Wednesday, October 3, 2012

Are CRNA's Better At Treating Chronic Pain Than Most Anesthesiologists?

That seems to be the question the Centers for Medicare and Medicaid Services is trying to answer. CMS has until November 1 to decide whether Medicare will reimburse CRNA's at the same rate as physicians for treating chronic pain, including invasive injections and prescriptions for narcotics. If Medicare does approve this plan, then the consequences will snowball as private insurers follow the lead of the federal government.

It appears that the main excuse for allowing CRNA's to start independently performing and billing chronic pain procedures is the lack of access of many patients to board certified pain specialists. As always, they pull up the old canard about having few anesthesiologists willing to work in rural settings, forcing patients to travel hundreds of miles to see one.

So from the logic of the discussion, the CMS will conclude whether 45,000 CRNA's are as qualified to perform pain procedures as 2,000 pain specialists board certified by the American Board of Pain Medicine. These 45,000 CRNA's will intuit on their own whether they will inject drugs into somebody's back with potentially life threatening complications, something that most general anesthesiologists who have had training in treating chronic pain but are not board certified to do so, would rather not touch. When the lone CRNA working in some rural clinic a hundred miles from the nearest specialty pain center encounters a patient complaining of low back pain, he or she is now suddenly able to diagnose and treat chronic pain right then and there because the government has given the green light to do so since the patient otherwise won't have "access" to more specialized professionals.

Does this make any sense at all? The CMS is saying it's okay for rural and poor patients to be subjected to minimally trained nurses injecting drugs into their backs and joints just because, well, there is nobody else around who will do it. The key to increasing the availability of well trained board certified pain specialists is not to go downmarket by using lesser trained nurses (two years of nursing and two years of CRNA schools vs. four years medical school, four years anesthesiology residency, and one year pain fellowship). Instead the CMS should be increasing the Medicare reimbursements for anesthesiologists, thus making Medicare patients more attractive. As it stands, Medicare screws anesthesiologists with the lowest reimbursement of any medical profession, just 33% of what a private insurer pays for the same service.

The CRNA's who are clamoring to get into the specialty pain business may regret doing so. They are going to find that Medicare reimbursement isn't that great. Their malpractice insurance will surely skyrocket. And in a few years, well, Medicare may decide that even CRNA's can't work cheap enough for all patients to be seen. They may decide that PA's are just as qualified as CRNA's to diagnose and treat chronic pain. They are starting a downward spiral that could hurt chronic pain patients most of all.


  1. Your logic is faulty. Being a professional means deciding if you have the training and knowledge necessary to perform a procedure. For example, the anesthesiologist who has been working in outpatient surgery for 20 years isn't going to walk in somewhere and start doing CABGs, even though he may be legally able to do so. How does a family practice doc or internal med guy know when to consult a cardiologist for management of CHF or HTN? You're right, as a CRNA I wouldn't touch complex pain cases, or prescribe narcotics for home use. I do, however, do epidural steroid injections with good success, and I have been trained to do so.

    1. Thank you! Took the words out of my mouth.

  2. Thought I would leave my first comment. I do not know what to say except that I have enjoyed reading. Nice blog, I will continue to visit this blog very often.

    Dr. Carl Balog

  3. Great post. I just stumbled upon your blog and wanted to say that I have really enjoyed browsing your blog posts.

  4. "The CMS is saying it's okay for rural and poor patients to be subjected to minimally trained nurses injecting drugs into their backs and joints" - well, for me this is not ok. It is still best to consult your doctors first. If ever your feel some pain in the joint or anywhere, maybe joint supplements can be taken but injecting of drugs is not recommended.

  5. Training for CRNAs is longer that 4 years.
    You can't have an AA do get into CRNA school.
    4 years for BSN, minimum of 1 year of experience as RN, 3 years for CRNA (all will be a doctorate program by 2017)= 8 years of training minimum.
    Most have more experience as a nurse prior to applying. Experienced nurses know the system much better than baby residents who are not used to being the sole provider for patients.

    Maybe if CRNAs received full compensation for their work, instead of Anesthesiologists taking a large chunk on patient's they've never seen-- you'd have more stay in the ACT model.
    Why shouldn't we fight back. Docs are claiming we don't have the training, but we are trained by not only CRNAs but DOCTORS also. So are you saying because we're trained by you, for as long as you are before your residency, that we aren't proficient? Even with years of experience in an acute care setting in the medical field prior to school? Then why do we give the most anesthetics in the nation? Anesthesiologists are giving less meds in the OR, and "supervising" more often. Money talks, and we are still "nurses" and like being at the bedside.