Role of MDA vs CRNA

  1. Pardon my inexpertness. :uhoh21:

    There have been a few threads up recently which have canvassed the roles of MDAs and CRNAs.

    I live in KY, and have shadowed CRNAs. They are required to get signed off by an MDA prior to the procedure - KY has not opted out from CRNA supervision. I was interested in learning the perspective on how MDAs comparitively view CRNAs with their MDA role. Interestingly enough, I found the following passage from my university's Department of Anesthesiology. Keep in mind, this passage is directed to patients who are learning about anesthesia...

    "In some hospitals, nurse anesthetists may assist the anesthesiologists with the monitoring responsibilities. However, it is the anesthesiologists who are responsible for the interpretation of that monitoring and who make educated medical judgments concerning the patient's responses, and when it is and when it is not appropriate to treat the patient."

    Despite this being their perspective, I am bothered that the passage implies that CRNAs just assist the MDA with monitoring. This is not upper limit practice. My question is - if a state has not opted out from MD supervision, what are the upper limits of CRNA practice? Can CRNAs perform the same procedures as the MDA, as long as they are supervised?
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  2. 11 Comments

  3. by   loisane
    CRNAs are educated to perform all the same functions as MDAs. Depending on state law, they may perform anesthesia independent from physician supervision. Many CRNAs work directly with surgeons, without MDA involvement.

    On the other hand, many anesthetics are delivered by a team of MDAs and CRNAs working together. Each of these teams may have their own philosophy/attitudes of how the team functions. But it is the stated policy of the professional anesthesiologist organization that the MDA is in charge, anesthesia is the practice of medicine.

    The professional organization of CRNAs policy is that anesthesia delivered by MDs is the practice of medicine, and anesthesia practiced by CRNAs is the practice of nursing. This position has been upheld in many court decisions.

    I heard KY state CRNA president speak last year. Kentucky was all set to opt out, and at the last minute the states anesthesiologists were succesful in their efforts to prevent the opt out. I would imagine that many Kentucky MDAs are of the "anesthesia is the practice of medicine" type. A department with such a philosophy would certianly describe anesthesia in the way you quoted.

    Remember, the very fact that Kentucky was eligible for opt out, means that their nurse practice act does NOT require physician supervision. So the "signing off" you have witnessed, is more likely hospital policy, than a legal requirement.
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    SIGH-Why-o-why do we have to keep repeating ourselves????

    No offense, ether. But it just seems like we keep repeating ourselves over and over. Having to explain ourselves, having to justify our practices, having to defend everything. Even on this forum, made up of educated RNs, who are INTERESTED in anesthesia. Sometimes it feels like spitting into the ocean. It just never seems to make a difference.

    I'm sorry. I am usually a positive person. But right now it feels like I am spinning my wheels. I have shared the positive, and now I am sharing the feelings of frustration. I hope some of you can identify.

    Really, absolutely nothing personal about this particular question. I guess it is just so complicated, that these questions will always be asked. I just need to take a deep breath, let it out, and move forward, once again.

    Thanks for listening. And, ether, keep asking whatever you need to. I want you to get all the information you can. Then, please, help us spread the word, and answer others when they ask these same questions, as I know they most surely will.

    loisane crna
  4. by   Kiwi
    :stone I'm sorry.
  5. by   loisane
    ether,

    No, no, no, no. Absolutely do not be sorry. That was not my intent, honestly.

    My frustration was not directed at you. Only at the environment our health care is in.

    Please, keep asking. To not ask only contributes more to the problem I am frustrated about!!!

    loisane crna
  6. by   yoga crna
    Ether,
    I have a lot of things I would like to say about your topic, but I couldn't say it any better than Loisane.

    There is one thing that I do need to add for you and everyone on this board.

    SUPERVISION, AS RELATED TO MEDICARE IS A REIMBURSEMENT ISSUE AND NOT A PRACTICE ISSUE (emphais intended). All of this business about opt-out, TEFRA Rules of Medical Direction, etc. are not practice requirements or standard of care requirements. They are simply reimbursement issues related to Medicare. Look at your state nurse practice act for scope of practice statements, not at what are reimbursement issues.

    We all need to understand the facts and argue them whenever someone else is misinformed.

    Yoga CRNA
  7. by   loisane
    yoga,

    An excellent point. I am very glad you emphasized this. In fact, I would say it is THE POINT about all these discussions of this type. It can NOT be over emphasized.

    loisane crna
  8. by   jemommyRN
    Thank you guys for answering the question *again*. We just really want to be sure of what we are getting into and who better to ask than experienced CRNAs whom we trust and respect their opinions.
  9. by   Trauma Tom
    Yoga CRNA or LOISANE,

    Thank you for addressing this issue.I have been confused on this issue. I could not understand why the opt out was so important since CRNA's can practice without MDA supervision. I have tried to research the OPT out issue however I have been unable to get a clear answer. My instincts told me it must have been about a financial issue. So answer me this. If I am practicing independently in a rural practice must I have physician supervision to bill medicare? Is this only a medicare issue or is third party billing and medicaid affected as well. Also, I do not understand why this is an issue, or do you get less compensation if not supervised by a physician? Does the supervising physician bill medicare and then they reimburse the CRNA. Or does this requiremnt somehow limit the compensation the CRNA gets paid. In other words, does the billing MD retain some of the payment for the service, and then pay the balance to the CRNA? I would appreciate some clarification on this issue, as it seems rather complicated, especially if it does not affect the practice laws of CRNA's.


    Tom

    Quote from yoga crna
    Ether,
    I have a lot of things I would like to say about your topic, but I couldn't say it any better than Loisane.

    There is one thing that I do need to add for you and everyone on this board.

    SUPERVISION, AS RELATED TO MEDICARE IS A REIMBURSEMENT ISSUE AND NOT A PRACTICE ISSUE (emphais intended). All of this business about opt-out, TEFRA Rules of Medical Direction, etc. are not practice requirements or standard of care requirements. They are simply reimbursement issues related to Medicare. Look at your state nurse practice act for scope of practice statements, not at what are reimbursement issues.

    We all need to understand the facts and argue them whenever someone else is misinformed.

    Yoga CRNA
  10. by   deepz
    Quote from Trauma Tom
    ......I do not understand why this is an issue, or do you get less compensation if not supervised by a physician? Does the supervising physician bill medicare and then they reimburse the CRNA. Or does this requiremnt somehow limit the compensation the CRNA gets paid......
    Very confusing stuff, T-Tom. First, CRNAs are paid the same local rate as MDAs by Medicare under Part B. Anesthesia is anesthesia. CRNAs were the first APRNs to be granted independent Medicare billing rights, back about 1987 or so.

    The current Opt-Out issue concerns the COP (conditions of participation) for hospitals. An institution cannot 'participate' and receive their *Part A* reimbursement from Medicare unless, basically, either, 1 -- CRNAs are nominally 'supervised' in whatever manner the institution chooses, or, 2 -- that State in question has been granted the Opt-Out by their Governor sending a letter to CMS, notifying CMS that the State will take advantage of the option. No need for approval back from CMS, etc.; sending the letter constitutes the Opt-Out.

    For CRNAs who function under condition 1 above, the concern has long been that, because of the nominal administrative function the 'supervising' doc (usually the surgeon) serves, even so simple a 'supervision' as co-signing a Pre-Anesthetic Evaluation H&P, that by that act the doc will incur vicarious legal liability for the acts and ommissions of the CRNA. MDAs are known to push this line. It is not true, but doc-to-doc misinformation often passes unquestioned, especially if repeated often enough and devised in a manner so as to appeal to some physicians' egos -- "Hey, you're in charge, aren't you?"; but in fact courts sank the Captain of the Ship Doctrine as it applies to medical liability long ago. We CRNAs are liable for our own acts, just as the surgeons are for theirs. AANA.com has a lot to read on this issue. Essentially, the surgeon's fear of vicarious liability is minimized in Opt-Out States.

    Very confusing stuff.

    deepz
  11. by   yoga crna
    As a profession, we MUST stop using the term "supervision". The perception of "supervision" is in conflict with the reality of independent practice. In my opinion, the only anesthetists who need "supervised" are student or a CRNA returning to practice after a long period. We can't have it both ways--either we are professional independent practitioners or technicians. I consider my self the former and have strong feelings about those CRNAs who believe that they must be supervised. Individual facilities and practice settings may have varying policies, but I would choose not to work in one that does not recognize my professional status.

    The AANA has fought for years for reimbursement rights for CRNAs and most insurance companies pay well for our services. This has nothing to do with "supervision", but payment for a professional service. Some nurses have trouble understanding this, but remember it is a lot easier to learn the business and economis of anesthesia than it is to do anesthesia. It is an educational issue.

    Yoga CRNA
  12. by   loisane
    Tom,

    I think deepz has summarized the major points well, which is quite a task for this complex subject.

    I would like to build on Yoga's very important point made earlier in this discussion. Recognition to practice as a CRNA is granted by the state. Each state has laws and regulations that govern the practice of nurse anesthesia. Each CRNA should be knowledgable about the laws of the state(s) in which they practice. The AANA website has a state by state summary of these, to get you started. The nurse practice act in some states does require that CRNAs be "supervised" by a physician. Other states do not have this language in their NPA. No state requires that the physician be an MDA.

    Then there are billing requirements. Many of the requirements that get quoted as "laws" are not legal requirements. They are issues that determine how an anesthetic may be billed. Medicare bills can be categorized in three ways-supervised, medically directed or non-medically directed. Each one of these categories have particular sets of regulations associated with them.

    These differences in billing categories can have a direct impact on your finances. The more you know about the business of anesthesia, the more control you have of your own earning potential. So your questions are good ones, although not easily answered.

    I must confess, I am not one of these business savy CRNAs. But we have Yoga, and deepz, and maybe others.

    loisane crna


    ps to ether, if you are still around. The complexity of this discussion makes me realize that I did not immediately appreciate the full context of your question. I am glad others did, and responded more appropriately than I did. Hope I'm forgiven ;-)
  13. by   Kiwi
    Thank you for you input. Yoga, Deepz and Loisane - you all represent this profession so well. Its people like you who cut the "red tape" in this tumultuous field of healthcare! There is a general trend in nursing to be more "professional". I've been priviliged to attend a progressive nursing school where have to wear Lab coats as part of our uniform, and share learning resources with the medical students. It really irks me that many of the ICU nurses I work with still insist on calling themselves blue collar workers, as if they were skilled labor.

    This is a confusing issue. I side a bit with Loisane - I'm not into the business aspect of this profession. But I do consider myself a strong advocate for patients and the CRNA profession. I consider it to be the best kept secret in healthcare due to the proficiency and safety.

    I will check out more about CRNAs practicing in KY. I've got a better grasp of it now.

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