Does anyone ever wonder what will happen when the market becomes flooded with CRNAs? Will we see a drop in salaries?
I am a SRNA and today I heard one of my program heads discuss with one of the anesthesia attendings about anesthesiology and where it will be in the future and the attending mentioned that anesthesia residency programs will, in the next year, begin their expansion into more of the perioperative arena and carve out a niche in this area. He said in the future MDAs will spend a lot of time in the SICU and will be trained to become heads of this units and CRNAs will deliver almost, if not all, anesthesia. He also said the market will not sustain paying 350K to an MDA to "push propofol".
That's all fine and dandy with me and it was great to hear the future looks good for us.
What surprised me, however, was to hear my program head say that more and more CRNAs, as well as PAs, will be put into the work force to the point that the market will be saturated. She said right now CRNAs make great money because of the shortage but with supply of providers increasing the market, will again, push our salaries down and more to the level of NPs.
Needless to say, I was not too optimistic about that comment and wonder if that will ever be an issue I need to worry about. She also stated the market will not bear paying 120-150K to us to just push fluids. I really didn't know what to think at that point and thought this lady was full of crappola.
This word supersivion gives us so much trouble. It would seem obvious that if someone is supervised, the supervisor is taking responsiblity. But, no badass, that isn't how it works in the world of anesthesia. I think you are probably not a CRNA, so you are not informed about the meanings of the word "supervision" to a CRNA. There are two things to know about supervision:
First, it is a term regarding billing arrangements for Medicare patients. In this context, saying a CRNA is supervised simply means that someone else is getting part of the fee. And in exchange for that fee, that 'ologist has performed steps in the course of the anesthetic as dictated by Medicare to earn that fee. In this case, the word supervision has no relation whatsoever to responsibility in terms of scope of practice, etc. The supervised CRNA could do the next case completely independently, without seeing an 'ologist and there would be nothing wrong with that, as long as it was billed in someother, appropriate way (and assuming all state laws and institutional policies were met)
The second way the word supervision is used is in the context of state law. Some states require that a CRNA be supervised by a physician. But even in this use of the term, the supervising physician does not assume responsibility for the CRNAs actions. I know this is complicated, here is a quote that says it better than I can:
True, if an anesthesiologist is involved in the case there is a good chance they will share some responsibility for any adverse outcomes. But it is not automatic. Each anesthesia provider is accountable for their own professional actions. CRNAs and 'ologist are held to the same legal standard in terms of accountability. This is surprising to many, probably because we are the only nursing specialty for which this is true.
Sorry to go a little off topic, but this is difficult for the best of us to understand. We have to help each other get educated to the facts of the issues of our profession. So I can never pass up an opportunity to share some facts.
loisane crna
Maybe I read too much into things but it is really not black and white. The quote you posted reads:
"A physician or authorized provider is not automatically liable when working with a CRNA, nor is the physician immune from liability when working with an anesthesiologist".
This is a just crafty way of twisting the words. Sounds like they were writen by a lawyer. What they are trying to say is that the surgeon is not automatically liable when a CRNA works with him but may be automatically liable when he works with an MDA? It doesn't make sense. They are trying to make it sound as if somehow we are less liable than an MDA.
The reason I keep wondering about this is to know why many CRNAs choose to be employes by a MDA group and have them take part of their fees.
Is it only medicare cases that forces us to share part of the fee with the supervising doc (whether surgeon or mda)?
the article is written to state a surgeon has no liability over anesthesia whether they are a mda or a crna. unless the surgeon "forces" the anesthetist (mda or crna) to make a decision detrimental to the pt.
crnas work with mdas because many of there groups have exclusive contracts with hospitals to provide anesthesia services. and if you want to work in that town then that is your choice. and remember docs have a lot of weight to throw around in hospital political arenas. surgeons stating they wont operate unless a mda is involved, (ie scratching backs) so the hospital, if they want certain surgeons to operate hire mdas. or their group to "supervise" crnas.
politics play a larger role than most ppl realize. i am certain that hospitals would love to save money (if mda and crna are both hospital employees) by hiring more crnas but if the surgeons wont work with crnas the hospital is screwed.
just a couple of angles to look at.
d
oh and many surgeons are under the false impression that if they work with crnas they are responsible for the crna action. this is the whole,,must be supervised by doc, podiatrist etc. this just means that a surgeon needs to request anesthesia to be provided, not be responsible for that anesthetic.
the article is written to state a surgeon has no liability over anesthesia whether they are a mda or a crna. unless the surgeon "forces" the anesthetist (mda or crna) to make a decision detrimental to the pt.
crnas work with mdas because many of there groups have exclusive contracts with hospitals to provide anesthesia services. and if you want to work in that town then that is your choice. and remember docs have a lot of weight to throw around in hospital political arenas. surgeons stating they wont operate unless a mda is involved, (ie scratching backs) so the hospital, if they want certain surgeons to operate hire mdas. or their group to "supervise" crnas.
politics play a larger role than most ppl realize. i am certain that hospitals would love to save money (if mda and crna are both hospital employees) by hiring more crnas but if the surgeons wont work with crnas the hospital is screwed.
just a couple of angles to look at.
d
oh and many surgeons are under the false impression that if they work with crnas they are responsible for the crna action. this is the whole,,must be supervised by doc, podiatrist etc. this just means that a surgeon needs to request anesthesia to be provided, not be responsible for that anesthetic.
Thank you for taking the time to explain the rules of the game.
The reason I keep wondering about this is to know why many CRNAs choose to be employes by a MDA group and have them take part of their fees.
This is a very good question, and I have been trying to think if I have ever come across any "facts" about this, or if it has ever been "studied", but I can't recall much.
I did remember one article that tried to describe CRNAs in various practice arangements (and you have to describe before you can explain). Here is that abstract:
AANA J. 2000 Oct;68(5):452-62. A comparison of nurse anesthesia practice types.Shumway SH, Del Risco J.Medical Center Hospital, McAllen, Texas, USA.
The present study examined the differences between anesthesia care team (ACT) and non-ACT practice types. Six practice variables were analyzed. We prepared and distributed a 13-item questionnaire to 1,000 practicing Certified Registered Nurse Anesthetists (CRNAs) with a 44.4% response rate. Data analysis revealed that nurse anesthetists in ACT practices had fewer years of experience and were younger than non-ACT nurse anesthetists (alpha = 0.05). Also, a significantly greater percentage of ACT nurse anesthetists were female, held master-level degrees, and practiced in urban and metropolitan locations. This also was true for placement of laryngeal mask airways and arterial lines, and in providing anesthesia for cardiopulmonary bypass, pediatric, intracranial, and trauma cases. However, a significantly greater percentage of non-ACT nurse anesthetists placed epidurals and central lines and were involved in pain management and critical care consultations. Income was significantly greater for non-ACT nurse anesthetists as well, but they worked more hours per week on average. Lastly, evaluation of employment arrangements showed that more than 91% (n = 361) of ACT nurse anesthetists were employees, and only 4% (n = 17) were self-employed. However, only 49% (n = 24) of non-ACT nurse anesthetists were employees, and almost 43% (n = 21) were self-employed. The present study demonstrates that significant differences exist between the 2 nurse anesthesia practice types examined. As nurse anesthesia practice arrangements continue to change and fewer CRNAs are hospital employed, each nurse anesthetist must be aware of current practice trends and understand the alternatives.
This data is 5 years old, time for a follow up (anyone need a student research project?)
Based on personal experience and opinion, of course Gaspassah is right about politics. You also have to think about the business savy it takes to be non-ACT. You have to negotiate contracts, which means you have to be seen as a player in the arena of health care providers, and you need negotiating skills to get a good contract. You have to deal with billing, either by doing it yourself or hiring someone to do it. You have to be willing to take the risk associated with being a non-employee.
Some CRNAs do this as independent contractors. And there are some CRNA only groups. It is possible to be successful, but it takes skills that don't automatically come with a CRNA education. From what I have seen, the people who have done it are very satisfied with their choice.
Is it only medicare cases that forces us to share part of the fee with the supervising doc (whether surgeon or mda)?
Much of health care policy analysis focuses on Medicare. Decision made there often trickle down, and are also adopted as policy by other payors. Part of having a good business plan is knowing your payor mix and what their policies are.
Good questions here. I think today's students are getting better at understanding the "big picture" earlier than they did in my day. That is good for us, and will help move our profession forward.
I was wondering if anybody has any estimates on how many CRNA's work with MDA groups versus operating as independents.
And, if there happens to be a large percentage of CRNA's who work with MDA groups, why is there so much resentment between the two?
It's almost like people are saying that the CRNA's need the MDA's either for their connections with hospitals, negotiating contracts, handling billing or Medicare (Part B excluded of course).
It's a bit confusing. Everybody talks about CRNA's being independent and not needing supervision but a lot of these posts seem to indicate that CRNA's still need MDA's in one form or another.
although i am not terribly anti mda, i dont really see why we NEED them. we are in competition with them in many arenas. if the power of the large mda groups didnt monopolize the contracts or use their connections with hospital administrators or surgeons (see my earlier posts about hosp. politics), there would probably be more crna run groups providing anesthesia for large and intermediate hospitals.
many mda groups have entrenched themselves in many cities and some goups are decades old and provide anesthesia at the same hospitals for decades. therefore in that sense if you are a crna and want to work in that hospital or city..yeah you many NEED them to work there to have a job. but to NEED mdas to provide quality anesthesia in any settings is preposterous.
people easily forget that these anesthesiologist go to school with some of the same surgeons for years, premed, med school, residency in the same hospitals or cities, there is definetly an "old boys network" that involves anesthesia. bob the mda to jim his buddy from med school. "hey our contract with X hospital is coming up soon i sure would appreciate it if you were to let he administrators know that you prefer to work with us (mdas) over crnas only cause you know those nurses need to be supervised by us." by the way i am going deep sea fishing on my twin outboard 32 foot boston whaler next weekend...you want to go?"
so the surgeon wanting to help his old buddy says no problem bob. i would love to."
jim to hospital administrator. "Ed i know that the anesthesia contract is coming up again and if you would like for my group to continue to operate in this facility i will only work if there are mdas available to supervise those anesthesia nurses"
this is all too easy for me to see. its the way politics work on any level.
then there are the hospital bylaw that were written when the hospital comes into existance. administrators and or boards of directors and or hospital committees that make the bylaws have mds on them so they write into the bylaw that anesthesia will be provided by the medically directed model. this by medicare law means that an anesthesiologist do or cosign the preop, and meet the 7 terfa rules for medicare reimbursement. present at induction emergence and any problem that arises during the case. hospital policy can superceed state law in that it can be more strict, it just cannot be more broad than state law. and the hospital bylaws are concidered law by jacho when it pertains to how the hospital opperates is anesthesia services.
i'm too tired to continue now but i'll pick this up later as more ideas come to me.
....if the power of the large mda groups didnt monopolize the contracts or use their connections with hospital administrators or surgeons (see my earlier posts about hosp. politics), there would probably be more crna run groups providing anesthesia for large and intermediate hospitals.
........... to NEED mdas to provide quality anesthesia in any settings is preposterous........
I have been reading this forum for the past year after deciding to persue anesthesia last summer.......I am to attend Arkansas State in Jan. I would like comment on the RN vs CRNA salary gap.
ASU graduated its first class this spring with all passing their boards 1st time, average sallary of the class $150,000.
I have made about as much money that can be made in the midsouth (staff er/icu RN): $30-35 an hour base, approaching $100k a year. In contrast to the $110-150 STARTING salary for CRNA's. Take into account also that to make $100k as a RN at $35-40/hr requires a lot of hours/ot/bonus pay etc and these rates are usually without benefits, or at max an option to buy basic insurance... and CRNA's with the same OT/call options will make MUCH more with MUCH better benifits in almost all cases.
I hope as others have said that I will LOVE anesthesia practice, but I also hop that I will be compensated for the same. This is no different than the way I feel about my current practice.
A lot of respect for deepz, gaspassah, and others for thier intelligent and persistant stances for CRNA practice.
BigDave
198 Posts
Very well put...thanks!