The American Association of Nurse Anesthetists makes a bold proclamation of their full practice, safety, independent capabilities, and economic advantage for our modern healthcare system.
Before we begin a discussion on the topic you should probably follow this link to the AANA's original statement.
Firstly, I have to disclose that I am in my third year of nurse anesthesia training preparing for graduation, so I am not a board certified CRNA yet. Anything I say is coming from the perspective of a new generation of CRNA DNP training which I've noted can be slightly different from those of older generations. I am also the elected political representative of my class throughout our program so I do stay more engaged and informed than some other anesthesia trainees. Last disclosure, I do serve the AANA and work on a committee that serves the board of directors.
Now, to understand where this new bold statement from the AANA came from I think it's necessary to understand it is in response to the ASA's statement about the Anesthesia Care Team last fall. Their statement unabashedly self-aggrandizes themselves and downplays CRNAs actual role as experts and independent anesthesia providers. In fact, they use wording that implies better education and training from their own assistants (AAs) than nurse anesthetists who has been providing safe competent anesthesia since the civil war.
Although, most CRNAs don't blame them for making a political statement like this promoting themselves and downplaying their competitors in the marketplace. That is the duty of a professional organization, to promote that organization. Anesthesia has been aggressively political since the early 1900s when physicians decided to start learning anesthesia and tried to make it illegal in California for a nurse anesthetist to continue practicing anesthesia. Who wants competitors if you think you can eliminate them, it just makes business sense.
After the political statement made last October by the ASA large amounts of CRNAs were outraged and demanded an immediate defending response from the AANA. The AANA is always careful and intentional in what it does, so they created a task force of influential and level headed CRNAs who would investigate the issue and come up with a diplomatic response. They spent 6 months discussing this and coming up with the response you are now reading. This statement was intentional and well thought out. It is supported and celebrated by a huge majority of CRNAs/SRNAs judging from responses in person and in private CRNA forums consisting of tens of thousands of CRNAs.
It's disconcerting that I have seen some negative comments online by people who aren't physicians. You would expect many physicians to react negatively to a non-physician provider talking about their education, training, and similar patient outcomes but it is odd to see some others ill-informed negativity.
The biggest confusing issue I see people have is that in the AANA's statement that is in response to the ASA's care team statement is that billing methods are often fraudulent. What many may not understand is that in a medical direction billing model (which is what the ASA is wanting everywhere) involves meeting 7 TEFRA requirements to bill for CMS. These requirements are very often not met even when physicians bill in medical direction, which is Medicare fraud. This is not just anecdotal. The ASA produced research they performed themselves that was published recognizing that a huge number of medical direction practices are not meeting the 7 TEFRA requirements. Medical direction benefits the physician because they can bill for 4 different cases at once while they are not providing the anesthesia but 4 different CRNAs are performing the anesthesia. You can see why they would want this to be a standard delivery method of anesthesia. Even when their own research shows they are fraudulently billing in many places they continue to push this model. This model is oftentimes the most restrictive and oppressive to CRNAs who choose to work with that anesthesia group. It is also one of the more costly models for hospitals to sustain, so it's not economically responsible or sustainable for many facilities.
CRNAs mention these issues with medical direction because it supports the movement nationwide for the collaborative model of anesthesia care. This model requires that both CRNAs and MDAs be independent full practice providers who work together on a team. They are equal partners and practice under their own license to provide safe high-quality anesthesia to their patients. In this model, there are no 7 TEFRA regulations so Medicare fraud is not an issue. The economic reason some in anesthesia will not like this anesthesia delivery model is that you can not bill for services of 4 CRNAs at once providing anesthesia. Each provider can only bill for their own anesthesia for a single case. It would do away with someone sitting in the break room drinking coffee while 4 other providers are working and earning you profit. You can see why certain people would not want this to happen.
I just wanted to clear that portion up about the AANA's statement so it had some context and people who are not in the anesthesia realm understand where that came from. Those of us in anesthesia are just so used to that issue I think we forget others are not informed about it.
I've no worries. I have never seen or heard of an MDA who would or could be on hand to do an epidural on a 16 year old Amish girl in active labor at a 12 bed rural critical access hospital like I did tonight.
I don't see there ever being enough physician anesthesia providers to service rural and underserved areas. They need us.
See response below. I lived in a smaller town in PA and saw a few physicians but it was a 100 bed hospital.
It's the AANA that is lobbying to keep physicians out of the rural areas, and it's been successful. That's why they make y'all become members right?
Seems as if Bluebolt is attempting to explain things in a pretty neutral way people, twinsmom is citing her two twins as her source(how fitting) and hogger sounds like some sort of physician who never specialized in anesthesia. Let’s just stick to the research and leave the assumptions aside. Just because I’ve witnessed MS4 in action doesn’t make me an authority on the rigor which goes into their profession. I am sure that MDAs and CRNAs are both highly trained professionals and the practitioners all fall into a normal bell curve.
Most anesthesiologists and CRNAs get along just fine from what I have seen at my hospital. My friend the doc tells me that as well. It's just a few who are always espousing "we are even better than MDAs" and putting down doctors education. We have CRNA friends in our RN/CRNA/MD circle.
See response below. I lived in a smaller town in PA and saw a few physicians but it was a 100 bed hospital.
It's the AANA that is lobbying to keep physicians out of the rural areas, and it's been successful. That's why they make y'all become members right?
1. The AANA has resisted having physician anesthesiologists/hospitals get extra money for working in rural areas. They are free to work in rural areas if they are willing to take the same salaries as CRNAs working in those areas, so far it seems they are not many takers. 2. There is zero requirement for becoming a member.
1. The AANA has resisted having physician anesthesiologists/hospitals get extra money for working in rural areas. They are free to work in rural areas if they are willing to take the same salaries as CRNAs working in those areas, so far it seems they are not many takers. 2. There is zero requirement for becoming a member.
Well, some of these hospitals don't employ the CRNAs. The CRNAs form their own groups and bill independently. I have friends who are CRNAs who work rural and make just as much money as my doc friend.
My friend has called around small towns and asked if they were looking for anesthesiologists and has been told straight up that "we don't use Anesthesiologists, we only use CRNAs.
And that's why she's encouraging me at my age to go the CRNA route instead of the MD route. More bang for my buck(less time training and less loans) and I can go rural again if I want. And since CRNAs and NP's are gaining so much autonomy in this country, it makes perfect sense.
I have a friend from nursing school who went on to become an MD and has been trying to get back rural with no avail. Then she tells me about rural pass through and how CRNA lobbying power has effectively prevented her from going rural because the hospital is given funding to bring on CRNAs and they block MD/DOs from attempting to get similar funding from the government. But if you hear it from the CRNAs, they all want to paint physician as all of them wanting to live in the big city and not care about rural healthcare. But then you wonder about the internal medicine, and OB-Gynes, and Family practice physicians who all are rural physicians.
Very sad because the AANA's agenda really clouds the picture.
What is really sad is how the ASA runs constant smear and public scare tactics against CRNAs telling the public and legislators that CRNAS aren’t safe to work independently with zero evidence to support those allegations. All with the sole reason to keep physician anesthesiologists salaries up, keep them out of the OR doing cases, and keep salaries for CRNAs as low as possible.
What is really sad is how the ASA runs constant smear and public scare tactics against CRNAs telling the public and legislators that CRNAS aren’t safe to work independently with zero evidence to support those allegations. All with the sole reason to keep physician anesthesiologists salaries up, keep them out of the OR doing cases, and keep salaries for CRNAs as low as possible.
I live out West where it's mostly physicians providing the anesthesia. So I don't know what you mean about keeping themselves out of the OR as that was not my experience when I was in the OR. Only in the past few years have I started seeing more and more CRNAs in the hospital.
I have to say that I have seen some bad docs out here though. Can't speak too much about the CRNAs working independently since they don't in my town, but I have seen some bad Wild Wild West medicine. I have seen bad CRNAs but again, we hardly use them. And I was the kind of circulator who always called for help when I thought the CRNA was in trouble whether or not they wanted me to call.
Most anesthesiologists and CRNAs get along just fine from what I have seen at my hospital. My friend the doc tells me that as well. It's just a few who are always espousing "we are even better than MDAs" and putting down doctors education. We have CRNA friends in our RN/CRNA/MD circle.
Yeah, let’s hop over to SDN and look at all the comments from physicians bad mouthing CRNAS. It’s a constant where most physicians bad mouth and degrade APRNS. Do you think we don’t hear the comments from physicians how they had to go save X in room and how that if they were a physician that wouldn’t happen why simultaneously saying that they had to go help physician in room X and how those things just happen. Do you not think we don’t hear the constant chest beating of physicians saying how they are needed to keep patients safe and all their schooling make them inherently better providers while never doing their own cases. How about the brand new non-board certified physician walking in and thinking they are better than every CRNA because they are an MDA? That’s just a few of the daily examples.
Yeah, let’s hop over to SDN and look at all the comments from physicians bad mouthing CRNAS. It’s a constant where most physicians bad mouth and degrade APRNS. Do you think we don’t hear the comments from physicians how they had to go save X in room and how that if they were a physician that wouldn’t happen why simultaneously saying that they had to go help physician in room X and how those things just happen. Do you not think we don’t hear the constant chest beating of physicians saying how they are needed to keep patients safe and all their schooling make them inherently better providers while never doing their own cases. How about the brand new non-board certified physician walking in and thinking they are better than every CRNA because they are an MDA? That’s just a few of the daily examples.
So you are saying that SDN contributors are "most doctors"? I highly doubt that. SDN just like this website is just a small fraction of physicians in the entire US. Most of them I doubt participate on online forums.
Come on. There are arrogant people on both sides. But if a CRNA is working in an ACT practice, you better believe I am gonna call for help when the patient needs it. I am there for the patient. Not for anyone's ego. There have been times that I have called for help for the docs too. The docs aren't afraid to call for help. What's wrong with calling for help.
And what is it with this whole MDA thing? Out here, we just call them docs.
Well, some of these hospitals don't employ the CRNAs. The CRNAs form their own groups and bill independently. I have friends who are CRNAs who work rural and make just as much money as my doc friend.
My friend has called around small towns and asked if they were looking for anesthesiologists and has been told straight up that "we don't use Anesthesiologists, we only use CRNAs.
And that's why she's encouraging me at my age to go the CRNA route instead of the MD route. More bang for my buck(less time training and less loans) and I can go rural again if I want. And since CRNAs and NP's are gaining so much autonomy in this country, it makes perfect sense.
1. CRNAs have always been independent and were around decades before physician anesthesiologists. CRNAs aren’t fighting for independence. They are fighting a battle to maintain independence that has unfortunately been taken away in some places through politics.
2. There are physician anesthesiologists only groups just as there are CRNA only groups. Most places don’t want to hire MDAs because of politics and money as inevitably the MDA is going to ask for more money than the CRNAs.
1. The AANA has resisted having physician anesthesiologists/hospitals get extra money for working in rural areas. They are free to work in rural areas if they are willing to take the same salaries as CRNAs working in those areas, so far it seems they are not many takers. 2. There is zero requirement for becoming a member.
So if my friend was interested in joining an independent CRNA group and make the same as they make because she will bill on her own, or are you saying she would be welcome with open arms by the independent rural CRNA groups?
Because if the hospital has straight up told her that they don't use MDs, and the AANA is trying to prevent physician expansion into rural areas, how exactly is she supposed to get a rural job?
1. CRNAs have always been independent and were around decades before physician anesthesiologists. CRNAs aren’t fighting for independence. They are fighting a battle to maintain independence that has unfortunately been taken away in some places through politics.
2. There are physician anesthesiologists only groups just as there are CRNA only groups. Most places don’t want to hire MDAs because of politics and money as inevitably the MDA is going to ask for more money than the CRNAs.
You really aren't answering the question and are not acknowledging the AANA agenda of keeping docs outside of rural hospitals. She doesn't care about CRNA independence. She says have at it and is encouraging me to be one. She cares about finding a job in the country because she likes it there, hates big city traffic and people but has met roadblock after roadblock and then finds out about the rural passthrough and the AANA blocking her efforts.
I never said anywhere in my post that 'CRNAs are figthing for independence". Where did I say that? You clearly have a chip on your shoulder. I say that most docs and CRNAs get along just fine, you bring up the docs putting down CRNAs on SDN; I say that my friend wants to go rural but keeps getting blocked and CRNAs are gaining more and more autonomy you bring up "fighting for independence". Are you OK?
Is it a tit for tat with the AANA because they feel that anesthesiologists are being too restrictive for them?
I live out West where it's mostly physicians providing the anesthesia. So I don't know what you mean about keeping themselves out of the OR as that was not my experience when I was in the OR. Only in the past few years have I started seeing more and more CRNAs in the hospital.
I have to say that I have seen some bad docs out here though. Can't speak too much about the CRNAs working independently since they don't in my town, but I have seen some bad Wild Wild West medicine. I have seen bad CRNAs but again, we hardly use them. And I was the kind of circulator who always called for help when I thought the CRNA was in trouble whether or not they wanted me to call.
Your experience is not the norm and doesn’t represent the western half of the US or the US in general. ACTs still make up the majority of anesthesia practices where the majority of MDAS will be “directing” and not doing any cases. Bad providers aren’t unique to either type of anesthesia provider. The biggest difference I’ve seen though is physicians can get away with being awful providers for a lot longer than CRNAs. ‘Yep, I’ve had circulators that did that too but would never think of doing that to an MDA. It shows how jaded and biased even nurses are to CRNAs.
SuziQ1978
27 Posts
See response below. I lived in a smaller town in PA and saw a few physicians but it was a 100 bed hospital.
It's the AANA that is lobbying to keep physicians out of the rural areas, and it's been successful. That's why they make y'all become members right?