Anesthesiologist VS. CRNA (Continued)

badgernurse · Jul 3, 2007

I'm kind of new to the political nature of all this and I'm sure someone will correct me if I'm wrong but the supervision thing is based on the Federal Supervision Rule and some states have chosen to opt out of this rule. Essentially it means supervision of a CRNA by an MDA is not required. Here's a link to more info:

http://www.aana.com/Advocacy.aspx?ucNavMenu_TSMenuTargetID=49&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=1790

However, individual companies may have an MDA supervising CRNAs. For example, Wisconsin is an opt out state meaning supervision is not required but xxx hospital may have MDAs supervising 30% of the time. Enter all the politics and I will stay away from that as you wish.

As far as what can the anesthesiologists do that the CRNAs can't, I'll let the more experienced answer that. I haven't gotten that far yet.

loisane · Jul 5, 2007

Spartan, there is not quick simple answer to your question. In order to answer it, you have to look at layers of regulation associated with CRNA practice.

CRNAs are educated and trained in all aspects of anesthesia care. This is referred to as "scope of practice". Layer one-education, professional standards of care and certification-all allow for a full scope of practice.

Layer two-state nurse practice acts. This of course varies from state to state. Some states require physician supervision of CRNAs, some do not. No state requires that the supervision be provided by an anesthesiologist. States that require supervision may vary in just what type of provider can provide that supervison. For instance, there are some state in which a CRNA could provide anesthesia for a dentist, and some where they could not. Every CRNA must be knowledgeable about their particular state nurse practice act.

Layer three-institutional policies. Even though all state nurse practice acts allow for full scope of practice for CRNAs, some institutions choose to limit the tasks they allow CRNAs to perform. Every CRNA must be knowledgeable about the institutional policies and the associated credentialling process that will specify what they are allowed. Sometimes they have a full scope of practice, other times not. For instance, some places do not allow CRNAs to insert lines or perform regionals. Even though those activities are legal, they are not allowed by institutional policy.

Layer four-liability insurance. You have to know what your coverage allows, or does not allow. I have heard that some insurance companies will not cover new graduates for out of hospital cases until they get several years experience. Some insurance decisions are completely arbitrary. I once had trouble finding coverage because I performed anesthesia for liposuction.

Layer five-reimbursement. This is where the opt outs that badger refers to come in. This issue is the most complex of all, and I don't know how much you really want to know, but here goes.

Medicare is in two parts. Part B pays providers. CRNAs have full billing rights equal to anesthesiologists under Part B.

Medicare part A pays the hospital. In order for a hospital to get paid, it must abide by the "Condition for participation". One of the conditions for participation is that CRNAs be supervised by a physician. Since that is not a consistent legal requirement in all states, this is an unfair requirement. Hospitals in states in which physician supervision is not required in their nurse practice acts, were having to provide that supervison in order to get paid by Medicare. There was a long, ugly fight about getting it changed. The end result was a compromise in which the states in which physician supervision is not required in their state code, may petition Medicare to "opt-out" of this part of the conditions for participation.

To summarize, CRNAs can perform all of the same tasks that an anesthesiologist can, related to anesthesia. I believe that it is likely that you could find a CRNA practicing at full scope in each and every one of the 50 states. It is also quite likely that you could find a CRNA functioning in a restricted capacity in each of the states. The reason for that restriction will vary for each situtation. Each practicing CRNA needs to be knowledegable about their options, and make the best decison for themselves about their individual practice environment.

Hope this helps.

loisane crna

Spartan05 · Jul 5, 2007

Spartan, there is not quick simple answer to your question. In order to answer it, you have to look at layers of regulation associated with CRNA practice.
CRNAs are educated and trained in all aspects of anesthesia care. This is referred to as "scope of practice". Layer one-education, professional standards of care and certification-all allow for a full scope of practice.
Layer two-state nurse practice acts. This of course varies from state to state. Some states require physician supervision of CRNAs, some do not. No state requires that the supervision be provided by an anesthesiologist. States that require supervision may vary in just what type of provider can provide that supervison. For instance, there are some state in which a CRNA could provide anesthesia for a dentist, and some where they could not. Every CRNA must be knowledgeable about their particular state nurse practice act.
Layer three-institutional policies. Even though all state nurse practice acts allow for full scope of practice for CRNAs, some institutions choose to limit the tasks they allow CRNAs to perform. Every CRNA must be knowledgeable about the institutional policies and the associated credentialling process that will specify what they are allowed. Sometimes they have a full scope of practice, other times not. For instance, some places do not allow CRNAs to insert lines or perform regionals. Even though those activities are legal, they are not allowed by institutional policy.
Layer four-liability insurance. You have to know what your coverage allows, or does not allow. I have heard that some insurance companies will not cover new graduates for out of hospital cases until they get several years experience. Some insurance decisions are completely arbitrary. I once had trouble finding coverage because I performed anesthesia for liposuction.
Layer five-reimbursement. This is where the opt outs that badger refers to come in. This issue is the most complex of all, and I don't know how much you really want to know, but here goes.
Medicare is in two parts. Part B pays providers. CRNAs have full billing rights equal to anesthesiologists under Part B.
Medicare part A pays the hospital. In order for a hospital to get paid, it must abide by the "Condition for participation". One of the conditions for participation is that CRNAs be supervised by a physician. Since that is not a consistent legal requirement in all states, this is an unfair requirement. Hospitals in states in which physician supervision is not required in their nurse practice acts, were having to provide that supervison in order to get paid by Medicare. There was a long, ugly fight about getting it changed. The end result was a compromise in which the states in which physician supervision is not required in their state code, may petition Medicare to "opt-out" of this part of the conditions for participation.
To summarize, CRNAs can perform all of the same tasks that an anesthesiologist can, related to anesthesia. I believe that it is likely that you could find a CRNA practicing at full scope in each and every one of the 50 states. It is also quite likely that you could find a CRNA functioning in a restricted capacity in each of the states. The reason for that restriction will vary for each situtation. Each practicing CRNA needs to be knowledegable about their options, and make the best decison for themselves about their individual practice environment.
Hope this helps.
loisane crna

THANK YOU!!!!!!!!!!!!

I know that the issue is confusing and very political but I really do appreciate you shedding some light on this issue. My main reason for asking is that I am currently an engineer who is taking life science classes in the hopes of getting into healthcare. My volunteer experience dealt with the OR and I was able to shadow many nurses as well as CRNAs so I am currently leaning towards nursing as opposed to med school but it seems like the jobs of anesthesiologists and CRNAs can overlap a lot and I wanted to make sure I am making the right decision before I start either nursing or med school.