Healthcare reform will end the Profes...

Healthcare reform will end the Profession of Anesthesiology

Posted in the Anesthesiology Forum

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Tim

Alice, TX

#1 Jul 19, 2009
I am shocked that no one is commenting on the potential impact of President Obama's Healthcare reform. As many of you may be aware, under the current proposals, payment of Anesthesiolgists and CRNAs will be a Medicare rates which are about 30% the level of private insurance. My state Anesthesiologist association projects that the bottom-line affect for most anesthesiologists will be a 50% cut in reimbursement. It is a foregone conclusion that in order to compete with the government option, private insurers will drop their reimbursement to the same levels as government.

Now Mr. Orzak, President Obama's budget director, states that there will be further 20% cuts in physician reimbursement in the future. This means that an Anesthesiologists or CRNAs income will be cut 60%.

I think just based on the principal of the matter, that is government dictating incomes of American citizens, I will likely retire from the profession (age 51), and simply stop working, and apply for as much government support as possible based on low income. I have been fortunate since I received an inheritance from my father which I could live off of.
Bing Shi

Denton, TX

#2 Jul 29, 2009
Absolutely agree!
Guy Kuo

Sammamish, WA

#3 Aug 22, 2009
Anesthesiology is a critical care specialty in which patient safety depends on maintaining the quality of care givers. It is a mentally and physically grueling specialty that demands perfection each and every time. If you want your patients to be at ease, you also have to do it in a seemingly effortless manner. From outside the profession, it is easy to be fooled by allusions to the anesthesiologist/patient relationship as merely provider and customer. That is simply not what goes through the minds of a quality anesthesiologist in a healthy practice environment. A good anesthesiologist focuses their entire attention on the patient's medical condition and how to most safely and most comfortably convey you through the dangers of medical procedures. Professional satisfaction comes from knowing you gave superlative care AND that you feel fairly compensated. Both needs must be met to have sustainable quality.

In my practice, we isolate the individual payment issues from the point of care. If you come into the OR or go into labor, we take care of you. We don't have to think about payment. The billing office takes care of that separately. We take care of you, the person. It does not matter if you are privately insured, on medicare, medicaid, or indigent. You are treated the same way. Concerns about getting paid would be a dangerous distraction. We learn your medical issues, formulate safe anesthetic strategies, tell you about your choices, agree upon a path, compassionately reassure you, and nimbly conduct you through a minefield of dangers during a highly compressed time span. You really should not be worrying about other things. When we do our job right, you never realize how much effort and skill is being brought to your benefit.

I can focus on taking care of you because I do not PRESENTLY have to worry about whether or not you can pay. I know that on average I can afford to take care of each person. It does not matter if you are rich, famous, well insured, on medicare, on medicaid, or indigent. I treat you the same way. We do quite a bit of care at reduced rate or no pay. That is part of being a physician. I am able to do so because I know I'll be okay at the end of the month.

The present health care reform plan would gravely injure the anesthesia specialty because it threatens to move reimbursements far down to the less than market value medicare rates....(continued)
Guy Kuo

Sammamish, WA

#4 Aug 22, 2009
(continued from prev)....The private insurance carriers would be naturally tempted to push their reimbursements down the the unsustainable government levels. I can afford to take care of medicare and indigent patients because other patient with normal reimbursement rates help make up the difference. Push everything down too far and the specialty becomes untenable. In Washington state we already have difficulty attracting anesthesiologists because our state has even lower than usual medicare reimbursement rates. Further, anesthesiology had its medicare rates erroneously set too low years ago. This error was scheduled to be corrected, but the present reform efforts would lock in that computation error permanently.

We cannot keep good people in anesthesiology if health care reform threatens to cut reimbursement down to medicare rates. The truly gifted won't stay in the field nor will they enter it. We already had this demonstrated about ten years ago after a downturn in the anesthesia job market. Medical students diverted into other specialities and the candidate pool shrank. Those who would not normally have been trained as anesthesiologists were accepted into training. When it became time for those to graduate, we were quietly warned that class of residents was not recommendable for hiring. Anesthesiology requires top quality people to maintain patient safety. You might recover and get a second chance if a mistake is done by someone in another profession, but in anesthesiology you really want it done right EVERY time.

My anesthesia group has been fortunate enough to select and retain only the best. Only when in actual practice do you really see that anesthesiologists are not all the same. They vary in skill, knowledge, effectiveness during emergencies, and degree of ethical conduct. As a patient, you want the best. Yes, a lesser, perhaps willing to work for cheaper, practitioner may be survivable 95% of the time, but during intraoperative emergencies, is that who you want safeguarding your loved ones? It is not always a clear disaster that shows the differences between a superior provider and a mediocre one. Things may simply go less than optimally because of poor skill or planning. You were unconscious and never knew how close you came to calamity.

Unfortunately, anesthesiology is a relatively small and nearly invisible specialty that by itself lacks political strength to resist being "thrown under the bus"in the name of health care reform. What is coming will negatively affect patient safety if so severe an erosion of the profession is allowed to occur. Please, let your representatives know you care about this "little" side effect hidden in the sweeping changes proposed.

Guy Kuo, MD
Guy Kuo

Sammamish, WA

#5 Aug 22, 2009
Anesthesiology is a critical care specialty in which patient safety depends on maintaining the quality of care givers. It is a mentally and physically grueling specialty that demands perfection each and every time. If you want your patients to be at ease, you also have to do it in a seemingly effortless manner. From outside the profession, it is easy to be fooled by allusions to the anesthesiologist/patient relationship as merely provider and customer. That is simply not what goes through the minds of a quality anesthesiologist in a healthy practice environment. A good anesthesiologist focuses their entire attention on the patient's medical condition and how to most safely and most comfortably convey you through the dangers of medical procedures. Professional satisfaction comes from knowing you gave superlative care AND that you feel fairly compensated. Both needs must be met to have sustainable quality.

In my practice, we isolate the individual payment issues from the point of care. If you come into the OR or go into labor, we take care of you. We don't have to think about payment. The billing office takes care of that separately. We take care of you, the person. It does not matter if you are privately insured, on medicare, medicaid, or indigent. You are treated the same way. Concerns about getting paid would be a dangerous distraction. We learn your medical issues, formulate safe anesthetic strategies, tell you about your choices, agree upon a path, compassionately reassure you, and nimbly conduct you through a minefield of dangers during a highly compressed time span. You really should not be worrying about other things. When we do our job right, you never realize how much effort and skill is being brought to your benefit.

I can focus on taking care of you because I do not PRESENTLY have to worry about whether or not you can pay. I know that on average I can afford to take care of each person. It does not matter if you are rich, famous, well insured, on medicare, on medicaid, or indigent. I treat you the same way. We do quite a bit of care at reduced rate or no pay. That is part of being a physician. I am able to do so because I know I'll be okay at the end of the month.

The present health care reform plan would gravely injure the anesthesia specialty because it threatens to move reimbursements far down to the less than market value medicare rates.(continued)
Guy Kuo

Sammamish, WA

#6 Aug 22, 2009
(continued from prev) The private insurance carriers would be naturally tempted to push their reimbursements down the the unsustainable government levels. I can afford to take care of medicare and indigent patients because other patient with normal reimbursement rates help make up the difference. Push everything down too far and the specialty becomes untenable. In Washington state we already have difficulty attracting anesthesiologists because our state has even lower than usual medicare reimbursement rates. Further, anesthesiology had its medicare rates erroneously set too low years ago. This error was scheduled to be corrected, but the present reform efforts would lock in that computation error permanently.

We cannot keep good people in anesthesiology if health care reform threatens to cut reimbursement down to medicare rates. The truly gifted won't stay in the field nor will they enter it. We already had this demonstrated about ten years ago after a downturn in the anesthesia job market. Medical students diverted into other specialities and the candidate pool shrank. Those who would not normally have been trained as anesthesiologists were accepted into training. When it became time for those to graduate, we were quietly warned that class of residents was not recommendable for hiring. Anesthesiology requires top quality people to maintain patient safety. You might recover and get a second chance if a mistake is done by someone in another profession, but in anesthesiology you really want it done right EVERY time.

My anesthesia group has been fortunate enough to select and retain only the best. Only when in actual practice do you really see that anesthesiologists are not all the same. They vary in skill, knowledge, effectiveness during emergencies, and degree of ethical conduct. As a patient, you want the best. Yes, a lesser, perhaps willing to work for cheaper, practitioner may be survivable 95% of the time, but during intraoperative emergencies, is that who you want safeguarding your loved ones? It is not always a clear disaster that shows the differences between a superior provider and a mediocre one. Things may simply go less than optimally because of poor skill or planning. You were unconscious and never knew how close you came to calamity.

Unfortunately, anesthesiology is a relatively small and nearly invisible specialty that by itself lacks political strength to resist being "thrown under the bus"in the name of health care reform. What is coming will negatively affect patient safety if so severe an erosion of the profession is allowed to occur. Please, let your representatives know you care about this "little" side effect hidden in the sweeping changes proposed.

Guy Kuo, MD
Guy KuoP2

Sammamish, WA

#7 Aug 22, 2009
(cont'd from prev)... The private insurance carriers would be naturally tempted to push their reimbursements down the the unsustainable government levels. I can afford to take care of medicare and indigent patients because other patient with normal reimbursement rates help make up the difference. Push everything down too far and the specialty becomes untenable. In Washington state we already have difficulty attracting anesthesiologists because our state has even lower than usual medicare reimbursement rates. Further, anesthesiology had its medicare rates erroneously set too low years ago. This error was scheduled to be corrected, but the present reform efforts would lock in that computation error permanently.

We cannot keep good people in anesthesiology if health care reform threatens to cut reimbursement down to medicare rates. The truly gifted won't stay in the field nor will they enter it. We already had this demonstrated about ten years ago after a downturn in the anesthesia job market. Medical students diverted into other specialities and the candidate pool shrank. Those who would not normally have been trained as anesthesiologists were accepted into training. When it became time for those to graduate, we were quietly warned that class of residents was not recommendable for hiring. Anesthesiology requires top quality people to maintain patient safety. You might recover and get a second chance if a mistake is done by someone in another profession, but in anesthesiology you really want it done right EVERY time.

My anesthesia group has been fortunate enough to select and retain only the best. Only when in actual practice do you really see that anesthesiologists are not all the same. They vary in skill, knowledge, effectiveness during emergencies, and degree of ethical conduct. As a patient, you want the best. Yes, a lesser, perhaps willing to work for cheaper, practitioner may be survivable 95% of the time, but during intraoperative emergencies, is that who you want safeguarding your loved ones? It is not always a clear disaster that shows the differences between a superior provider and a mediocre one. Things may simply go less than optimally because of poor skill or planning. You were unconscious and never knew how close you came to calamity.

Unfortunately, anesthesiology is a relatively small and nearly invisible specialty that by itself lacks political strength to resist being "thrown under the bus"in the name of health care reform. What is coming will negatively affect patient safety if so severe an erosion of the profession is allowed to occur. Please, let your representatives know you care about this "little" side effect hidden in the sweeping changes proposed.

Guy Kuo, MD
nurse anesthetist

Brentwood, TN

#8 Aug 31, 2009
When I had anesthesia a nurse anesthetist did the anesthesia. I never saw the anesthesiologist. It had a shoulder scope with a nerve block, also done by the nurse anesthetist. It worked wonderfuly. What do anesthesiologist do that nurse anesthetist don't do? Why don't we just use nurse anesthetist instead, would that not save money?
MKMDK

Tampa, FL

#9 Sep 5, 2009
nurse anesthetist wrote:
When I had anesthesia a nurse anesthetist did the anesthesia. I never saw the anesthesiologist. It had a shoulder scope with a nerve block, also done by the nurse anesthetist. It worked wonderfuly. What do anesthesiologist do that nurse anesthetist don't do? Why don't we just use nurse anesthetist instead, would that not save money?
Yeah and lets let PAs and ARNPs run all primary care clinics. That will save money too. Better yet, they can do surgery as well. This is insane and makes me sick to my stomach. How dare you recommend eliminating a specialty that provided the groundwork for your current career? Maybe I'll open a 10 month program and start training recent high school grads how to administer anesthesia. We'll pay them 50K and eliminate CRNA's. That will save money!
MKMDK

Tampa, FL

#10 Sep 5, 2009
Another brilliant idea. How about we cut the bloated CRNA salaries and keep the doctors that founded the profession. CRNAs get payed way more that any other NURSE and that seems to be the only reason people go in to it. Anesthesiologists are no where near the highest paid doctores. If we cut CRNA salaries that would save loads of money while keeping the doctors in the profession.
bill

Lawrenceburg, TN

#11 Sep 11, 2009
Well MKM, get out of the lounge and sit the stool!
MDA's are their own worst enemy. Why do you insult the profession by saying a high schooler can give anesthesia. Crna's and MDA should be working together not against each other. ITs always the MD that is attacking the CRNA. Im not trying to take you job but you sure want to eliminate mine. You couldnt make what you do without the billing revenue you get from the miricle of medical direction. Which is going away by the way
AAAA

Kansas City, MO

#12 Sep 27, 2009
What about anesthesiologist assistants?
Todd

United States

#14 Nov 16, 2009
I was almost killed by a CRNA in a rural hospital where they were trying to save money and refused to hire a knowledgeable anesthesiologist (am MD that is). CRNA's simply are unable to think about physiology and pharmacology unless it follows a prescribed algorithm. If anyone doubts that, they should get a CRNA and an anesthesiologist in a room together with a panel of anesthesia experts and start asking each one of them questions and analyzing their replies. When my case went to court, it was clear the CRNA was clueless.
Gerald

Pittsburgh, PA

#15 Dec 8, 2009
I want an anesthesiologist doing my anesthesia 1:1 when I have surgery. Anyone who wants a nurse (CRNA) should be free to select one. The argument that the MDA and CRNA's are "equal" in any meaningful way is ridiculous; I know several providers on both sides of the debate and they DO NOT work together. One observation: the argument that one can "dilute" the qualifications to administer anesthesia (ie: CRNA or AA instead of MDA) without decreasing patient safety is just plain wrong. If you buy into the notion that "the CRNA is a more cost-effective, but just as good" alternative to the MDA, then you are on a slippery slope. What's next? Replace the CRNA with an even less-qualified provider (perhaps we need a SCRNA (semi-CRNA) with even less training and earning less.
Medical Student NYC

New York, NY

#16 Dec 14, 2009
nurse anesthetist wrote:
When I had anesthesia a nurse anesthetist did the anesthesia. I never saw the anesthesiologist. It had a shoulder scope with a nerve block, also done by the nurse anesthetist. It worked wonderfuly. What do anesthesiologist do that nurse anesthetist don't do? Why don't we just use nurse anesthetist instead, would that not save money?
To answer your question, nurse anesthetists have very little understanding in the physiology of the human body. I am not trying to be over critical, just honest. If anything goes wrong intraoperastively, they are absolutely clueless. This is especially true with the elderly and children who can quickly crash on the operating table. Do you really think a nurse anesthetist can learn in 2 years what it takes an anesthesiologist to learn in 8?
Gerald

Donora, PA

#17 Dec 15, 2009
I just had surgery, and the most painful part was to admit that I was WRONG (write that down kids, I'm, a 25,000 hour airline pilot and rarely admit being wrong about anything)....I made it clear that I wanted an MDA to do my case and this was agreed to. The MDA met with me a week before surgery and trashed the CRNA's (yeah, they are only nurses)...so I'll do your case personally. What a disaster. The MDA didn't even show up until 2 hrs after my surgery and he didn't have a clue as to what was going on. I was really pissed and started to storm out, but one of the CRNA's asked me if I wanted to still have the surgery without Dr. X (the MDA).....I was in a lot of pain and the CRNA offered to help; ofr some reason, she was really nice to an airline pilot (don't know why; I'm nobody medically)...anyway; the MDA sort of dropped out and the CRNA did my case.......even as the CRNA was doing the Bier Block, the MDA had to add "great anesthesia, glad you have a nurse"....my surgeon told me that he thought the CRNA was fine and we proceeded.. an unsedated Bier Block for 30 min surgery was painful, but it worked.......the CRNA did a great job and I must admit; she was equal to any MDA whom I have met..........I "demanded" an anesthesiologist and ended up with "just a nurse".....damned glad that I did
finder

East Orange, NJ

#18 Dec 20, 2009
nurse anesthetist wrote:
When I had anesthesia a nurse anesthetist did the anesthesia. I never saw the anesthesiologist. It had a shoulder scope with a nerve block, also done by the nurse anesthetist. It worked wonderfuly. What do anesthesiologist do that nurse anesthetist don't do? Why don't we just use nurse anesthetist instead, would that not save money?
I think your grammar speaks for itself. Would it save money? Yes. So would teaching the housekeeper to sit in the operating room and give anesthesia. You can teach a monkey to take out an appendix, should we? It'd be free.
finder

East Orange, NJ

#19 Dec 20, 2009
Oh and Gerald..your story is a bit silly, in summary: CRNA was nice to me, MD wasn't...me like CRNA better now. Me prefer cardio/neuro toxic substance injected in me using an archaic technique because crna not know how to do precise technique with fraction of toxicity risk...me like crna because crna hold my hand...doofus.
Gerald

Donora, PA

#20 Dec 21, 2009
finder wrote:
Oh and Gerald..your story is a bit silly, in summary: CRNA was nice to me, MD wasn't...me like CRNA better now. Me prefer cardio/neuro toxic substance injected in me using an archaic technique because crna not know how to do precise technique with fraction of toxicity risk...me like crna because crna hold my hand...doofus.
finder: The anesthesiologist made the decision to use the Bier's Block, he just present to do it. Read my earlier comments; I was quite certian that an anesthesiologist was much more qualified than a CRNA. Hearing the anesthesiologist trash the CRNA did little to bolster my confidence in the MD superiority issue. The tone of your commments is immature and not helpful.
MDA

Van Nuys, CA

#21 Dec 21, 2009
As with anything in life, you get what you pay for. Anesthesiologist are Medical Doctors who have extensive training. Sure there will be instances where the anesthesia delivered was not optimal; but there are far fewer instances, when compared to CRNA (nurse anesthetist).

Nurse anesthetist (CRNA) receive only 2 years of training. MDA (Anesthesiologist-Physician) undergoes a grueling 8 years of training. It is absurd to believe that the training is anywhere remotely equivalent.

My group had the option of hiring CRNA into our practice. Overwhelmingly, we decided that we would prefer quality and accept nothing less. Several of the anesthesiologist had personal experiences with CRNA and were vocal in expressing their desire NOT to hire any CRNA.

I've had several medical misadventures directing CRNA. On several occasions, the CRNA did not listen to my recommendations. The CRNA did NOT inform me when they were starting or ending cases. The CRNA did NOT inform me in a timely manner when case was going badly. On several occasions, they explicitly did the opposite of my instructions and then blamed me when things went wrong.

Currently, obtaining an anesthesiology residency is competitive. You will need to have high MCAT scores and be at minimal in the top half of your graduating medical school class. People attracted into the field of anesthesiology enjoy applied physiology and pharmacology. They know how medications work. Their delivery of medications is tailored to the individual patient. On observing CRNA perform anesthesia, it appears to be cookie-cutter text book. Because of their training, they do NOT have a strong grasp of physiology or pharmacology (of course there are exceptions). And we should not expect CRNA to have extensive knowledge. Their training is far inferior. As previously stated, 2 years cannot be equivalent to 8 years. They know how to perform anesthesia on uncomplicated cases. If there is any deviation from the norm, they simply cannot perform.

For your information, my undergraduate was at Yale University. Attended Cornell Medical School, and did my Anesthesiology in the Harvard Hospitals - Brigham and Women's Hospital. As a senior resident rotating in the Veterans Hospital, I had an encounter with a student CRNA. She was on her second month of training. One of the veterans asked her if there was a difference between MDA and CRNA. This student replied that the two are equal. I found this puzzling as she had done her nursing degree at a local community college and had gotten her bachelors several years latter through an online course. Apparently my ivy league education in her mind was equivalent.

To summarize, if excellence is demanded, it should also be compensated. You get what you paid for. If my family member or loved one was having surgery, I would insist on a medical doctor as the anesthesiologist. As I would insist that the operation be done by a Physician - Surgeon. Sure there are many competent CRNA, but personally, I wouldn't want to risk it.

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