Here's what CRNAs really think about AAs

[georgia_aa]

and this from the president of the aana

here we go again......

americans say "no" to low-level assistants providing anesthesia to civilian and military patients, survey reveals

park ridge, ill.--the vast majority of americans would not want their anesthesia care to be provided by anesthesiologist assistants (aa) instead of physician anesthesiologists or certified registered nurse anesthetists (crnas), according to the results of a recent nationwide survey of registered voters.

conducted by public opinion strategies (pos), an independent research firm based in alexandria, va., the survey revealed that 85 percent of americans would be concerned if they or their family members were scheduled to have surgery under anesthesia to be provided by an aa. in particular, women and senior respondents expressed the greatest concern about aas providing anesthesia to them or their families.

the newest of the three types of anesthesia providers recognized in the united states, aas have been around for more than 30 years. by comparison, nurse anesthetists have been providing anesthesia care in the united states since the late 1800s; anesthesiologists since the early 1900s.

despite the fact that they have been in existence for more than a quarter of a century, there are fewer than 700 aas in the country today. more than 36,000 anesthesiologists and 30,000 crnas provide more than 99 percent of the nation's anesthesia care, while aas provide less than 1 percent and only under the direct supervision of an anesthesiologist. however, anesthesiologists are not required to remain in the operating room with the aa for the duration of a patient's surgery.

currently, aas are specifically licensed to practice in only six states, and are not officially recognized by the department of veterans affairs (va) or tricare, the main healthcare programs for active and retired military personnel. however, tricare is currently accepting public comments on a proposal to allow aas to give anesthesia to military patients, veterans, and their families. the proposal was published in the federal register on april 3, 2003 (volume 68, number 64); the comment period closes june 2.

"americans should be alarmed that there is a movement to have aas recognized in more states, and also by the va and tricare programs for military personnel, veterans, and their families," said rodney lester, crna, phd, president of the american association of nurse anesthetists (aana). "the pos survey clearly shows that the public is not comfortable with the idea of aas providing their anesthesia care, and for good reason. little is known about these assistants. their safety record has never been studied; they are not nearly as educated or experienced as crnas and anesthesiologists; and they are severely restricted in their scope of practice."

survey respondents expressed their displeasure with the tricare proposal, with 83 percent indicating they are concerned about the federal government approving aas in the military.

"there are significant differences in the education, experience, and scope of practice of aas versus crnas and anesthesiologists," said lester. "for instance, aas are not required to have a healthcare education or background prior to beginning their anesthesia training. they could be an english major and qualify for aa school. crnas and anesthesiologists receive a minimum of seven and eight years of education and clinical experience respectively, all directly related to healthcare and anesthesia."

lester also pointed out that crnas and anesthesiologists are qualified to provide every type of anesthesia care, including general, regional, and local, while aas are not. for example, aas who graduate from the emory university program in georgia do not receive clinical instruction in the administration of regional anesthesia, lester said.

survey results revealed that the public shares lester's concerns. according to the results:

• 72 percent of respondents are very concerned that anesthesiologists, while responsible for supervising aas, are not required to stay in the operating room with these assistants throughout the surgery;
  
• 66 percent are very concerned that no studies have ever been conducted to determine the safety record of aas;
  
• 63 percent are very concerned that aas can sit for their certification exam six months before completing their anesthesia education; and
  
• 59 percent are very concerned that aas are not trained to provide all types of anesthesia.
  

in addition, said lester, unlike crnas, aas cannot practice unless directly supervised by an anesthesiologist. "this restriction is definitely necessary, but it does mean that aas cannot take call; cannot practice in settings where anesthesiologists aren't available, such as most rural hospitals; and cannot be deployed in combat situations unless an anesthesiologist is deployed with them. the list goes on from there.

"the suggestion made in some circles that producing more aas will help reduce the number of anesthesia provider vacancies simply doesn't hold water, not when aas can only practice with anesthesiologists holding their hands," said lester.

lester noted that there are only two aa programs in the country, compared with 85 nurse anesthesia programs. "approximately 1,400 new nurse anesthetists will graduate from nurse anesthesia school this year, up from about 900 five years ago. more than 1,000 new anesthesiologists will probably complete their residencies. the vacancy situation is definitely being addressed. by comparison, approximately 40 new aas will graduate this year. to suggest that aas are the solution to the provider vacancy situation is ludicrous," lester said.

"it's really quite amazing that the american society of anesthesiologists (asa) has been pushing in recent years for aas to be recognized in more states and in the military," said lester. "the asa has been telling the public for years that patient safety is its number one priority, and then the asa goes out and extols the virtues of aas whose safety record has never been studied, and whose educational background pales in comparison to that of anesthesiologists and crnas.

"the real reasons why the asa is promoting aas are obvious: control and money," said lester. "aas have to work with anesthesiologists, and anesthesiologists can bill for supervising them, even if that means 'supervising' them from the break room. it's a way for the asa to control the anesthesia marketplace. that is definitely not in the best interests of our public or military patients."

[jwk]

This is old material, and came out last year when the AANA and others were fighting to keep AA's out of TriCare.

Fortunately, the folks at the DOD could see through the smokescreen and all the negative comments and approved AA's as providers for TriCare. The formal notice of the final ruling in the Federal Register provided some interesting reading. In particular, it answered each negative comment and criticism thrown at the AA profession with a well thought out response.

The AANA is already trying to put a positive spin on the ruling, but for some reason, that spin isn't available to the general public - it is password-protected on their website.

[Sheri257]

So are you guys posting this stuff just to stir the pot, or what?

As you know, I've been pretty unbiased regarding the AA issue, and have posted many statements in your favor.

But I'm not sure that posting this old stuff accomplishes anything, especially since there's nothing new here. It sure seems like you're going out of your way to fan the flames.

I'll certainly remember this the next time you guys complain about the being flamed on this board.

[alansmith52]

perhaps I don't understand the tricare descion but I thought that it found in favor of CRNA's not AA's

[gaspassah]

While the final rule authorizes TRICARE reimbursement of care involving AAs, it does so with several important restrictions:

It contains strong language stating the rule does not introduce AAs into military hospitals (MTFs) where a great deal of TRICARE benefits are provided. Language preceding the rule states, "We want to stress that this final rule affects only services provided in civilian facilities and is wholly separate from services provided within the military's direct care system. AAs will not practice in MTFs; they will not be commissioned, nor will they deploy in support of our troops." "The AANA raised significant concerns with the Pentagon over the wisdom of introducing AAs into MTFs, since AAs are a type of healthcare provider that cannot be deployed or even put to use without an anesthesiologist immediately available to provide medical direction," said President McKibban. "The agency heard our concerns. The important result is that the final rule does not introduce AAs to military hospitals."

It defines "direct supervision" of AAs as meaning the seven TEFRA conditions called for in Medicare Part B. No more than four AAs may be so supervised by an anesthesiologist, and if the state where the care was provided has tighter conditions then the state's rule is the one that must be followed. "We were concerned that TRICARE's proposed rule on AAs did not define 'direct supervision' at all," said President McKibban. "This final definition does not appear to expand AAs scope of practice."

It does not expand the number of states where an AA may practice, answering a significant concern AANA had expressed about the proposed rule.

In addition, the final rule repeals the physician supervision requirement that TRICARE had imposed on nurse anesthetists. Language preceding the rule states, "TRICARE recognizes the increased training required by certified registered nurse anesthetists compared to AAs, and as a result, authorizes CRNAs to practice independent of physician supervision in those states where the licensure permits. TRICARE is publishing a provision in this rule to clarify CRNAs' authority to practice independently." This portion of the final rule takes effect with the rest of the rule, and is subject to public comment to the agency through June 21, 2004. "On the issue of physician supervision of CRNAs, TRICARE now defers to state statutes and regulations," said President McKibban. "TRICARE now effectively mimics Medicare Part B, which does not impose a physician supervision requirement on care provided by CRNAs. This change acknowledges the safety of nurse anesthesia care."

[alansmith52]

yeah, thats what i thought:

[jwk]

So are you guys posting this stuff just to stir the pot, or what?

As you know, I've been pretty unbiased regarding the AA issue, and have posted many statements in your favor.

But I'm not sure that posting this old stuff accomplishes anything, especially since there's nothing new here. It sure seems like you're going out of your way to fan the flames.

I'll certainly remember this the next time you guys complain about the being flamed on this board.

I for one was not trying to fan the flames. (except for the comment about the password-protected part of the website :) ) I was mainly pointing out that it WAS old news, and the final TriCare decision was just released two weeks ago, which georgia_aa may not have been aware of.

The medical direction requirements are fine - 1 on 4 max is not a problem. This has been the norm for us for many years.

Also, in pursuing our cause with TriCare, we did not seek to work in military hospitals, so that point is moot at present.

Finally, we weren't seeking to expand our scope of practice through TriCare. This issue was primarily about reimbursement for TriCare patients being treated in non-military facilities in the states in which we already are in practice.

We're happy with the ruling. Obviously, many of you are as well.

[alansmith52]

on the 4th thursday of each month without an "R" yeah baby