The August issue of Health Affairs published a study indicating that there is no difference in complications or death following surgery between nurse anesthetists (CRNAs) working alone and anesthetists working under an anesthesiologists's (MD's) supervision. Currently, to receive Medicare reimbursement, your anesthetists need to be supervised. However, states can petition CMS to allow unsupervised anesthetists, and the number of "opt-out" states and number of "unsupervised" cases has grown. In the interim there's been apparently no increase in the number of problems.
I'm not too surprised because as far as I've heard from physicians and anesthetists, being a "supervising physician" amounts to having CRNAs as employees of your practice and covering them with your malpractice insurance. Not, you know, actually supervising every individual case.
The study authors indicate that this means we should be opting for cheaper anesthetists rather than more expensive anesthesiologists. CRNAs cost, by informal estimates I've heard, about 10 times less than an MD. However, I thought part of the reason CRNAs are less costly is because they don't have to buy their own malpractice insurance, but are rather sheltered under the anesthesiologists they work for. I'm not sure how this works in "unsupervised" cases; are the anesthetists employees of the hospital and covered under the hospital's insurance?
The study authors also speculate that anesthesiologists are taking on more of the higher-paying cases, e.g. privately insured cases and more technically involved or higher acuity cases, leaving the lower-paying cases, e.g. Medicare-insured and simpler cases to the lowly CRNAs. As bad as that sounds (yet it's probably true, because it makes economic sense), it could have skewed the results. A study which examined similar acuity of care among CRNAs and MDs might be better. Not that I balk at the idea of taxpayer-subsidized surgeries being performed by lower-cost but equitable professionals, while the people who can pay for their own insurance can go to higher-paid professionals if they want; but I doubt that the consumer is making the choices here!
Funnily enough the only comment to this on the Health Affairs blog is by the American Medical Association, which decries the study and says it's fully funded by a CRNA lobbying agency. But isn't the AMA the largest physician lobbying agency?
CRNAs do not exist in Canada. All anesthesia is performed by anesthesiologists... actual physicians.
ReplyDeleteI'd be interested in a study that compared the two groups in cases where there were complications.
ReplyDeleteI remember talking to an ana... anes... a gas passer before an operation. He described how he had held up an operation until a technician could arrive to show him something about the backup machine that was perplexing him. Even though the machines almost never break, and the backup machine would probably work just fine in any case, he wasn't going to start until he had dotted every i and crossed every t. That's where I get the notion that a professional isn't someone who just performs well in the normal case. It's someone who is prepared for the abnormal case.
States without the opt out provision require any MD supervision(usually the surgeon)not exclusive MD anesthesiologist supervision.
ReplyDeleteEven CRNA's in non-opt out states that work independently carry their own malpractice insurance. The supervision requirement is on paper only. Courts hold ALL anesthesia providers responsible for their own work, regardless of the type license they possess.
ReplyDeleteGRRREEAT point about the consumer probably not making the choice of anesthesia provider.
ReplyDeleteYou hit the nail on the head.