Is it because they can bill multiple cases at the same time within ACT practices?
I've heard that reimbursement is the same for CRNAs or MDAs providing the anesthesia, is this true? In other words, if an independent CRNA performs the same case as an independent MDA, will they be reimbursed the same amount?
Thanks!
P.S. This is not a should MDAs/CRNAs make more than each other etc. etc. question. This is specifically about current practices with billing and cost of anesthesia.
Actually,I have worked in a variety of settings. I have probably have worked in more states and practices in my short time as a CRNA versus all your time as an AA and that doesn't include other countries. I would like to see an independent on site surprise audit of your billing, because there has yet to be an ACT that follows all the TEFRA rules at a 4:1 ratio or even a 3:1 ratio.
You are going to keep saying it is possible and I'm going to stick with my experience and the research and say it isn't possible to be 100% compliant with TEFRA rules at those ratios. We are at impasse.
You've been a CRNA for what - 4 years or so? Wow, vast experience. If you've worked in that many places because you're job hopping, it doesn't indicate much of a work ethic, or if it's due to working locums, well, there's a reason a lot of places use locums and it's rarely because they're stellar practices. Try settling down somewhere and make a life for yourself.
"...there has yet to be an ACT that follows all the TEFRA rules at a 4:1 ratio or even a 3:1 ratio"
Says who? Oh, that's right - some study you've read. Got it.
You've been a CRNA for what - 4 years or so? Wow, vast experience. If you've worked in that many places because you're job hopping, it doesn't indicate much of a work ethic, or if it's due to working locums, well, there's a reason a lot of places use locums and it's rarely because they're stellar practices. Try settling down somewhere and make a life for yourself.
"...there has yet to be an ACT that follows all the TEFRA rules at a 4:1 ratio or even a 3:1 ratio"
Says who? Oh, that's right - some study you've read. Got it.
Let's see I am military so my work ethic is quite good…Which I think you already knew and have commented on before.
As an SRNA I worked in Ohio, DC, Delaware, and Maryland at civilian institutes. As a CRNA I work at two different civilian facilities in Alaska. I have also done rotations at NNMC Bethesda, Walter Reed (when it was still open), JBER, and worked in two other countries all this in my short-time as a military SRNA/CRNA.
Where exactly have you worked throughout the country with your AA certification that you know all about these type of practices.
You speak for one ACT practice and you try to discredit peer-reviewed research because it doesn't agree with you.
So, I want you tell about your vast experience at all these ACT practices that let you be so knowledgeable. When there are 30K+ CRNAs working in ACT practices in every state and US territory there are what 3K AAs working in handful of states.
Find one piece of credible evidence to back up any of your claims for a change.
Actually,I have worked in a variety of settings. I have probably have worked in more states and practices in my short time as a CRNA versus all your time as an AA and that doesn't include other countries. I would like to see an independent on site surprise audit of your billing, because there has yet to be an ACT that follows all the TEFRA rules at a 4:1 ratio or even a 3:1 ratio.
"working" in a variety of settings is also interesting to me. Why so many moves?
Also, I have to agree with jwk on the fact that MD's do not need to be in every room at the same time. We have 3 MD's who do a fabulous job of the 1:4 ratio. You cannot categorically say that 1:4 ratios can't be met "anywhere." It depends on their management background and what types of surgeries they are supervising. The research may show a problem with some hospitals, but there are many others that do a great job. Also, start times can be staggered, not every case needs to start at 7:00. We start our first ones between 6:30 - 7:30 which actually allows for late surgeons or patient admission/testing issues.
Lastly, academic facilities do not have to be as efficient as private institutions. Even the leading researcher in anesthesia, Franklin Dexter, MD/PhD states that it is very difficult to do comparative research with private vs. academic institutions as they perform very differently and budgets (and how OR's are managed) are also different.
Let's see I am military so my work ethic is quite good…Which I think you already knew and have commented on before.
As an SRNA I worked in Ohio, DC, Delaware, and Maryland at civilian institutes. As a CRNA I work at two different civilian facilities in Alaska. I have also done rotations at NNMC Bethesda, Walter Reed (when it was still open), JBER, and worked in two other countries all this in my short-time as a military SRNA/CRNA.
Where exactly have you worked throughout the country with your AA certification that you know all about these type of practices.
You speak for one ACT practice and you try to discredit peer-reviewed research because it doesn't agree with you.
So, I want you tell about your vast experience at all these ACT practices that let you be so knowledgeable. When there are 30K+ CRNAs working in ACT practices in every state and US territory there are what 3K AAs working in handful of states.
Find one piece of credible evidence to back up any of your claims for a change.
Good grief, if I counted student rotations I'd have to add at least 15 more hospitals to my list of "experience". AA students do clinical rotations in every state that has AA's, from New Mexico to Vermont, from Michigan to Florida, in all types of facilities from small hospitals to big ones, university-affiliated hospitals, children's hospitals and of course the VA.
In private practice, actual work experience, I've had two primary full-time employers, and half a dozen part-time/PRN gigs that I've worked at through the years on days off and vacation. The smallest were 2-OR ASC's, the largest a three-hospital system plus multiple ASC's running 80+ operating locations each morning.
The military is FAR different than private practice, wouldn't you agree? "Civilian hospitals in Alaska" - I'm sure there are a few fine hospitals in Alaska, but none would qualify as a large anesthesia practice. You want to speak of your experience working in a couple hospitals in the least populous state in the union and some military hospitals, and somehow feel qualified to extrapolate that to busy ACT private practices which you know absolutely nothing about, and then in the same breath discount what I've been doing for more than 30 years and tell me I don't know what I'm talking about? You fall back on "studies" that don't even relate to modern private practice because you don't have the experience to know better.
And oh yes, there are indeed many thousands of CRNA's working in ACT practices throughout the country - and many of them are more than a little PO'd at the AANA for the way they are marginalized because they're not all practicing independently in BFE.
"working" in a variety of settings is also interesting to me. Why so many moves?
Also, I have to agree with jwk on the fact that MD's do not need to be in every room at the same time. We have 3 MD's who do a fabulous job of the 1:4 ratio. You cannot categorically say that 1:4 ratios can't be met "anywhere." It depends on their management background and what types of surgeries they are supervising. The research may show a problem with some hospitals, but there are many others that do a great job. Also, start times can be staggered, not every case needs to start at 7:00. We start our first ones between 6:30 - 7:30 which actually allows for late surgeons or patient admission/testing issues.
Lastly, academic facilities do not have to be as efficient as private institutions. Even the leading researcher in anesthesia, Franklin Dexter, MD/PhD states that it is very difficult to do comparative research with private vs. academic institutions as they perform very differently and budgets (and how OR's are managed) are also different.
I haven't moved at all, if you go back and read I am military. I have been stationed at one place as CRNA, been deployed once, and have a part-time arrangement at two different places. My primary training site was the DC area with several out of state civilian rotations. Most of the military CRNAs I work with work have at least 2-4 civilian places they have part-time arrangements with.
I still say show me all the billing and I will show that ACTs at 4:1 or 3:1 ratio are a farce. There are going to be several billing errors daily in that kind of system.
I don't believe in the ACT system I think it is nothing more than way to for paying a bunch of MDAs to do nothing but pretend to supervise.
If non-academic ACTs are doing so well at following TEFRA guidelines then show me any reasonable study from a creditable source that shows this, and I will modify my statements.
Good grief, if I counted student rotations I'd have to add at least 15 more hospitals to my list of "experience". AA students do clinical rotations in every state that has AA's, from New Mexico to Vermont, from Michigan to Florida, in all types of facilities from small hospitals to big ones, university-affiliated hospitals, children's hospitals and of course the VA.
In private practice, actual work experience, I've had two primary full-time employers, and half a dozen part-time/PRN gigs that I've worked at through the years on days off and vacation. The smallest were 2-OR ASC's, the largest a three-hospital system plus multiple ASC's running 80+ operating locations each morning.
The military is FAR different than private practice, wouldn't you agree? "Civilian hospitals in Alaska" - I'm sure there are a few fine hospitals in Alaska, but none would qualify as a large anesthesia practice. You want to speak of your experience working in a couple hospitals in the least populous state in the union and some military hospitals, and somehow feel qualified to extrapolate that to busy ACT private practices which you know absolutely nothing about, and then in the same breath discount what I've been doing for more than 30 years and tell me I don't know what I'm talking about? You fall back on "studies" that don't even relate to modern private practice because you don't have the experience to know better.
And oh yes, there are indeed many thousands of CRNA's working in ACT practices throughout the country - and many of them are more than a little PO'd at the AANA for the way they are marginalized because they're not all practicing independently in BFE.
You don't have a clue about Alaska hospitals. The military is its' own beast, but I have had to work at several civilian hospitals and still work at two different civilian facilities.
Yes and there are multitudes of CRNAs working ACT practices that complain daily that there is billing fraud on a daily basis.
Like I said above find one credible piece of evidence showing that ACT practices consistently meet TEFRA requirements and I will modify my statements. Until that time I still say there isn't one ACT practice I have seen or heard of that consistently meets TEFRA requirements.
I think you're trying to describe what is commonly known as a "collaborative" practice, and those are popping up here and there. However, in a collaborative practice, CRNA's and MD's don't have the same employer. If a CRNA assigns their billing rights to the group to collect AND is an employee of the group, that's not really a collaborative practice since an employer / employee relationship exists which means by definition they're not "independent". Or perhaps this group you describe is billing as medical supervision rather than medical direction.
Sorry for such a slow responce- The employee relationship does not prevent a CRNA from independent practice. It is not medical supervision, the majority of my charts don't have an anesthesiologist name anywhere from pre-op to post-op.
On another note-I see from your profile information that you have 32 years nursing experience-are you a nurse?
So if it is essentially the same amount being billed per case for either MDA AND CRNA (in ACT) or MDA OR CRNA (independent practices), then is there any financial incentive for hospitals to have one type of practice vs. the other (MDA only, CRNA only, mixed, or ACT)? How does the hospital make money? Do they make money from anesthesia or do they just make money for hosting the facilities to perform the surgery?
I guess I have more questions than I realized.
One last one - is there any good book or resource to learn the business aspects of the OR and the parties therein?
If the Anesthesia dept is owned by the hospital, and the providers are hospital employees, then the expense is measured as ~$150K (CRNA)-vs-~$250K (MDA) (as an example)...you can staff 5 ORs for $750K with CRNAs or 3 ORs with MDAs for $750K…..if you were a penny-pinching CFO….how would you staff?
This is just an example of a human resource expense, the ACT model is more expensive than the solo CRNA since you are now paying two salaries for the same room.
Sorry for such a slow responce- The employee relationship does not prevent a CRNA from independent practice. It is not medical supervision, the majority of my charts don't have an anesthesiologist name anywhere from pre-op to post-op.
On another note-I see from your profile information that you have 32 years nursing experience-are you a nurse?
From a BILLING standpoint, you may be correct. From a practical and legal standpoint, I don't think you are. Regardless of how the bill is submitted, an employer, by definition, has control over their employees.
Here's the cut and paste from my profile info that I entered. The "nursing experience" header that shows up is placed there by allnurses.com, not me. Nice try.
City, State, Country:
Country Flag: ADAEAFAGAIALAMANAOARASATAUAWAXAZBABBBDBEBFBGBHBIBJBMBNBOBRBSBTBVBWBYBZCACCCDCFCGCHCICKCLCMCNCOCRCSCTCUCVCXCYCZDEDJDKDMDODZECEEEGEHERESETEUFAMFIFJFKFMFOFRGBGDGEGFGHGIGLGMGNGPGQGRGSGTGUGWHKHMHNHRHTHUIDIEILINIOIQIRISITJMJOJPKEKGKHKIKMKNKPKRKWKYKZLALBLCLILJLKLRLSLTLULVLYMAMCMDMEMGMHMKMLMMMNMOMPMQMRMSMTMUMXMYMZNANCNFNGNINLNONPNRNUNZOMPAPEPFPGPHPKPLPMPNPRPSPTPWPYQARERPRSRURWSASBSCSDSESGSHSISJSKSLSMSNSOSRSTSVSYSZTCTDTFTGTHTJTKTLTMTNTOTQTRTTTVTWTYTZUAUGUKUMUSUYUZVAVCVEVGVIVNVUWAWFWSYEYTZAZMZW
An individual can be a Licensed Independent Practitioner, and be an employee, from a legal standpoint. Increasing numbers of physicians are becoming employees of various types of organizations. They are subject to the organizations policies and procedures, but they are responsible for their clinical decisions. Obviously the employing organization cannot determine the physician's clinical decisions.
Over the past 16 years in our group, twice CRNAs have been involved in malpractice issues (and both times were found not at fault, knock on wood), and both times they stood alone. At first everyone in the OR was named, from the surgeon to the OR staff, but an anesthesiologist was not named because none was involved in the cases. All were released except for the CRNAs. It was very stressful for the CRNAs but actually turned out to be a good thing because now the surgeons in our community are comfortable that they are not at increased liability with doing cases with CRNAs. One of the cases went to trial and had an anesthesiologist expert witness for the plaintiff. He spent his time attacking the fact that the CRNA was independent, and had little testimony related to the actions the CRNA took while caring for the patient. The jury found in favor of the CRNA. I think the expert witness really believed that all he had to do was tell everyone that a CRNA couldn't work without supervision and the case was done.
Legally I am responsible for what I do, and on rare occasions I have refused to do something that one of my employing anesthesiologists have told me 'it's fine, you can do that'. It's my license and I make my decisions.
jwk
1,102 Posts
You've been a CRNA for what - 4 years or so? Wow, vast experience. If you've worked in that many places because you're job hopping, it doesn't indicate much of a work ethic, or if it's due to working locums, well, there's a reason a lot of places use locums and it's rarely because they're stellar practices. Try settling down somewhere and make a life for yourself.
"...there has yet to be an ACT that follows all the TEFRA rules at a 4:1 ratio or even a 3:1 ratio"
Says who? Oh, that's right - some study you've read. Got it.