Missouri In The Lead For Dead Last: The race for last among states re: access to healthcare.

September 25, 2014

By Jean Covillo, APRN, CRNA

Managing Member Excel Anesthesia, LLC

“The Anarchist”


According to the  Commonwealth Fund, an  independent, private  foundation that provides  comparative data related  to 38 health indicators  and state response to  national health policies      and initiatives, Missouri ranks a heartbreaking 44th overall. This is an overall decline from the 2010 report where Missouri ranked 33rd (Commonwealth Fund, 2013)

The reasons are simple and easily correctible.

First: There are not enough physicians applying to practice in rural Missouri. This is not uncommon in other states throughout the nation. Most states, including all immediately surrounding Missouri have adapted to this crisis and legislatively passed statutes that allow Advanced Practice Registered Nurses (APRNs) to practice to the full extent of their training and education. This education includes both a Bachelor’s degree in nursing along with a Master’s or Doctoral Degree in their chosen specialty practice, as well as several years of clinical training and oversight beyond those years of experience as a registered nurse. These APRNs have been competently fulfilling the health care needs of these areas and have done wonders in making up for the shortages of providers.

Second: In Missouri this doesn’t happen! Missouri APRNs have been legislatively restricted from practicing to the full extent of their scope of practice, which further compounds the problem by making it impractical and oftentimes impossible to provide care. In fact, Missouri is one of the most restrictive APRN scope of practice states in the entire nation. To clarify: Missouri has close to the worst ranking in access to care and the most restrictive scope of practice for APRNs in the nation!

You might wonder why this is? The answer is very simple…it is called money, power, and greed. A few weeks following a well attended fundraising event sponsored among others by the Missouri Nurses Association for the benefit of electing District 34 Mo Senatorial Candidate Dr. Bob Stuber, a vicious, slanderous, deceitful E-mail was written and circulated by Warren E. Hagan M.D., President, Buchanan County Medical Society. The credentials Dr. Hagan included in this E-mail were those included in his official elected capacity as the President of the Buchanan County Medical Society of which all participants were sent a copy. In the E-mail Dr. Hagan accused the nurses of “anarchy” for supporting a candidate, (Dr. Bob Stuber who is also a fellow physician) who believes in furthering Missouri citizens’ access to health care by encouraging legislation allowing APRNs to work to the full extent of their education and training.

Although most physicians would agree that the restrictive APRN scope of practice requirements in Missouri need to be revised in order to match those of the surrounding states and the need to adapt to the increasing patient population/ physician shortages; there are a FEW who continue to erect roadblocks by falsely claiming patient safety concerns (while studies support the opposite) and other various scare and bully tactics in order to “hold on to their turf”: “turf” that NO physician really wants as evidenced by the shortage in those areas. Apparently the rational is, “its better for patients to have NO access to healthcare than access to care administered by an APRN”.

The solution according to the incumbent candidate for Missouri Senate, Dr. Rob Schaaf devised and passed in the 2014 Missouri legislature session was to create a new category of physician provider called an “Assistant Physician”. Instead of lifting/revising cumbersome, outdated restrictions on highly qualified and competent Missouri APRNs who were already positioned, experienced, skilled and ready to practice in their specialty, he decided to promote an entirely new category of provider with virtually no professional clinical experience simply because they had the designation “physician”. A medical school education is an extremely rigorous and demanding program, and anyone should be proud to complete it. But medical schools do not design their curriculum for their graduates to hang out a shingle and see patients the day after the degree is conferred. Medical schools prepare their graduates for residency-a three or four year period, equally rigorous and demanding-where they then learn the complex and delicate art of caring for patients. The latter cannot be taught only in classrooms.

Nonetheless, the Missouri politicians (Senator Schaaf and Rep. Frederick) justify creation of this new “assistant physician” (a made-up title confusingly similar to the respected and well-credentialed “physician assistant”) as a strategy to address the shortage of primary care in many areas of their state. While the shortage is a problem that should never justify compromising patient well-being and safety. An ill-trained, ill-prepared provider can do more harm than good, prescribing dangerous medications, misdiagnosing serious illnesses, and threatening life and limb. Errors and misjudgments are too common even among veteran physicians, much less a green, new grad. It’s not fair to these aspiring young physicians to put them in a position to do harm, and it’s certainly not fair to their patients.

See the following link for more-  http://www.forbes.com/sites/leahbinder/2014/07/22/defying-the-ama-some-politicians-lower-standards-for-practicing-medicine/

Schaaf’s bill passed and managed to escape veto allowing newly graduated medical students who have been denied acceptance into residency programs and have not passed all of their exams, to provide direct patient care in these Missouri rural areas with marginal oversight….. “Are you kidding me?!! Most young adults graduating from medical school, although highly educated, have no experience, which is why they complete residencies. Without residencies they have little to no experience personally starting IVs or taking blood pressures, let alone taking care of patients with OSA on CPAP, angina, CRF, COPD, HTN, diabetes, CHF or, heaven forbid a combination of co-morbidities without a seasoned physician overseeing their care!”

Our company, Excel Anesthesia works with hundreds of physicians every day. We are very proud to work as a team with our physicians and CRNAs and respect the educated minds of both physicians and APRNS. We believe the contribution of all is essential to the care of our fellow citizens and the key to improving access to care here in Missouri; ranking 44th is not only unacceptable, it’s a crime of abandonment. It does not benefit anyone to disempower those educated, trained, and capable of performing health care services in order to better promote one person’s or professions’ selfish gains. It must stop NOW!

Sadly, this vocal minority of influential physicians including Dr. Hagan and incumbent Senator Rob Schaaf are making Missouri policies and laws with their own special interests in mind. But it’s the Missourians who are suffering the consequences.

We CAN Make a Difference! We have the opportunity to remove Dr. Schaaf from office!


Here is How: 1. Register to Vote

2. SHOW UP TO VOTE-November 4, 2014

3. Vote for Dr. Bob Stuber for Missouri Senate District-34

REMINDER-RSVP Today-Dr. Bob Stuber Fundraising Event Tuesday Aug 26

NURSE LOGO SHIRTSMissouri Nurses are joining together to host a Fundraising event for Dr. Bob in Kansas City Missouri at Piropo’s Bar and Grill August 26. Even if you can’t attend we would appreciate any and all donations. Please see details located on the attached flyer! Special Guests include Attorney General Chris Koster, Fmr State Senator Wes Shoemyer, and Fmr Lt. Governor Joe Maxwell.

We need your support! Dr. Bob is running against Rob Schaaf, the Senator that is making all the legislative blockades for nurses here in Missouri. If you can’t make it, please contribute! Help us get the word out. I have personally mailed every nurse in Platte and Buchanan county an invitation. But this election affects all Missouri nurses, regardless of whether or not you are an RN, LPN, Nurses Aid, APRN, anesthesia or nurse practitioner! Please share this and help in any way possible! Even a small donation given by everyone will make a huge difference.

There are 93,000 nurses in Missouri and 2,600 in these counties. Patients in Missouri depend on our ability to get the vote out on November 4, 2014. See attached flyer for details on how you can contribute and or attend!

Please upload this image to any Social Media Groups in which you participate. Images that are .jpeg format, (such as this one) will download to your computer or phone as a picture and are readily up-loadable and can be included in your post. Just save it to your phone pics and post to the FB or Link-ed in group in which you participate. Help get the word out! Thank you everyone!

RSVP by clicking on this link: https://www.eventbrite.com/e/dr-bob-stuber-for-missouri-senate-fundraiser-piropos-august-26-tickets-12625775033


Microsoft Word - Corrected Stuber Invite Parkville.docx

Medical Licensing and the Doctor Shortage

SurgeonA 2011 study published in the Milbank Quarterly found Obamacare would create a need for between 4,300 and 7,000 more physicians in the United States by 2019. Avoiding a physician shortage is complicated by the fact that becoming a licensed physician is an expensive and slow process. Strict licensing standards have become a significant barrier to entry in many fields, but nowhere is the influence of licensing more sharply felt than in the health care industry. In many instances, states control licensing standards, professional discipline, and the various costs associated with the process. These standards are usually championed by existing practitioners to slow or block entry of new competitors.

Supporters of strict state licensing standards argue they assure quality, but critics argue the arduous and often expensive licensing process harms the health care market by hindering entry for new physicians and thereby impeding the competition that lowers costs and improves consumer access to healthcare services. Shirley Svorny of California State University at Northridge and the Cato Institute argued in a 2008 paper that the current licensing system for physicians serves to benefit incumbent clinicians instead of consumers, and that the health care market would be better served by eliminating professional licensing.

“Licensure not only fails to protect consumers from incompetent physicians, but, by raising barriers to entry, makes health care more expensive and less accessible,” Svorny wrote. Institutional oversight and a sophisticated network of private accrediting and certification organizations, all motivated by the need to protect reputations and avoid legal liability, offer whatever consumer protections exist today. Consumers would benefit were states to eliminate professional licensing in medicine and leave education, credentialing, and scope-of-practice decisions entirely to the private sector and the courts.”

There are several paths state legislators and medical boards can choose to lower these regulatory barriers. The first proposal, recently introduced as a piece of model legislation by the Federation of State Medical Boards, would make it easier for doctors licensed in one state to treat patients in another. According to the New York Times, this reform would not only cover in-person visits but also videoconferencing and online visits. The proposed legislation would create an interstate compact, and the Times reports it has political support from both sides of the aisle.

The second proposal, supported by the Institute of Medicine and National Governor’s Association, would expand the scope of responsibilities for nurse practitioners (NPs), allowing them to provide additional health care services. This extension would only apply to registered nurses who have also received a graduate degree in nursing. Allowing NPs to administer care would greatly reduce the upcoming doctor shortage and increase access to care. Currently, 19 states and the District of Columbia allow NPs to diagnose and provide some form of treatment for certain illnesses. Although critics of these efforts claim expanding the scope of practice will lower the overall quality of care, a 2012 article in Health Affairs reviewing 26 studies noted the “health status, treatment practices, and prescribing behavior [of NPs] were consistent between nurse practitioners and physicians.”

Although a complete repeal of medical licensing may not be practical, allowing physicians to treat patients across state lines and expanding the scope of practice of nurse practitioners are two incremental steps states can take to address the doctor shortage.

The following articles examine the doctor shortage, scope of practice, and medical licensing from varied perspectives.

Medical Licensing: An Obstacle to Affordable, Quality Care
Shirley Svorny of the Cato Institute argues licensure not only fails to protect consumers from incompetent physicians but also makes health care more expensive and less accessible by raising barriers to entry. Only institutional oversight and a complex network of private accrediting and certification organizations, all motivated by the need to protect reputations and avoid legal liability, offer whatever consumer protections exist today.

The Medical Monopoly: Protecting Consumers or Limiting Competition?
Sue A. Blevins of the Cato Institute examines the effect of government health care policies on the health care market. Blevins finds licensure laws appear to limit the supply of health care providers and restrict competition to physicians from non-physician practitioners. The primary result is an increase in physician fees and income, driving up health care costs.

Research & Commentary: Reimbursement Flaws in Medicaid and the ACA
Heartland Institute Senior Policy Analyst Matthew Glans examines the growing problem of physician reimbursement under the ACA. Fewer doctors are accepting new Medicaid patients today, in part due to low reimbursement rates and a sharp increase in Medicaid enrollment caused by states expanding Medicaid programs in response to the promise of additional federal funds under the Affordable Care Act (ACA).

Medical Licensing in the States: Some Room for Agreement—and Reform
Charles Hughes of the Cato Institute discusses the growing doctor shortage, how it is likely to increase with the implementation of Obamacare, and the steps some states are taking to address the issue.

A Cure for what Ails Us
Justin Owen, Trey Moore, and Christina Weber of the Beacon Center of Tennessee analyze the current predicament facing Tennessee policymakers in the wake of the ACA. The report also offers state-led solutions that would move the nation’s healthcare system in the proper direction, treating the diseases that weaken the system themselves, rather than merely treating symptoms.

Medical Licensing Impedes Quality, Affordability of Care
This article from the Heartlander discusses a report by Shirley Svorny of the Cato Institute that argues medical licensing is ineffective and inefficient, and that patients would be better served relying on brand recognition when choosing doctors.

Six Reforms to Occupational Licensing Laws to Increase Jobs and Lower Costs
Byron Schlomach of the Goldwater Institute argues reforming licensing could open career opportunities and reduce costs without sacrificing consumer safety. The paper recommends six reforms.

Obama Health Care Law Exacerbates Primary Care Physician Shortage
Writing in the Heartlander, Loren Heal reports President Obama’s health care law is likely to increase demand for primary care physicians, even as the nation already faces shortages of doctors in this field.

The Role of Nurse Practioners in Meeting Increasing Demand for Primary Care
This paper from the National Governors Association summarizes the literature on nurse practitioners and the current practice rules governing NPs.

Nothing in this Research & Commentary is intended to influence the passage of legislation, and it does not necessarily represent the views of The Heartland Institute. For further information on this subject, visit Health Care News at http://news.heartland.org/health, The Heartland Institute’s website at http://heartland.org, and PolicyBot, Heartland’s free online research database at www.policybot.org.

The Heartland Institute is available to send an expert to your state to testify or brief your caucus, host an event in your state, or send you further information on this or any other topic. If you have any questions or comments, feel free to contact Heartland Institute Senior Policy Analyst Matthew Glans at mglans@heartland.org or 312/377-4000.
Heartland Institute: The Government Relations Team | AMonahan@heartland.org | Heartland Institute | One South Wacker Drive #2740 | Chicago, IL 60606

Victor Quintero, CRNA, APRN-Medical Missions- Antigua, Guatemala 2014


My Friends!

 Victor Quintero, CRNA, APRN, Senior Partner of Excel Anesthesia, LLC recently returned from a medical mission in Antigua, Guatemala that was arranged through the Medical Mission Foundation (MMF) based in Kansas City. This would mark his 7th trip of voluntary service with this particular organization and his 12th overall Mission helping those in dire need of medical care. The group spent one week working at Obras Sociales del Santo Hermano Pedro, translated to mean, “Social Works of Brother Saint Peter”.     The building in which these services are provided is as large as a city block, providing health care needs for the poor and homeless. In addition to surgical services, Obras Sociales also is an orphanage, and an extended care home for the elderly, and mentally/physically handicapped people. This trip consisted of a fairly large group of approximately fifty volunteers comprised of a mixture of non-medical volunteers, doctors, surgeons, residents, medical students, nurse anesthetist, anesthetist students, audiology team and translators. The non-medical volunteers bring joy to the children by providing and dispensing, art supplies as well as giving art lessons. Most of the children have never had crayons, watercolors, or any other kind of art supplies, so  you can imagine this art lesson is a big hit with the kids; keeping them occupied while waiting for their or their relative’s turn in surgery. MMF travels the world 4-6 times a year and is unique from many other missions in the emphasis it places on medical services and providing art lessons/ supplies to each site and every child.

“This year we had three specialties”, Victor relates, “General Surgery, ENT and Urology. We ran five ORs doing forty!,… YES FORTY, tonsillectomies on Monday; mostly on children. Needless to say the PACU was very busy! For the week, we did 113   surgeries and the audiology clinic saw hundreds of patient and handed out over 100 hearing aids; pretty amazing when you consider that the patients and the staff don’t speak English and were usually finished by five o’clock. I can only dream that     we could be so efficient in the US. The Guatemalan staff is excellent; with IV skills, hard work ethic and positive attitude! It’s a privilege to work alongside them in their O.R.” Victor describes a typical day as follows: “For most of the team our day begins at 06:30 by eating a fabulous Guatemalan style breakfast, then we walk a few blocks over to Obras to get ready for surgery and usually start surgery around 7:30, (imagine that). Between 11:30 12:30 we break for a Guatemalan lunch and hopefully are finishing up surgeries by 5:00 pm since most of the Guatemalan staff need to catch chicken buses to get back home. The American volunteer staff typically unwinds by walking a few blocks through this beautiful colonial town to a roof  pub called the Sky bar. There we talk about our day while drinking “Gallo” (Guatemalan beer) or soda with fantastic views of the city and its distant volcanoes. Then its dinner and bed so that we can do it all over again for the next five days. There is no mistaking; it is hard work, but we have so much fun, make new friends, connect with old friends while helping people who are truly in need and appreciative of our efforts. Overall this was my 12th mission. Each one is unique and personally fulfilling. If you ever have the opportunity to participate, ..do so! You will not regret it.”

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Stuber Fundraising Event

BOB STUBER FUNDRAISERJoin Missouri Nurses for this Fundraising Event!  It is critical for our profession to support Dr. Bob Stuber For State Senator.  Our profession depends on it!

Dr. Stuber says, “Nurses, WE CAN MAKE A DIFFERENCE!  I understand the critical role our nurses provide in Missouri healthcare and am a strong supporter and advocate for the entire nursing profession.  Patient access to care in Missouri has been recorded as among the worst in the nation.  Many years of volunteer medical service for public healthcare has given me the valuable insight necessary to find workable solutions.  We need to relax the restrictions currently being promoted by legislators such as Dr. Bob Schaaf  on APRNs of our state to ensure that the demand for quality medical care is not impeded.  Doing so would allow more patients to receive quality care in an efficient and cost effective manner”.


DR. BOB STUBER-Candidate for Missouri State Senate- District 34

WHERE:  PIROPOS PIANO BAR located at 4141 N. Mulberry Drive, Kansas City, Missouri 64116

WHEN:  TUESDAY AUGUST 26 from 7:00-9:00pm

Special Guests planning to attend include:

Chris Koster, Missouri  Attorney General 

Fmr. Senator Wes Shoemyer

Fmr. Lt. Governor Joe Maxwell

Suggested Minimum Donation of $35 per person and $50/ family

Please make all checks payable to:  Stuber for Senate

If unable to attend you can mail your donation to Stuber for Senate c/o Covillo, 6324 N. Chatham Ave. Suite 233, KCMO 64151

RSVP By E-mailing ElectStuber@gmail.com with total number attending.

For more information about Dr. Bob Stuber please visit his website: http://www.stuberforsenate.com/


Remodeling Anesthesia Delivery

Eliminating Anesthesia Subsidies

By Jean M. Covillo, CRNA, MA, ARNP

EA Ladder Man

As CMS is considering measures of efficiency, Excel Anesthesia LLC offers insight, along with cost-effective recommendations, for remodeling the anesthesia care delivery practice model.  These suggestions take a closer look at the various existing anesthesia practice models, especially those requiring subsidies. Literature indicates that CRNAs acting as the sole anesthesia provider are the most cost-effective model for anesthesia delivery, (1) without any measurable difference in the quality of care between CRNAs and other anesthesia providers, or by type of anesthesia delivery model. (2) 

The standard anesthesia care team model utilizes “medical direction” billing, by anesthesiologists with a ratio of one anesthesiologist per a maximum of four CRNAs/AAs. Increasingly, facilities and stakeholders are examining safe, cost-effective alternatives to offset the growing prevalence of unnecessary anesthesia subsidies.  Armed with the facts, many are opting for a total Remodel of the traditional “anesthesia care team”, by implementing the model of care that is best suited for their specific patient clientele; saving millions without sacrificing patient safety.

This is not meant to imply anesthesiologists are not needed nor considered necessary in some facilities; rather the existing “medical direction anesthesia care team model” is not cost-effective and alternatively has not been shown to be a safer model. (2) When facilities choose to utilize anesthesiologists, they can do so more cost-effectively by removing ratio restrictions, (1:4) as long as they are utilizing CRNAs.  Anesthesiologists must supervise/medically direct AAs at no greater than a 1:4 ratio, therefore AAs are not eligible to participate in this model.  Consequently this approach takes advantage of more CRNAs at a lesser expense, while reducing the expense of the total number of anesthesiologists.  Eliminating the medical direction model frees the Anesthesiologist from the inefficiency of directing CRNAs which further enables both to provide separate billable services to more patients.  Both providers are then able to administer care to their own patient volume rather than sharing the care and reimbursement of one patient.  These services will then result in each receiving 100% of the awarded reimbursement rather than splitting this same amount by 50%, which occurs in the “medical direction model” or an even lesser amount as found in the “supervision model”.

In summary, the costs incurred by facilities utilizing the medically directed anesthesia care team model are by far, the highest and most inefficient of all models utilized.  The following describes some of the reasons why:

MEDICAL DIRECTION – 7 Steps Must Be Completed by Anesthesiologists to Qualify for Medicare reimbursement

  • Under the medical direction practice model, the medical directing anesthesiologist must complete seven steps in order to bill for this modality. CMS has clearly stated that medical direction is a condition for payment for anesthesiologist services and not a quality standard. (4) One of the seven necessary steps for making a medical direction claim includes being “present at induction”, yet oftentimes this is delayed. For every minute spent waiting for an anesthesiologist to arrive and be “present at induction”, some of the costliest resources in the hospital are wasted. The clock is running on the surgeon, circulating nurse, scrub tech, and nurse anesthetist waiting in the operating room. Waiting costs cascade throughout the day, postponing the surgery schedule to require overtime and on-call staff, delaying the surgeon’s rounds to affect patient care and discharge of the patient from the healthcare facility. Waiting costs also
    add opportunity costs, diverting needed resources from other patient care.


  • Another of the seven necessary steps in making a medical direction claim includes the anesthesiologist being “present at emergence from anesthesia”. However, strong evidence in the literature shows that anesthesiologists fail to comply with federal requirements, either the Part A conditions of participation or Part B conditions for coverage. Lapses in anesthesiologist supervision are common even when an anesthesiologist is medically directing as few as two CRNAs, according to a 2012 study published in the journal Anesthesiology, (5) the professional journal of the American Society of Anesthesiologists. The authors reviewed over 15,000 anesthesia records in one leading U.S. hospital, and found supervision lapses in 50 percent of the cases involving anesthesiologist supervision of two concurrent CRNA cases, and in more than 90 percent of cases involving anesthesiologist supervision of three concurrent CRNA cases. According to the 2012 AANA Annual Membership Survey, anesthesiologists are present for emergence for only 5 percent of medically directed cases. The combined costly delays associated with case start times and keeping a patient anesthetized until the anesthesiologist arrives for emergence results in sky rocketing hospital and surgery center costs and an overall devastating loss in profitability and sustainability.


  • Failure to comply with all 7 steps results in the inability to bill Medicare as “medical direction” resulting in the need to bill “supervision by anesthesiologist or Non- medical Direction”.  Supervision results in a reduction of claim amount, reduction of claim reimbursement, and danger of oversight leading (billing Medical Direction vs. Supervision) to an increased risk of Medicare audit, loss of Medicare provider eligibility for participation (part-A and part-B); and in some cases may lead to an investigation of fraud. (8)


  • According to a nationwide survey of anesthesiology group subsidies, (6) 98.8 percent of responding hospitals reported that they paid an anesthesiology group subsidy. Hospitals pay an average of $160,096 per anesthetizing room, to anesthesiology groups; an increase of 13 percent since the previous survey in 2008. Translated into concrete terms, a hospital with 20 operating rooms pays an average of $3.2 million in anesthesiology subsidies. Anesthesiology groups receive this payment from hospitals in addition to their direct professional billing, which also adds to the costs the hospital must pay.



  • Anesthesiologist Assistants (AAs) are UNABLE to provide service without an anesthesiologist supervising or medically directing.  The ratio of Anesthesiologists to AAs cannot exceed one anesthesiologist to four AAs, which is the same ratio for CRNAs, however CRNAs can work non-medically directed with no ratio requirements. (7)(8)
  • When AAs provide service as “medically directed”, the reimbursement is the same as a “medically directed” CRNA. (8)
  • CRNAs ARE able to provide service WITHOUT an anesthesiologist “medically directing/supervising” and are reimbursed by Medicare for the procedure at the same rate as an anesthesiologist working alone or the total combined payment reimbursement of both an anesthesiologist and CRNA under “medical direction”. (8)




Delivery Model CRNA Anesthesiologist
Anesthesiologist alone (Base units + Time Units) * Conversion factor
CRNA Non-Medically Directed (Base units + Time Units) * Conversion factor
Medical Direction (Base units + Time Units) * Conversion factor *0.5 (Base units + Time Units) * Conversion factor *0.5
Supervisory (Base units + Time Units) * Conversion factor *0.5 Maximum of Four units- regardless of time


*Time Units:  1 Time Unit = 15 Minutes

*Conversion Factor: Specific to Region (Average is $18.00/ Unit)


  • Anesthesiologist-$336,000/yr (1)
  • CRNA-$170,000/yr (1)
  • AA-$170,000/yr (7)



  • INCREASE the utilization of Non-Medically Directed CRNAS (Non-medically directed by an anesthesiologist) in order to eliminate overall expense, reduce the risk of Medicare fraud/and or reduced billing amounts due to supervision ratios.
  • REDUCTION/Replacement of the number of consulting anesthesiologists with more CRNAs.
  • Consider on-site Anesthesiologists to provide other billable services while remaining immediately available for consultation if the facility considers it necessary and the patient clientele warrants it.
  •  Reduction or elimination of AA employees since they are incapable of billing for services as “non- medically directed” and therefore would not be able to provide service under this cost-saving model. (8)


Healthcare facilities are looking for sustainable, safe and efficient alternatives to reduce the overall healthcare costs.  CRNAs acting independently provide anesthesia services at the lowest economic cost, and net revenue is likely to be positive under most circumstances.  The supervisory model is the second lowest cost, but reimbursement policies limit its profitability.  The non-medically directed CRNA is the only model likely to have positive net revenue in venues of low demand, such as may be found in rural hospitals or facilities in which there are fewer rooms or patient volume. (1)

Other models, including medical direction models where one anesthesiologist directs two to four CRNAs are likely to require subsidies in cases where overall demand is not consistent with full utilization of facilities. In facilities where demand is high and relatively stable, the medical direction 1:4 model is relatively stable however once the operating rooms begin to diminish in volume as is typical throughout the day, it quickly becomes very costly and inefficient.  The medical direction 1:1 model is almost always the least efficient model. (1)(4) Finally, if the facility chooses to follow the non-medically directed model, AAs cannot be utilized, as they are only eligible to provide service under an anesthesiologist medically directed model. (7)(8)

Taken with the average expense of an anesthesiologist salary at close to twice that of a CRNA, the loss of net revenue, and the addition of subsidies, it is no wonder healthcare facilities are taking another look at the overall structure and remodeling their anesthesia department.

(1) Paul F. Hogan et. al, “Cost Effectiveness Analysis of Anesthesia Providers.” Nursing Economics. 2010;

(2) Brian Dulisse, Jerry Cromwell, “No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians.” Health Affairs. August, 2010.

(3) 42 CFR §415.110(a), Conditions for payment: Medically directed anesthesia services.

(4) 63 FR 58813, November 2, 1998. American Association of Nurse Anesthetists
AANA – 4

(5) Epstein R, Dexter F. Influence of Supervision Ratios by Anesthesiologists on First-case Starts and Critical Portions of Anesthetics. Anesth. 2012;116(3): 683-691.

(6) Healthcare Performance Strategies. Anesthesia Subsidy Survey 2012. American Association of Nurse Anesthetists
AANA – 5

(7) American Academy of Anesthesiologist Assistants, 2013 Website:  www.anesthetist.org/faq#salaries

(8) CMS Manual System; Pub 100-04 Medicare Claims Processing; transmittal 2716; 140.3.3-Billing Modifiers


Join me at the AANA Mid-year Assembly April 5-9, 2014

Mid-Year Assembly 2014

Post Written by Jean Covillo, Managing Partner for Excel Anesthesia

I look forward to seeing many of my fellow CRNAs at the AANA Mid-Year Assembly in Arlington, VA at the Crystal Gateway Marriott. The Mid-Year Assembly informs attendees about legislative issues affecting nurse anesthesia practice, encourages them to become advocates for the nurse anesthesia practice and profession, and provides opportunities to meet with legislative representatives for states and regions. The Mid-Year Assembly is for all CRNAs and student registered nurse anesthetists interested in issues, trends and influences related to practice and professional advocacy.

I have scheduled time to meet with US Congressman Sam Graves, from Missouri’s 6th congressional district, and Senator Roy Blunt to have general discussions regarding CRNAs and the importance of allowing them to practice to the full extent of their education and training. When it comes to APRNs, Missouri is one of the most restrictive states, as well as having a large medically underserved population. We need to educate our legislators about the important role all APRNs play in providing quality healthcare to those medically underserved citizens of Missouri and across the United States. I encourage all those attending the AANA Mid-Year Assembly to schedule time to meet with the US Senators that represent your State and US Congressmen and Congresswomen that represent your District.

Click here to find out about your US Congressperson.

Click here to find out about your US Senator.

Click here to register for the AANA Mid-Year Assembly.

Karen Parker and The Eye Team – Medical Mission to Haiti

Haiti Mission TripKaren Parker, one of the partners at Excel Anesthesia, participated in a medical mission in Haiti as part of a group called The Eye Team. Karen and the team spent a week visiting the Haiti Christian Mission in St. Louis du Nord.  They performed some much needed eye surgeries on children and adults.

In total, they performed 997 procedures during the trip, including cataract removals and corneal transplants.

Karen doesn’t really enjoy the travel part of the mission…  lots of sitting in airplanes and airports.  But once she gets to Haiti, and sees all of the need for good eye care, she knows she is doing a “really good thing.”  When she gets back home, she loves looking at all of the pictures that were taken.  We asked her to give us a few for this blog post, and she did!  See the slideshow below for some great pics from her February 2014 trip!

You can tell that Karen and the rest of The Eye Team have had a significant impact on the people they helped in Haiti.  Our favorite picture is the one to the right, with the happy little boys after a surgery.


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See you at the MoANA Spring Meeting – March 28-30, 2014

Chase Park HotelThe Missouri Association of Nurse Anesthetists (MoANA) 2014 Spring Meeting will held March 28-30, 2014 at the Chase Park Plaza Hotel in St. Louis, MO.

Although most attendees focus on the professional development sessions, don’t pass up the opportunity to participate in the MoANA business sessions as well. Getting involved in your local association is the best way to promote the continued growth of our practice and show support for those that volunteer their time to ensure MoANA continues to fulfill their mission.

Friday, March 28th from 6:00 PM to 10:00 PM is the Open Board Meeting.
Saturday, March 29th from 10:30 AM to 11:30 AM is the MoANA Business Meeting.
Saturday, March 29th from 12:30 PM to 1:30 PM is the AANA Update.

MoANA LogoAnother important aspect of the Spring Meeting is the opportunity to support the Political Action Committee (PAC). MoANA PAC represents the interests of CRNAs in Missouri. It is a voluntary, nonprofit committee established to elect candidates that will advance MoANA’s legislative program. MoANA PAC is important because it allows CRNAs to speak with one strong voice, reinforcing our “presence” at the state capitol. The PAC is not affiliated with any one political party, but supports individual candidates, and works to persuade other candidates to hear the voice of the CRNAs.

Saturday, March 29th from 5:00 PM to 7:00 PM is the PAC Reception.

We look forward to seeing all MoANA members there!

A Word of Caution to State Legislators from the FTC

State Legislators should carefully evaluate proposals to limit Advanced Practice Nurse’s scope of practice.

Please read the update sent from the American Nurse Association.


On Friday, March 7, the FTC issued a staff paper approved by the Commission 4-0, titled
The release stated, “Federal Trade Commission staff has issued a policy paper suggesting that state legislators should be cautious when evaluating proposals to limit the scope of practice of Advanced Practice Registered Nurses (APRNs). By limiting the range of services APRNs may provide and the extent to which they can practice independently, such proposals may reduce competition that benefits consumers.”, the paper states.

“Even well-intentioned laws and regulations may impose unnecessary, unintended, or overbroad restrictions on competition, thereby depriving health care consumers of the benefits of vigorous competition.” the staff policy paper states.

The policy paper, called Policy Perspectives: Competition and the Regulation of Advanced Practice Nurses, notes the potential benefits of improved competition in the provision of primary health care services.

While addressing APRN practice, this policy paper could speak to the broader scope of practice for all registered nurses. RNs typically do not contend with the legislative/regulatory barriers imposed upon APRNs; however, organizational culture and institutional policy may arbitrarily restrict RN practice and care. “Improved collaboration and coordination among all health care providers is a fundamental goal of many health care quality and cost-containment initiatives.”

“The policy paper is part of the FTC’s ongoing efforts to promote competition in the health care sector, which benefits consumers through lower costs, better care, and more innovation.”

In addition, ANA staff will be in attendance at the Federal Trade Commission’s public workshop, “Examining Health Care Competition,” on March 20-21, 2014, to study certain activities and trends that may affect competition in the evolving health care industry. The workshop will explore current developments related to:

professional regulation of health care providers;
innovations in health care delivery;
advancements in health care technology;blogANALogo measuring and assessing health care quality;
price transparency of health care services.

If you have any questions or comments, you can reach Andrea Brassard at andrea.brassard@ana.org or April Canter at april.canter@ana.org.