AANA members

subee, MSN, CRNA · May 15, 2006

Let me preface this by saying that I am a CRNA (Texas Weslyan, class of ancients) turned MD (UT Galveston School of Medicine) that has been on both sides of the argument.
I joined an academic institution after two years in private practice, in one of the most prestigious programs in Texas and the nation. One of my colleagues was sent this link and he in turn sent it to me because of his anger over it.
Having been on both sides, I would argue that the "HR5246 makes training residents more attractive/training SRNA's less attractive" argument is a false one. I am on the residency review committee and participate in the business committees of this program. It is similar to just about every other strictly academic practice.
The training of residents has been and will always be more expensive than the training of SRNA's. A resident makes an average of $40K in residency training on top of health, disability, 401K, book/education fund, and liability insurance coverage. SRNA's get no pay, limited on site health coverage, and liability. Still, it costs money to train both and we need more money to train both.
Even if we received a windfall of cash, we could never get rid of or even reduce our CRNA's and/or SRNA's because they are a vital component to the quality of health care provided at this institution. On top of that, we and any other training program can't just double the size of the residency. The ACGME and ABA require each resident to have a certain number of subspecialty cases in order to graduate, the most important being hearts, heads, pedi, and OB. heartICU, you probably know better than me that the number of heart cases is going into the toilet (haven't done hearts since residency and don't want to do any more) as are the number of heads now that radiologists are doing coils in the brain. When a residency expands, it is usually for expanded coverage of a new facility or new service (vascular, general, ortho, etc.).
It takes at least one year, plus submission of case loads and particularly subspecialty case loads, to get an approval to expand, and usually only one or two spots, almost never more unless a program doubles in size (four years ago one satellite academic program in Florida went from a two hospital system to a five hospital system, and even then only 4 spots were given to them because of the limits in heart and pedi numbers).
What bothers me is that all academic programs are having a hard time keeping and hiring great teachers. My program over the last year lost three young and bright MD's (guys that wanted to teach and do research, unlike some of my colleagues). On top of that, the hospital still had to cap CRNA work hours to make budget. Our chief CRNA is saint that juggles a full work and administrative slate yet still makes our CRNA's happy to stay here on at least a part time basis, but every year we lose one or two more great CRNA's to private practice in the city or suburbs.
Go ahead and oppose HR5246, but don't think you're just hurting MD's/residents and "levelling the playing field". This isn't a competition. A residency exists under its own restrictions and limits and on top of that more funding isn't going to make administrators all of a sudden want to spend MORE money on the benefits and extras it costs to train more trainees, i.e. the expensive residents. Once again, residency programs can't expand by more than one or two spots at most and only if the subspecialty numbers justify it, and top of that, Medicare ALREADY PAYS for the training of residents in EVERY field of medicine. HR5246 means we get to collect more on work the residents do, and more money means we get to hire or at the very least keep the best teachers and researchers in our programs, be they MD or CRNA.
By opposing HR5246, you're hurting everyone in an already underappreciated and underfunded academic community and it still won't make training SRNA's more attractive than they ALREADY ARE. It IS creating a tense environment for the CRNA's and a consequence is that more capping of work hours might happen as departments struggle to balance budgets and keep faculty salaries competitive enough to keep teachers on board (I make half of what I did in private practice but I can accept it because I'm given a little more time to spend with my family).
If HR5246 passes, the AANA can then make a similar proposal and argue discrimination on its behalf to increase reimbursement to 1:1 for supervised SRNA cases and that will then bring even more money to the academic programs and make everyone happy.
B.J.W., M.D., CRNA, RN, PFOT (soon to be proud father of twins)

Thanks for taking the time to add your comments and enjoy those little babies when they come. Congrats.

KeithEMU · May 16, 2006

Instead of just opposing the bill, because the bill is a just cause, wouldn't it be better to ask that the bill just be modified to include SRNA programs? In other words, all anesthesia programs would be allowed to charge.

CRNAtoMD · May 16, 2006

This is the third time I will try to post a response and I hope the board gremlins don't eat it up again.

CMS' rules are rules that originally applied only to physician trainees but were later bastardized to SRNA training programs. CMS will not consider the rule as it applies to SRNA's only and doesn't want to consider it for both residencies and SRNA training programs because it is a rule that again was written for residencies originally and the cost of considering both makes CMS want to just drop it like a hot potato.

If the bill passes and the rule is changed for residents, the AANA has a precedent and can push CMS to correct the rule for SRNA training programs on the basis of unfair discrimination against SRNA's (read: BIG LAWSUIT if they don't change it). Since they won't reconsider the rule just for SRNA programs and don't want to reconsider it for both, we have to start with HR5246 first.

MMacFN let me address your questions one by one.

We need more anesthesiologits. If we increase public spending for more then we are that much closer to displacing more CRNAs.

No. This rule change applies only to academic practices. My program loses $30 million in lost resident billing, $12 million in lost SRNA billing ANNUALY. That extra money would be used to hire more CRNA's and anesthesiologists, but the anesthesiologists would be anesthesiologists that would be required to teach and do research. To do that, they cannot be in the OR all or even just most of the time so they have to supervise to have time away from the OR to do research and to have time (and someone) to teach. It CANNOT be a sudden new influx of residents because as stated above, the ABA and ACGME will not allow it based on subspecialty training numbers. Will private docs suddenly flock to the academic centers? Only the ones that actually want to teach and do research. If you just want to work and make money, private practice offers too much more than even the most competitive academic center. Who does that leave? CRNA's and SRNA's which have no ACGME or ABA limits in the number that can be hired/trained at an academic program.

2) I also agree with your ascertion that it is much cheaper to train a SRNA than any MD residency. Secondly, its a 4 year (or 3) residency for an MDA and so you could (theoretically) train 2:1 or 3:1 CRNAs for every MDA. So it easily appears that this should be of no threat to the CRNA population. I would ask, however, isnt this a slippery slope? Here is what I mean:
- Add more residents = less resources for SRNA training and increased competition for cases. In an MDA run hospital (the majority) it seems clear who will get prefrence in cases.
- Other hospital Anesthesia Depts see this success and also increase their MDA residency (or open one) based on the new bill and the funding. Now multiple hospitals decrease SRNA training resources in favor of MDA residency resources.

Again, it isn't that easy, especially to open a residency program. To start one requires multiple submissions of plans to the ACGME, full accreditation, appropriate didactics, staff, didactic facilities, etc. all of which can add up to millions of dollars. Last year, the ACGME placed 20 anesthesiology residencies on probation for training violations (specialty case numbers, work hours violations, etc.). The majority of residency programs aren't looking at the funding as a way to expand their residencies, it's looking at it as a way to remain solvent and not OVERWORK their CRNA's, SRNA's, and residents. With the restrictions of the ACGME and ABA, ALL of those programs would have hired MORE CRNA's to correct the residency deficiencies, not expand the residency and provide an even more substandard experience, had the funding been available.

3) If your the AANA and you continually feel under attack based on the general ASA premise that "anesthesiology is the practice of medicine not nursing" wouldnt you be skeptical of the motives? Remember, it wasent that long ago that the ASA was attempting to turn the CRNA into a subserviant Physician Assistant type role with that very statement.

There is a lot of rhetoric on both sides. It is a vicious cycle of action and reaction that seems to be endless. Physicians want CRNA's to be dependent practitioners, CRNA's want to independent practice and the right to practice pain management, on and on and on. I hate both sides of this story. Neither side is innocent and neither side can be faulted for looking out for their own, but this isn't something that is just found in anesthesia. Look at ophthamologists and optometrists, obstetricians and midwives, general practitioners and nurse practitioners, etc. Everyone wants to be "the man/woman". It all comes down to what you feel your sphere of influence should be. This is an issue that can't be settled on this board.

4) What does it say to the AANA/CRNA/SNRA when the government not only increases public funding for MDA residency slots, but is also paying them a stipend salary yet the SRNA is not paid and covers all their own expenses for similar free student labor? Med students already did it in their internship/med student days, nurses already did it in nsg school... why is that OK now? What message does that send to SRNAs? It wouldnt be a stretch to say that the message might be seen as this:
By increasing public funding for MDA training, yet not addressing the inherant costs of SRNA training the Government appears to value the MDA over the CRNA.
Afterall, is there really a difference in cost incurred by the SRNA or MD in training in a year? It would seem the government could put less than half that money into SRNA training and get twice the providers.

When I finished nursing school I had a $45K debt but I was immediately able to get a job and pull in $45-50K/year starting. When I finished medical school, I had $114K debt and wanted to start working, but I could not because while I had finished med school, I did not have and could not get a license until I finished my third board exam and applied for a state license which takes months after the exam result is returned.

During internship and residency, without income and little to no time to moonlight, I and my family would have starved. As an SRNA I was still working in local ER's and ICU's and earning enough money and of course learned after I finished, that I could have gotten special educational loans.

The government doesn't value the MD over the SRNA. It recognizes that the inherent nature of internship and residency precludes working outside of the training program to earn income to just live. It recognizes that the resident has to spend 4 years doing nothing but training and learning at high hours/week. The 80 hour work week helps, but many programs push their residents to that limit and without pay, do you think the resident would have time after the 80 hours/week training to study, sleep, AND earn enough income just for expenses, not to mention family, family time, etc.?

5) Does the hospital actually incur any expense for the MDA or the SRNA? Are there costs for each as it is and how much of that cost is absorbed by the public money?

The salary of the resident is Medicare funded, although that funding is sporadic and not always what it is promised to be, therefore the department has to be ready to meet the shortfall that always occurs. As I stated before, the costs to the hospital for funding a resident are significant. SRNA training costs are primarily Liability Insurance and limited on site health insurance.

6) This statement sounds good:
If HR5246 passes, the AANA can then make a similar proposal and argue discrimination on its behalf to increase reimbursement to 1:1 for supervised SRNA cases and that will then bring even more money to the academic programs and make everyone happy.
However, waiting until after the ASA gets what they want seems counter productive and possibly doomed to failure. What is wrong with suggesting amendments to this same bill for 1:1. Then everyone is happy and noone loses? Waiting until the ASA already gets what they want to make an attempt (which will most certainly be opposed by the ASA) seems a setup for failure?

I PM'd you the reasons in response to your PM. CMS made this a physician only issue. It doesn't want to change the rule for physicians. Adding the extra cost of SRNA reimbursement to the effort would make them LESS pliable to the idea. So it boils down to this: CMS won't reconsider the rule just for SRNA's, and doesn't want to reconsider it for both because of a doubling of cost to the Medicare system. It MIGHT reconsider the rule for physicians at this time. That is the only starting point. I know that the AANA doesn't believe CMS isn't willing to consider both together, but I wrote to CMS and they were very clear that this was being viewed as strictly a physician issue at this time. Change it, set the precedent for SRNA training programs, and then both sides can get what they want and most importantly, our beloved training programs can finally climb above sea level.

Nitecap · May 16, 2006

This is the third time I will try to post a response and I hope the board gremlins don't eat it up again.
CMS' rules are rules that originally applied only to physician trainees but were later bastardized to SRNA training programs. CMS will not consider the rule as it applies to SRNA's only and doesn't want to consider it for both residencies and SRNA training programs because it is a rule that again was written for residencies originally and the cost of considering both makes CMS want to just drop it like a hot potato.
If the bill passes and the rule is changed for residents, the AANA has a precedent and can push CMS to correct the rule for SRNA training programs on the basis of unfair discrimination against SRNA's (read: BIG LAWSUIT if they don't change it). Since they won't reconsider the rule just for SRNA programs and don't want to reconsider it for both, we have to start with HR5246 first.
MMacFN let me address your questions one by one.
No. This rule change applies only to academic practices. My program loses $30 million in lost resident billing, $12 million in lost SRNA billing ANNUALY. That extra money would be used to hire more CRNA's and anesthesiologists, but the anesthesiologists would be anesthesiologists that would be required to teach and do research. To do that, they cannot be in the OR all or even just most of the time so they have to supervise to have time away from the OR to do research and to have time (and someone) to teach. It CANNOT be a sudden new influx of residents because as stated above, the ABA and ACGME will not allow it based on subspecialty training numbers. Will private docs suddenly flock to the academic centers? Only the ones that actually want to teach and do research. If you just want to work and make money, private practice offers too much more than even the most competitive academic center. Who does that leave? CRNA's and SRNA's which have no ACGME or ABA limits in the number that can be hired/trained at an academic program.
Again, it isn't that easy, especially to open a residency program. To start one requires multiple submissions of plans to the ACGME, full accreditation, appropriate didactics, staff, didactic facilities, etc. all of which can add up to millions of dollars. Last year, the ACGME placed 20 anesthesiology residencies on probation for training violations (specialty case numbers, work hours violations, etc.). The majority of residency programs aren't looking at the funding as a way to expand their residencies, it's looking at it as a way to remain solvent and not OVERWORK their CRNA's, SRNA's, and residents. With the restrictions of the ACGME and ABA, ALL of those programs would have hired MORE CRNA's to correct the residency deficiencies, not expand the residency and provide an even more substandard experience, had the funding been available.
There is a lot of rhetoric on both sides. It is a vicious cycle of action and reaction that seems to be endless. Physicians want CRNA's to be dependent practitioners, CRNA's want to independent practice and the right to practice pain management, on and on and on. I hate both sides of this story. Neither side is innocent and neither side can be faulted for looking out for their own, but this isn't something that is just found in anesthesia. Look at ophthamologists and optometrists, obstetricians and midwives, general practitioners and nurse practitioners, etc. Everyone wants to be "the man/woman". It all comes down to what you feel your sphere of influence should be. This is an issue that can't be settled on this board.
When I finished nursing school I had a $45K debt but I was immediately able to get a job and pull in $45-50K/year starting. When I finished medical school, I had $114K debt and wanted to start working, but I could not because while I had finished med school, I did not have and could not get a license until I finished my third board exam and applied for a state license which takes months after the exam result is returned.
During internship and residency, without income and little to no time to moonlight, I and my family would have starved. As an SRNA I was still working in local ER's and ICU's and earning enough money and of course learned after I finished, that I could have gotten special educational loans.
The government doesn't value the MD over the SRNA. It recognizes that the inherent nature of internship and residency precludes working outside of the training program to earn income to just live. It recognizes that the resident has to spend 4 years doing nothing but training and learning at high hours/week. The 80 hour work week helps, but many programs push their residents to that limit and without pay, do you think the resident would have time after the 80 hours/week training to study, sleep, AND earn enough income just for expenses, not to mention family, family time, etc.?
The salary of the resident is Medicare funded, although that funding is sporadic and not always what it is promised to be, therefore the department has to be ready to meet the shortfall that always occurs. As I stated before, the costs to the hospital for funding a resident are significant. SRNA training costs are primarily liability insurance and limited on site health insurance.
I PM'd you the reasons in response to your PM. CMS made this a physician only issue. It doesn't want to change the rule for physicians. Adding the extra cost of SRNA reimbursement to the effort would make them LESS pliable to the idea. So it boils down to this: CMS won't reconsider the rule just for SRNA's, and doesn't want to reconsider it for both because of a doubling of cost to the Medicare system. It MIGHT reconsider the rule for physicians at this time. That is the only starting point. I know that the AANA doesn't believe CMS isn't willing to consider both together, but I wrote to CMS and they were very clear that this was being viewed as strictly a physician issue at this time. Change it, set the precedent for SRNA training programs, and then both sides can get what they want and most importantly, our beloved training programs can finally climb above sea level.

I welcome your post man and hope you continue to post here. While you pointed out strong reasons in support of the bill some anesthesiologists seem to be focusing on the CRNA Vs MD battle. They see this bill as a turning point in their favor in these constant political confrontations b/t the 2 groups. It is the anesthesiologists that are pushing the bill with this agenda in mind that are focused on while the good aspects of the bill ignored by the AANA.

It is similar to the CRNA that desires to dip into the chronic pain realm. If indeed you are a CRNA then you should know as well an anyone that the large majority of CRNA's have no desire what so ever to get into the pain business. Most CRNA's could give a rats a$$ about chronic pain to be honest with you. Yet those rural guys that do pain procedures are one of us and the AANA supports them and the services they provide to these rural areas.

Many many CRNA's could give a flip about independent practice as well. Many are happy working in the ACT model yet all MD's think all 30,000 CRNA want to practice or want their states opted out.

Since a large number of SRNA's train in private practice MD groups increasing reimburstment for SRNA's would greatly increase the revenus of many anesthesiologists. In fact I know several ASA member MD's who are all for an increase in SRNA reimburstments.

I understand the concerns of your debt yet my 2.5 yrs of CRNA school will cost more the the $114K that your four years of medschool cost not including lost RN income of about $140k in that 2.5 yrs. Both professions must make sacrifices to get where they desire.

MmacFN · May 16, 2006

Its all a tough topic.

The difficulty is in seperating the political positioning from the actual facts. I wonder if that is ever possible.

CRNAtoMD · May 16, 2006

Hi Nitecap,

I totally agree that both sides must make sacrifices to coexist. I would like to see it start with HR5246. For the reasons I have outlined above, I would like to see an olive branch extended by both sides to get HR5246 done and a subsequent ruling on SRNA programs done. If both sides can get behind this, that's a heck of a way to restart a good relationship.

Your tuition was $114+K? Wow. I thought the average per credit hour tuition rate was between $650-800/hour with usually 55-70 credit hours needed to graduate. Works out to around $40-60K total. What program is charging that much?

jwk · May 16, 2006

Hi Nitecap,
I totally agree that both sides must make sacrifices to coexist. I would like to see it start with HR5246. For the reasons I have outlined above, I would like to see an olive branch extended by both sides to get HR5246 done and a subsequent ruling on SRNA programs done. If both sides can get behind this, that's a heck of a way to restart a good relationship.

I think that's wishful thinking after the ThoughtBridge fiasco.

SueBee RN-BSN · May 16, 2006

All of this makes me not want to stay in nursing. I know the AANA is strong. It's hard to be a part of a profession like nursing when another profession (medicine) is trying to stunt the growth of nursing, for economic reasons, (not safety reasons).

I look at the midwives in Missouri. They had a school ( that was shut down), and great practice some years ago. Then the OB's decided their $$$$ were to little, and the midwives were the cause. The OB's snapped their fingers, and the midwife was reduced (meaning: unable to practice their full scope) to WHNP. Now Missouri women have no choice of provider. Nurses don't have the freedom to obtain their CNM, and practice, without moving their home. Insurance now must pay the price of the MD, far greater than the CNM.

This is not about midwives, but APN's in general.

How enjoyable is it to have to fight for your job via politics over $$$. The PA's here in Missouri are having the same trouble. Some DO's are upset about the PA's taking DO $$$$. They are trying to get rid of the PA.

APN's have their own lic. and should not ever be governed by another profession.

Balder_LPN, LPN · May 16, 2006

It's clear that some congressman has a brother / uncle /some inlaw who is an anethesiologist. That how alot of those things work, Or the anesthistists (spelling??) professional association donated him some money.

Polititions...they're the :devil:

CRNAtoMD · May 16, 2006

Even if that was the case, who cares. The academic programs are struggling and if they continue to lose good people to private practice, who will train the next generation of providers? Worst case scenario is the people who couldn't work anywhere else are the only ones the academic centers can hire, so you have the worst physicians teaching our young minds.

Today, my program just lost another faculty anesthesiologist to private practice. He was denied tenure because given the current budgetary constraints, they can only have a certain number of tenured faculty members and he was passed over because of his youth in favor of an older, but equally talented and accomplished faculty member. It gets to be depressing.

jwk · May 17, 2006

It's clear that some congressman has a brother / uncle /some inlaw who is an anethesiologist. That how alot of those things work, Or the anesthistists (spelling??) professional association donated him some money.
Polititions...they're the

Besides the lousy spelling, you're incredibly naive. The AANA and it's minions donate TONS of money to politicians every year. I'm not pretending that physician's don't - but to think one side does it and not the other is ludicrous. And let's remember - Slick Willie's mom was a CRNA.

subee, MSN, CRNA · May 17, 2006

Even if that was the case, who cares. The academic programs are struggling and if they continue to lose good people to private practice, who will train the next generation of providers? Worst case scenario is the people who couldn't work anywhere else are the only ones the academic centers can hire, so you have the worst physicians teaching our young minds.
Today, my program just lost another faculty anesthesiologist to private practice. He was denied tenure because given the current budgetary constraints, they can only have a certain number of tenured faculty members and he was passed over because of his youth in favor of an older, but equally talented and accomplished faculty member. It gets to be depressing.

Yeah I know, we picked tough jobs. The only problem I have with the bill is this: Should ANYONE get 100% payment for performing in two different locations? At the same time I appreciate the academician's frustration. Every little community hospital "has to" have a pediatric anesthesiologist to do tubes and tonsils depriving the teaching centers of a provider and a teacher.

I'm too dumb to be the health care czar, but in a single day of wand waving I couldn't do any worst than we're getting.