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, The Heartland Institute’s website at, and PolicyBot, Heartland’s free online research database at

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 or 312/377-4000.
Heartland Institute: The Government Relations Team | | 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, 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 with total number attending.

For more information about Dr. Bob Stuber please visit his website:


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:

(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 or April Canter at


Waste not, want not. Don’t dispose of your PCs… Repurpose.

Post Written by Brant Myers, Director of Operations for Excel Anesthesia

Part of my role at Excel Anesthesia is to maintain and manage the IT stuff around the office. Over the last year we have improved our workflow by changing some of the applications we use on a daily basis. As it happens, our old PCs just couldn’t keep up with these changes.

We were left with a choice.  We could upgrade our existing equipment, or buy new machines.

Fortunately, new PCs were not only outlined in our IT strategic plan last year, but also included in the budget.  We purchased and installed new PCs for our corporate office in 2013.  As a result, I have the task of making sure the old PCs are disposed of securely.  Based on my past experience, this is usually not an easy task and can be expensive. Part of the expense is making sure that data on the old machines is destroyed so that we maintain HIPAA compliance.

Connecting For GoodI know of local organizations that recycle old computer parts, but these PCs might still be useful to someone willing to take the time to rebuild them and install more memory (RAM).  As I was deciding the best course of action, got an email from my long-time colleague Rick Dean.  Rick and I had run into each other many times over the years at not-for-profit IT events.  We loved to “talk shop” and share our IT experiences. We’ve kept in touch over the years, mostly through LinkedIn, but it was his recent email that caught my eye.

Connecting For Good - Refurbishing ProgramRick is a founding board member of Connecting for Good, a not-for-profit organization dedicated to making sure that everyone has access to broadband Internet, regardless of their income. While Internet access is available at libraries, schools and other public institutions, they believe connectivity in the home is essential for all Kansas City families if they are to fully participate in our digital society.

Connecting to the internet requires a computer and an internet connection.  Their computer refurbishing program provides lower cost access to computer hardware.   This program was a perfect fit for our needs, and Connecting for Good will be getting all of our old machines.  Everybody wins, and we feel like we are doing a good deed instead of just recycling the old PCs!

Do you normally recycle your old machines?  Do you keep them in a closet to collect dust because you didn’t know what to do with them?  I hope this is a good for solution for you… please let us know!

What’s in a name? – CRNA, AA, Nurse Anesthetist or Anesthetist, the difference is significant.

JCBuisnessWhat’s in a name? CRNA, AA, Nurse Anesthetist or Anesthetist?

Warning! The pristine patient safety record that certified registered nurse anesthetists (CRNAs) have historically achieved is at risk.  Currently all reputable studies show; there is no difference in patient outcomes when CRNAs provide care to patients individually vs. CRNAs who provide care under the medical direction of an anesthesiologist, (Department of Health, 2005), (Dulusse & Cromwell, 2010), and (Newhouse, et al., 2011). Nowhere in these studies does it measure patient safety outcomes when utilizing Anesthesiologist Assistants (AAs). The publicized outcomes of these patient safety studies has been the primary reason why states are permitted to “opt-out” of the CMS requirement for CRNA supervision when billing for Medicare part A. Therefore, it is imperative that all data that is recorded in the patient electronic medical record be entered accurately and consistently when documenting the title or category of the healthcare provider performing the care.

Increasing numbers of hospitals and surgery centers have implemented some version of electronic medical record system to facilitate participation in health information exchange. While this is an important step in enabling providers to access and review their patient’s pertinent health information, it is also a powerful tool for reporting evidenced based outcomes.  With that in mind, it is imperative that the EMR/EHR systems include the ability for each provider to be categorized separately and consistently.  Otherwise, the data used for reporting outcomes will be compromised, leading to inaccurate conclusions, and potentially dangerous policy.

In the past two weeks we have encountered several instances in which different providers were lumped together in a single category when anesthesia services were recorded. One in particular involved a large, multi-location hospital in the Kansas City area. This hospital was in the process of training providers to utilize the new EMR software. During the training, one of the CRNAs tried to locate the field that correctly identified him as a CRNA but the software only offered either a combined field that listed AA/CRNA or the remaining field choice, Anesthesiologist. Neither of these is correct or accurate.

The effects of lumping different providers into a single category are:

1.  Distinction between CRNA and AA is blurred
2.  Integrity of the data is compromised
3.  Evidenced Based Safety Outcomes results are inaccurate
4.  Compromised CRNA safety record

In addition, we have recently encountered multiple bills in the Missouri House and Senate that if passed will require the adoption of some form of cloud based health information exchange. All these bills contain confusing, ambiguous, and inconsistent definitions of Health Care Providers, such as “nurse anesthetists” and “anesthetists” which refer to CRNAs and AAs respectively. Referring to AAs as anesthetists could blur the distinction between the two providers.

In current laws and statutes, the term anesthetist has referred to CRNAs for decades, if not centuries. CRNAs and AAs are entirely separate providers with completely different training, education and experience.  CRNAs have an extensive healthcare background and a pristine patient safety record.  CRNAs have a bachelor’s degree in nursing, several years’ experience in intensive care performing direct patient care as a registered nurse, and a Master’s Degree and or Doctoral Degree specializing in anesthesia. CRNAs are also Advanced Practice Registered Nurses (APRNs) and are certified by a nationally recognized certifying body. CRNAs are qualified to make independent judgments and are able to practice without an anesthesiologist in all aspects of anesthesia.  In many states, CRNAs are completely independent of any physician supervision. CRNAs are able to bill Medicare, insurance companies and patients directly, and receive direct reimbursement for their services.  CRNAs have been providing care for over 150 years and have had many years to establish this incredibly high patient safety record.  In fact, there are approximately 32 million anesthetics administered to patients every year by CRNAs (Missouri Association of Nurse Anesthetists, 2011).

AAs, on the other hand, have only been providing service for approximately 45 years. There has been inadequate time and inadequate patient volume to establish a proven safety record, whether good, bad, or otherwise. Because of this, it is important to be vigilant and mindful when entering the title/credentials of the medical professional providing the care in order to maintain the sterling reputation of our profession and the integrity of our patient safety record. I prefer the CRNA safety record to accurately continue to reflect, as it should, to only those services provided by CRNAs. Marketing companies focus on the term “Branding” when trying to promote a product or service.  In the business industry, the best way to promote an inferior product is to make the product “seem” like it is the same as an established, superior product. So long as the public thinks it is the same, they will think they are getting a good deal. CRNAs are in danger of losing our branding. By merging our profession with that of another, we risk diluting our safety record and could soon be perceived by the public, and the policy makers, as the same.

As CRNAs, what can we do to promote and protect our own professional branding?

  • Be vigilant.  As our hospitals and surgery centers begin to implement EMRs, we need to ensure our designated provider field lists only CRNA and not nurse anesthetist, not anesthetist, and certainly not AA or any combination thereof.  If you see this and cannot get it changed, then inform your state association of the AANA.
  • Introduce yourselves appropriately to everyone as Certified Registered Nurse Anesthetists, or CRNAs.  Politely correct anyone who might incorrectly refer to you as tech, an anesthetist, a nurse without qualifying your advanced degree, or even a nurse anesthetist.
  • Support your state association and get involved. There are diplomatic methods to educate our co-workers without appearing combative in the workplace.
  • Get proactive at the federal CMS level and spearhead requirements for
specific roles/titles of providers when submitting claims involving
PQRI on the CMS EMR. There will soon be emerging standardized form fields for reporting data consistently in these health information exchange software programs.

If we could be at the table so to speak with the programmers working through CMS, Medicaid expansion, and the ACA, we would be in a position to protect THE INTEGRITY OF OUR DATA SUBMISSION and our specific practice. It’s imperative we lead the initiative. Otherwise we will be swallowed up in the system. Goodness knows, we saw first-hand with the ACA “roll-out” how well the initial programming went!

Most importantly, remember who we are and be proud of our profession. Be willing to educate others about our practice. Let’s work together to develop a pragmatic approach to ensuring our provider designation remains intact. This is our Practice!  Let’s get busy taking care of it!  Feedback is welcome.

Dulisse, B. & Cromwell, J. (2010). No harm found when nurse anesthetists work without supervision by physicians. Health Affairs, 29 (8).
Newhouse, Stanik-Hutt, J., White, K. M., Johantgen, M., Bass, E. B., Zangaro, G., et al. (2011). Advanced Practice Nurse Outcomes 1990-2008: A Systematic Review. Nursing Economic$, 29(5), 230-251.
Newhouse, R., Stanik-Hutt, J., White, K. M., Johantgen, M., Bass, E. B., Zangaro, G., et al. (2011). Advance Practice Nurse Outcomes 1990-2008: A Systematic Review. Nursing Economic$, CNE Series, 21.