Originally posted by juddson
1. In your state, are CRNA's permitted to practice without MDA supervision or direction?
Well, I'm a legal resident of Texas, but I'm going to school in New York. Still, I wouldn't limit it to my experiences or my states. Let's use a hypothetical taking a recent issue raised on this thread and one of the HCFA exceptions, let's say Colorado, for the sake of argument.
According to the exception in Colorado, a CRNA could administer anesthesia without the previous legal requirement of a "supervising" physician's countersignature. This would mean that the CRNA is,
de facto, operating on his/her own without 'supervision' or 'direction.'
Originally posted by juddson
2. If they ARE allowed to practice without MDA supervision or direction, must they be supervised or directed by the the surgeon?
Technically, in the scenario I present, they are not. As the law previously stood, they would have been. But, as was successfully lobbied, many of the "supervising" physicians had little or no training in the administration of anesthesia and felt uncomfortable taking on the burden - and legal ramifications - of "supervising physician" because of this. As a result (as happened in Colorado), many such surgeons (or podiatrists, or obstetricians, etc.) would send their higher-risk patients to Denver or larger cities in Colorado where an MDA (or other surgeon, etc.) was willing to take the legal burden of "supervising physician." This is the paramount reason why the HCFA rule was enacted - so these small, community hospitals would not lose such patients to bigger cities that had, according to the law, more adequate facilities.
Originally posted by juddson
3. In either case, who typically "employs" a CRNA in your state? Or may they be self-employed?
CRNAs have historically been members of MDA practice groups. They can, I supposed, be 'free-lance' or form their own practice group if they have a working relationship with a hospital, a particular MDA group, or a surgeon who is willing to take the responsibility of the "supervising" physician and/or indemnify their work. With the new HCFA ruling in the states where the exemption is approved, this is no longer an issue because there is no need for the "supervision" level by a physician.
Originally posted by juddson
4. Irrespective of "employment", who is responsible for "choosing" them to be the anesthetic provider? That is, by what mechanism are they "assigned", "scheduled", etc., to provide anesthetic. Consider two scenarios: The first is a hospital trauma OR, the second a suburban outpatient surgery center.
Practice groups make contracts with hospitals, surgical practice groups, HMOs (etc.) to provide anesthetic services. If there are surgeries at a hospital that have a contract with a particular anesthesiology group, then that group - and all of that groups employees - are authorized to provide services under that contract. Because historically CRNAs have worked for MDA run practice groups and because the law previously
always required supervision, they were marginalized. This means, they were often hired by such a group, given a salary, and only a portion of what service they provided and was billed for was actually given to them. It doesn't matter if it is a hospital or a surgical outpatient center. The contract is to provide the service. The CRNA got a portion of those contract fees as a salary. Often, the amount that the practice group bills the hospital/surgicenter and/or Medicare is substantially higher than the CRNA actually gets paid. It would be no different than if a 1st year MDA took a contract job, for salary, at a practice group and received only a portion of his/her actual billed services in return. Do you follow? The difference is that an MDA does not, by law, have to be supervised (and all of the legal ramifications that go with that) because of the legal status of their license, all of which is regulated by the HCFA, state medical licensing boards, etc.
Originally posted by juddson
5. How are CRNA's in your state currently compensated?
Again, I think the answer is above. If there was a private practice group consisting solely of CRNAs that had a contract with a particular group and did not need to be supervised, they would receive 100% of what they billed. They would not have to pay a fee or share the fee they collect with any supervising physician. In the case where the CRNA's work is supervised, the supervising physician collects a portion of the total fee.
Per Medicare, for example, a physician can collect 50% of the fee of a CRNA for up to four cases at a time. Therefore, if a particular charge is $100 for a case, the CRNA working on the case only gets $50 of what's actually billed and the MDA gets $200 because he/she is supervising four cases at the same time. In other words, with the new ruling in those states that allow the exemption, CRNAs will make twice what they used to for the same caseload whereas MDAs will make 1/4 what they used to.
Does that make sense?
-Skip