Founded in 1936, the Florida Association of Nurse Anesthetists (FANA) represents 3,500 Certified Registered Nurse Anesthetists (CRNAs) licensed in Florida. FANA advocates for our patients and members in legislative and governmental affairs and serves as a resource for CRNAs, the nursing and medical professions, hospitals, health care facilities and others interested in anesthesia care.
CRNAs provide comprehensive anesthesia care to patients before, during and after surgical and obstetrical procedures and are the primary anesthesia professionals in rural and medically underserved areas. CRNAs practice in every setting in which anesthesia is administered including traditional hospital surgical and obstetrical suites, interventional pain management, critical access hospitals and ambulatory surgical centers. CRNAs also practice in the offices of dentists, ophthalmologists and plastic surgeons.
FANA attends AANA fall leadership academy in Miami.
Representing FANA at the AANA Fall Leadership Academy at the Eden Roc Hotel in Miami Beach, pictured from left: Jose Castillo, VP Rosann Spiegel, President Jorge Valdes, Deb Malina, and Debra Diaz.
Anesthesiologists are gaming the systemPublished in The Hill's Congress Blog, July 4, 2013
Certified Registered Nurse Anesthetists (CRNAs) are among the APRN groups that are an important part of this solution. They are not, however, seeking "expanded practice" or a new scope of practice or reimbursement mechanisms. CRNAs, as they have throughout history (preceding anesthesiologists), administer anesthesia in the same places and utilize the same techniques as their physician counterparts and do so cost effectively, with no compromise in quality of care, according to two recent studies in the peer-reviewed journals “Health Affairs” and “Nursing Economics”.
These facts have historically lead to an almost continuous turf battle, all centered on reimbursement. The current environment serves only to promote a new intensity to this conflict, as organized medicine feels increasingly threatened. The evidence is clear, patient safety is not an issue. It never has been.
As part of a compromise that led to CRNAs being the first advanced nursing group to obtain direct reimbursement from federal agencies in the 1980s, a novel billing scheme emerged. This system allowed anesthesiologists to recoup double the revenue by “medically directing” (sometimes referred to as “supervising”) as many as four CRNAs, than they would by personally administering an anesthetic. To bill for this “medical direction” the anesthesiologist must meet seven criteria. Failing to meet even one of these criteria makes a claim submitted for “medical direction” fraudulent. Recently a $1.2M settlement was reached between the University of California-Irvine and the federal government over exactly this type of fraudulent billing. This is the tip of the iceberg.
Now, even in light of this settlement (or perhaps more correctly, because of this settlement), the American Society of Anesthesiologists (ASA) wishes to relax the federal rules for reimbursement. Instead of meeting the current requirement for being “immediately available”, a patient in the operating room could have an anesthesiologist who is farther away than that–a specific distance or time “impossible to define”, and this would still be considered “supervising.” This is all too reminiscent of the situation in Minnesota in the 1990s when anesthesiologists were billing for medical direction–from the golf course! This led to a $10M+ settlement and institution of corporate integrity policies. (Perhaps it’s time for ASA to review those policies?) Yet, everything old is new again when trying to protect one's turf.
To make this whole issue even more absurd are two recent studies published in the journal “Anesthesiology,” the official publication of the ASA, and “Anesthesia & Analgesia.” In one, communications with “supervising” anesthesiologists were evaluated revealing that less than 2 percent of such communications originated from those being “supervised” in the OR. In the other, the authors revealed significant lapses in the ability to meet the accountability rules as the number of “medically directed” CRNAs increased – lapses which occurred 99 percent of the time! The study also identified a 22-minute delay when anesthesiologists try to meet the guidelines in order to properly bill for medical direction. With Medicare anesthesia provider reimbursement at a rate of $1.43 per minute, and perhaps millions of such delays every year, the waste of Medicare dollars adds up very quickly, even when the criteria can be met. But this is only a small part of the inherent economic fiasco. While patients waits for an anesthesiologist, the standard Operating Room charges are also accumulating at a rate of $25-50 per minute!
In contrast with the above, and with a philosophy similar to the IOM report, the United States Air Force recently updated its policies for the provision of anesthesia services. The policy states that collaboration among anesthesia providers, independent of specific training background, is the preferred practice model. Unlike the civilian market, there is no financial incentive or profit motive involved in providing anesthesia services to our military heroes and their families, just the desire to provide safe and efficient care.
The solution to this problem is exquisitely simple. The president, via his HHS Secretary, must eliminate reimbursement for medically directed anesthesia claims other than those incurred when teaching students or residents. All anesthesia professionals privileged to relieve pain and suffering should actually administer anesthetics. As a society we simply cannot afford to have highly trained anesthesiologists, whose residencies are financed by taxpayers, “supervising”. If a procedure requires multiple anesthesia providers due to surgical acuity or complexity, the current regulations provide for full reimbursement. The system currently incentivizes inefficiency without any gain in quality or safety, and potentially pays for services not rendered. This change eliminates the waste of millions or even billions of taxpayer-supported health care dollars and the submission of fraudulent claims. This would force anesthesia departments to become more efficient and allow all Americans to receive the same high level of care as our military heroes. Horowitz, CRNA, ARNP, practices in Florida.
Recently FANA has become aware that some confusion exists on the issue of supervision of Anesthesia Assistants (AAs). There have been no changes to the statutory language as noted below. If you encounter discrepancies in this regard, you may file a complaint to the Florida Dept. of Health.
Section 458.3475(1)(g), Fla. Statutes:
“Direct supervision” means the onsite, personal supervision by an anesthesiologist who is present in the office when the procedure is being performed in that office, or is present in the surgical or obstetrical suite when the procedure is being performed in that surgical or obstetrical suite and who is in all instances immediately available to provide assistance and direction to the anesthesiologist assistant while anesthesia services are being (g) performed.
A complaint may be filed against a licensed health care practitioner at the DOH website:
The phone number for the DOH complaint office is: 850/245-4339.