursement.
   

The cost-effectiveness is realized when stipend money necessary to sustain MDA only and MDA/CRNA groups is no longer required by the majority of CRNA practices. While I realize that this does not save the insurance carriers or CMS any money, the savings are realized by the facility by not having to pay for the stipend. Ideally, these savings should be passed on to the patient. But that’s another discussion. In situations where the CRNA is employed by the facility, the lower salary requirements further enhances the cost savings by the facility employing those CRNA’s.

1. The number anesthesia providers required to staff the ACT model is greater than that needed to staff the ACT model. Commonsense dictates that if it takes five providers (MDA/CRNA) to accomplish the same service as four providers (CRNAs) can accomplish, then more money will be required to meet the same need. If the reimbursement is the same for both providers, which in most instances it is, one could argue that the same amount of money is just split between providers and no increased cost. However this thought process undermines the most essential consideration - it cost more money to employ five providers than four providers and thus 20 providers versus 16 providers. The additional four providers (MDAs), in the latter scenario, would result on an increased salary demand of about $1-$2 million annually. This money has to come from somewhere. If the reimbursement stays the same regardless of the number providers then the money has to be made up somewhere, once again this typically this is made up by the facility in the form of a stipend. Since MDA only model typically also requires increased reimbursement, the short fall again needs to be made up. CRNA only models rarely need stipend monies - a CRNA billing for themselves with a reasonable case load can easily generate $200 - $300/annually.
   

Please keep in mind that the working premise is predicated on the current blending of model practices across the country, M.D. only, MD/CRNA (Directed model), and CRNA only billing for themselves or being salaried by a facility. If all practices billed solely for themselves and did not rely on stipends from the facilities the disparity in cost-effectiveness between providers would be diminished. However, this would also result in MDA’s realizing less money for their services and thus leveling the playing field for anesthesia provider income - something the MDAs are none to happy about - which I am sure most of wouldn't be.

Excellent post but may I ask the source of information from the bulleted points?

[mcvcrna]

Thank you. I have learned to understand this issue through 15 years of experience as a CRNA, 9 years of political involvement to include state presidency, government relations Chairmanship as well as national level government relations committee involvement, countless articles read and numerous lectures given on the subject matter. I have worked in each of anesthesia models, not as just an employee but in leadership roles that dealt with this very issue. For the past 5 years I have owned and operated an independent CRNA practice. Understanding these issues has been essential for my success as well as the success of countless CRNA owned practices throughout the country. Citing references would be arduous to say the least given the fact that the knowledge I have gained over the subject matter has come through years and years of immersing myself in the available data and experiences of others and myself.

[jwk]

Thank you. I have learned to understand this issue through 15 years of experience as a CRNA, 9 years of political involvement to include state presidency, government relations Chairmanship as well as national level government relations committee involvement, countless articles read and numerous lectures given on the subject matter. I have worked in each of anesthesia models, not as just an employee but in leadership roles that dealt with this very issue. For the past 5 years I have owned and operated an independent CRNA practice. Understanding these issues has been essential for my success as well as the success of countless CRNA owned practices throughout the country. Citing references would be arduous to say the least given the fact that the knowledge I have gained over the subject matter has come through years and years of immersing myself in the available data and experiences of others and myself.

According to a couple others in this thread, this type of experience and common sense is not important. Their view is that unless you have peer-reviewed studies (EBM is their favorite buzzword), anything you say is of little value.

However, even though we disagree, I appreciate your opinion based on your experience.

Here's where I think your assumptions are wrong, based on my 30+ years of experience and involvement in anesthesia politics and organizations at both the state and national level:

You assume that all groups that have MD's get stipends because they can't get paid enough from insurance and CMS payments alone. That is simply a false assumption - there are plenty of groups out there that receive no stipend at all. There are a myriad of factors that go into this - payor mix, size and location of hospital, size of group, coverage required by hospital, etc. My group covers three hospitals with 24/7 in-house MD and anesthetist coverage and has never received a stipend from the hospital. A group like ours, which provides excellent service and quality of care at zero cost to the hospital, is gold. An AMC can't come in and displace us - what would their claim be? They can't be cheaper - we don't cost anything now. They can't do it better - nobody is out there claiming they're changing to an AMC because the quality of care will improve.

You also want to give the impression that only MD or ACT practices take stipends. You and I both know that isn't true - there are CRNA groups or individual CRNA's that take stipends as well, and the Medicare Part A pass-through in and of itself is a form of stipend that is only available to CRNA's.

Your assumption that ACT practices require more personnel compared to a CRNA-only practice is an apples to oranges comparison. Yes, at least one MD will be required for four rooms in an ACT practice, but that MD does other things besides provide medical direction. They see patients in pre-op, do blocks or epidurals, place lines, handle the PACU, etc., providing efficiencies that aren't possible if all your providers are in the OR. Ah, I know you're thinking a CRNA can do the same thing - you've just lost your argument with number of providers. As you've already indicated, reimbursement is the same. How the compensation numbers are shifted around is up to the employer and has nothing to do with the costs to the patient.

Here's the most important thing in your whole post - "I realize that this does not save the insurance carriers or CMS any money". Exactly the point I've been trying to make for a while. To the people who actually pay the bills, you're not cheaper than an MD.

[wtbcrna, MSN, DNP, CRNA]

Your assumption that ACT practices require more personnel compared to a CRNA-only practice is an apples to oranges comparison. Yes, at least one MD will be required for four rooms in an ACT practice, but that MD does other things besides provide medical direction. They see patients in pre-op, do blocks or epidurals, place lines, handle the PACU, etc., providing efficiencies that aren't possible if all your providers are in the OR. Ah, I know you're thinking a CRNA can do the same thing - you've just lost your argument with number of providers. As you've already indicated, reimbursement is the same. How the compensation numbers are shifted around is up to the employer and has nothing to do with the costs to the patient.

Here's the most important thing in your whole post - "I realize that this does not save the insurance carriers or CMS any money". Exactly the point I've been trying to make for a while. To the people who actually pay the bills, you're not cheaper than an MD.

1. Yes, CRNAs can and do all the things that you mentioned. I do all of these things on a regular basis. Who do you think does all these things in military practices and CRNA only practices.

2. As I have already pointed out CRNA only practices can save CMS money. Eliminate some of the CMS sponsored anesthesiology resident slots and save taxpayers nearly a million dollars in training costs per resident. Simply by eliminating the costs of having to regulate and bill for medically directed services by TEFRA could save millions of dollars.

3. JWK you have experience with only one type of practice. The ACT model. You cannot speak personally for any other type of practice, because your credentialing as an AA does not allow AAs to work in any other type of environment, and from your posts it sounds like you have worked for one anesthesia practice for most of your career. The CRNAs on here all have worked/trained in a variety of anesthesia environments. The one paper on cost effectiveness of different type of practices which you have not addressed specially address large ACT practices. Simply stating, that a "large" ACT practice can be nearly as cost effective as a CRNA only practice. Large practices such as yours are only a small portion of ACTs and that explains why most ACTs need stipends to survive. CRNA only practices can need stipends to survive too, but since the costs are less the need for stipends and the overall amount of the stipends is going to be less than ACT practices.

4. All those points are not opinions by a poster they were covered in the articles I have already provided in this thread and the other one that you are frequently commenting on here.

5. Everyone but some anesthesiologists and AAs would benefit from eliminating ACTs medical direction model. Hospitals could do more surgeries with less anesthesia providers. The costs to CMS (as I already pointed out a couple of times) and to the hospitals would be decreased. The political and legal costs could be greatly decreased by the largest medical PAC (ASA), and the AANA. We could focus efforts on more mutual outcomes in anesthesia. There is absolutely no benefit to gained from ACT practices other than to make anesthesiologists more money.