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Is Medical Direction of CRNAs a Reimbursement Scheme or Safer for Patients?
A point-counterpoint between a nurse anesthetist and an anesthesiologist.
Jay Horowitz, John Dombrowski
Publish Date: January 9, 2017   |  Tags:   Anesthesia
medically directed anesthesia AT ISSUE Should Medicare stop paying for medically directed anesthesia claims and recognize both anesthesiologists and CRNAs as independent practitioners?


Stop Paying for Medical Direction of CRNAs
Nurse-only anesthesia would save billions and improve OR efficiency.

A CRNA is stationed in each of your 4 ORs. Patients and surgeons are ready to go. But only 1 of the 4 cases can proceed. The holdup? The attending anesthesiologist can't start 4 rooms at once. But he can oversee 4 cases at once. And he can bill twice as much for medical direction as opposed to performing the anesthetic himself (he'd receive 50% of each of 4 medically directed anesthetics as opposed to 100% if he did one himself) — all thanks to a ridiculous reimbursement scheme for anesthesia services that should be abolished.

When billing for medical direction of CRNAs, anesthesiologists must complete 7 magic steps to qualify for payment — from performing a pre-anesthetic examination and evaluation, to monitoring the course of anesthesia administration at frequent intervals.

Medical direction can set the day on a trajectory of inefficiency and needlessly rising costs. In an ASC, you'll have to pay staff overtime because rooms run later and you'll have to track down surgeons to finish dictations because they had to leave in a rush. Costs increase, but your revenues do not, because you only get a fixed facility fee.

In the hospital OR and HOPDs, the unbundled, charge-master charges for OR time are $80 per minute (still the most common form of charging for OR time). The costs are astronomical regardless of how you do the math. The anesthesiologists' own literature, without caveat or disclaimer, says so, even at 1:3 medical direction; the cost and waste is even higher at 1:4. We'd save billions just by reducing OR time payments incurred while waiting for an anesthesiologist to meet the 7 steps (osmag.net/wm7osf), start the case and avoid fraud.


Team-Based Anesthesia Best for Patient Safety
Physician-led anesthesia care team model is proven and reliable.

As we look to the future of health care, identifying ways to save on costs is increasingly critical. But that savings cannot come at the price of patient lives. We must ensure that we put our patients, their health and their safety first. Some erroneously believe that when it comes to anesthesia, we could save money by eliminating team-based models of anesthesia care. They say there is no risk. But they are wrong.

Mr. Horowitz's Nov. 28 article, "How to Save $20 Billion (Without Repealing and Replacing Obamacare)," which links to the author's recent blog on The Hill (osmag.net/nutjj3), is replete with errors and assumptions that are not based on the reality of how anesthesia care is provided. The 2 most glaring are the use of operating room "charges" (rather than payment) and the "average delay of 22 minutes" in cases with a 1:3 supervision ratio. The author asserts that his proposed policy change would save the government money, but Medicare, most Medicaid and other payers pay by case type, not operating room time, so his assumptions of "delayed time" and "charges per minute" are irrelevant. Additionally, the assumption of a "22-minute delay" in cases with a 1:3 supervision ratio are based on a study that has been cited for significant flaws. The author then uses this calculation and applies it to all U.S. surgeries, although only a fraction of surgical cases uses 1:3 medical direction for anesthesia care.


Anesthesiologists are highly skilled and valued members of the OR team, but their value is severely diminished when they're relegated to "medically directing," all in the service of an inefficient and outdated reimbursement scheme that serves no purpose other than preserving power and control. When someone tells you it's not a turf battle or about the money, it's most certainly about both.

Removing payment for medical direction would do wonders for on-time starts. Imagine having an anesthesiologist or CRNA ready to start cases on time in every room every day without delay. There's no statute, regulation or law in the United States requiring an anesthesiologist to medically direct or supervise a CRNA. Anesthesia providers incapable of rendering an anesthetic from induction to emergence alone should reevaluate their career choices.

Most anesthesiologists have no idea how claims are submitted in their names. If you submit a claim as medically directed and you fail to meet even 1 of the 7 criteria for each and every anesthetic, that claim is fraudulent. I hope the new administration, one not beholden to PACs and lobbyists, can look at how much eliminating payment for medical direction of CRNAs would save, and acknowledge all the evidence that anesthesia care is safe — regardless of the practice model. OSM


This discussion regarding healthcare spending is not about a turf battle, it is about quality health care and the safety of our patients. Nurse anesthetists are valuable members of the anesthesia care team, but they are not physicians and cannot replace physicians. In fact, eliminating physician-anesthesiologists may actually cost more, as other physicians may be needed to consult or provide the services of a physician-anesthesiologist.

We cannot risk potentially expensive complications or jeopardize patients' lives. There's a reason 46 states and the District of Columbia, by statute or regulation, require nurse anesthetists to work in a team-based relationship with a physician, whether through physician supervision, collaboration, direction, consultation, agreement or some other arrangement for anesthesia delivery. Let's be clear: Independent research on anesthesia outcomes conclude that care is safer when a physician-anesthesiologist is involved. There are no independent studies showing that nurse-only anesthesia care provides safer care or a level of care comparable to team-based anesthesia.

The anesthesia care team is a model proven to provide patients with high-quality and safe care. The focus should be on looking for ways to continue to improve that team rather than eliminate members from it. OSM