How do CRNAs/SRNAs benefit anesthesiology residents? - page 10

I was searching for information on the Wake Forest CRNA program and happened upon this information on the Wake Forest anesthesiology program. Dr. Royster has an interesting view on how CRNA's/SRNAs... Read More

  1. Visit  loisane} profile page
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    Quote from TejasDoc
    I don't imagine it is going to cost the health care consumer any less to get anesthesia from a CRNA than it would have from an anesthesiologist.
    To really address cost, you have to look at "total cost to society". In addition to patterns of reimbursement, you have to look at cost to educate the professional. Our government is very much in the business of offsetting the cost of education for health professionals. So the cost of that education is passed on (at least partially) to all taxpayers. I don't pretend to know enough about how it all works to have specific opinions. But I think it is reasonable for all of us to at least be aware of the complexity of a true cost analysis.

    I know you like sources, so I have a couple for you. I know, you are busy trying to learn medicine/anesthesiology! I suggest the age old method of letting them stack up until you can get to them. (Actually, I think I have only read one of these, in its entirety). I have a few topics of interest, that I keep in mind. Whenever I run across an article, I hang onto it. Used to be that meant making a copy, and throwing it on the ever increasing pile of paper in my office. Now it is easier, if you can find an internet source for full text articles, just save it on your hard drive in alot less space. Or just keep a list of the references, and dig up the articles later. (This is a great way to do a less painful lit search, for any of you interested in doing research someday in your professional life.)

    Anyway, the articles. Both are by Jerry Cromwell PhD, a health economist. He does have AANA affiliations (but I believe we should read everything with a critical eye, regardless).

    Alternative cost-effective anesthesia care teams. Nursing Economics. July/August 2000. 18(4)

    Barriers to achieving a cost-effective workforce mix:Lessons from anesthesiology. Journal of Health Politics, Policy and Law. December 1999. 24(6). 1331-1361.

    Quote from TejasDoc
    As far as I know now, reimbursements are the same whether or not an anesthesiologist or a CRNA does the case, but in general, in the case of supervision or direction, the anesthesiologist takes half.
    But if we limit our theoretical discussion to the ACT, the total reimbursement for the entire case could be considered being paid to the team. The particulars for how it is divided at that point, are probably best left for another discussion.
    Quote from TejasDoc
    You said you thought there might be cases when the expertise of an anesthesiologist would be needed, but not every case. But which cases?
    Each institution would need to make these predictions. This is what health care administrators do (or are supposed to do!) Some places might need one ologist for a suite of 12 rooms. Another place, with lots of high risk patients might need several for 12 rooms. Some places might elect to have CRNAs only.

    These questions are completely appropriate, and very important. I am usually the first one to say "follow the money, it will explain everything".

    So I do not in any way want to discount the role of money in this. But here is one glaring thing about all this that really sticks in my craw. How come we are making decisions about how we will deliver care, based on reimbursement policy? Shouldn't it be the other way around? I think it is all part of a pattern of what is wrong with health care, the bean counters are telling the health care professionals how to take care of patients. The whole thing is backwards!

    I think it would be the greatest thing if nurse anesthesia and anesthesiology could find a way to talk the same language. To put the needs of patients first (I mean on a global/professional level. There is no doubt that this is done on a clinical level, already). Then figure out the absolute best way to deliver care. Then work together to fix reimbursement so it a better match for the reality of how that care is actually delivered.

    Quote from TejasDoc
    From a financial point of view, I'll lead a very good life if supervision of CRNAs in an anesthesia care team stays the predominant model.
    But you will have to jump through the 7 TEFRA hoops, or risk committing fraud. I have worked in such departments. You need LOTS of ologists to be able to keep it up. If you don't have enough, the ologists are running themselves ragged, trying to keep up with all the cases. And they end up attending to details that don't really need their attention. It seems like a tremendous waste of talent, skills, and resources to me.
    Quote from TejasDoc
    But if CRNAs are doing all their own cases under a full scope of practice, well, how will this help me? You really just then become my direct competition for employment.
    If we are comparing two independent practices, this is true. I hope you won't take this as avoidance, but I'm not going to go there. This is complicated enough, just limiting the discussion to ACT function.

    Quote from TejasDoc
    The ASA is protecting the practice of anesthesiology for me ... so I wouldn't be reclaiming anesthesiology,...
    There are innovative ACT functioning with full CRNA scope, I bet they are making money. These ologists, IM(extremely)HO, have found a way to put more "medicine" back in their practices. Hence my reference to "reclaiming anesthesiology". They are focusing on providing the care that they are uniquely qualified to provide-the perioperative medical support. When you carve out an innovative niche for yourself, you don't have to worry so much about competition. The roadblock to more of this, IMHO, is the ASA's definition of nurse anesthesia as delegated medicine.
    Quote from TejasDoc
    I'd just be giving a bigger chunk to you if I tried to vote in a more pro-CRNA leadership. Why would I want to do that?
    Another very good question, to which I wish I had a great, winning answer. I know an answer exits, but it will take me some more personal/professional growth to develop it. I am glad you asked it, because it motivates me to find the answer to it.

    This is the purpose of civilized debate and negotiation. Of course, I wouldn't characterize my suggestion as voting in more pro-CRNA leadership. But obviously, that is how it is perceived. So my challenge, is how can I make you see it the way I do? I need first to see it the way you do. And then we keep talking until we both see it the same way.

    Our professions still have far to go. But I am encouraged by the process.


    loisane crna
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  3. Visit  in2b8ix2b8} profile page
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    Quote from TejasDoc
    So I'm not really sure, what was wrong with that statement that made? I said absolutely nothing about anesthesiologists or supervision, not a thing. All the things you wrote about have to do with increased knowledge, which is exactly what I was talking about. BUT, since you brought it up. While I can't prove that anesthesiologists are not the reason why anesthesia is so much safer now than 100 years ago, I would be surprised if you can prove that is was NOT anesthesiologists. Like I said, I can't prove it, but I could put forth some arguments that would support the possibility. Anyway, I just had to chime in and say that you're putting words in my mouth or you're not reading my posts carefully enough. Either way, if you're going to call me out about something I've said, I should have said it.



    Why is the word 'order' here in quotes? Does someone actually have to put an order in the chart for anesthesia services to be provided in the states that require physician supervision? Is that the only involvement that they have? If they have to put an actual order in the chart, then I don't understand why 'order' would be in quotes. AND, if they have to put an order in the chart, then I don't understand how they're not liable if something goes wrong and it is determined that anesthesia was at fault. If I'm in the ICU, and I write an order for a dopamine drip, and it is later determined that the dopamine drip killed the patient, I'm screwed. And I wouldn't have administered the drip, the ICU nurse would have administered the drip, but I wrote the order ... sooooooo. But maybe it's a different kind of order, I don't know.



    I don't think we can throw around the word 'order' unless we're talking about a medical order from a physician, as we all know it. From our point of view as health care professionals, physician orders have a very specific meaning, if this isn't the right word, we need to find out what is the right word.

    Countless lawsuits ... but not just lawsuits, countless lawsuits ... so, I need a lawsuit to use as a reference. Just one, something I look up, something that is a matter of record in a court of law here in the United States. What would be even better is the precedent setting case in this matter. But since there are countless numbers of them, any really juicy one will do, but I need a real point of reference.



    I'm glad you also find it hard to believe that all states do not require the services of an anesthesiologist for the provision of anesthesia care. Whew, I didn't think we'd agree on anything. :> Actually, I'm getting the distinct feeling you're not reading my posts. To be totally honest, I don't care. Read my posts, don't read my posts, save 'em, burn 'em, whatever. But if you're going to argue with me about issues that I've already commented on, at least make sure that you're quoting me properly. I didn't say that the states required anesthesiologist supervision, I said some states require PHYSICIAN supervision, and then asked if a physician is in a position to supervise anesthesia care, shouldn't that physician be an anesthesiologist. Now I've said it twice.



    Ok, it's decided, you're not reading a thing I'm writing. I actually wrote out a list of things and said "Let's just call these 'practice priviledges' to make it easy." So why did you ask what I was talking about? I spelled out specifically what I was talking about and called the group of things I was talking about 'practice priviledges'.

    So your post was really just jumping down my case about a bunch of things I didn't actually say. Please let me know if you find those cases, I think they'd make interesting reading.



    Nope, he didn't, he actually did a very bad job. Loisane, you do such a good job posting, your comments are well thought out and well articulated. I'm going to agree with gaspassah on this one and say you've got him beat.

    TD
    My comment concerns the improved safety of anesthesia over the last 100 years: Improved drugs and monitoring! Can you imagine dropping ether and not having pulse oximetry or the other 'standard' monitors we employ today? It's not the arrival of the latecomers, anesthesiologists, to the practice of anesthesia that can take credit for the improved safety. The accumulation of knowledge is huge, leading to evidence-based practice. Did you know that the first anesthetic-related death is from aspiration? Now, patients are NPO based on such data, just as surgical procedures have improved over the years due to better equipment and a huge compilation of data and 'learning from the past'.


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