Sunday, April 3, 2016

CRNA Equivalency Is All A Sham

The Holy Grail for the ASA would be to find a study that definitively showed that physician anesthesiologists give better patient care than CRNA's. Yet after all these years, just like the Grail itself, that research has been quite elusive. Many studies have shown little difference in patient outcome between physician anesthesiologists and CRNA's. Maybe we've developed monitoring technology to the point where virtually anybody can anesthetize a patient with little risk of harm. Or perhaps studies comparing CRNA's and physician anesthesiologists haven't included enough patient numbers to produce a sufficient and unequivocal result.

Now there is another possibility for why we can't seem to prove that we are better than the nurses many of us are supervising--fraud. A new study published in Anesthesia & Analgesia by Amr Abouleish, M.D., M.B.A. from the University of Texas Medical Branch, Galveston, has found that determining who is administering anesthesia is more complicated than expected. Researchers frequently use billing codes to determine who is administering the anesthetic to the patient. The billing codes can use the QX modifier to show that a physician anesthesiologist is giving a high level of care, or the QZ modifier to show that a CRNA is being supervised by an anesthesiologist, another physician, or performing unsupervised work. Thus it is impossible to determine with a QZ modifier who is caring for the patient, the nurse practicing solo or being supervised. Yet prior studies used the QZ code to represent cases where the patient was supposed being cared for by CRNA's unsupervised. The infamous Health Affairs paper was one of those that found no differences in the care given by physician anesthesiologists or CRNA's. It relied on the QZ code as a marker for CRNA's working alone.

Now the Texas researchers have shown that the use of the QZ modifier to determine solo CRNA activity may be inaccurate and possibly fraudulent. Abouleish's team evaluated over 9,000 patient records and found 538 hospitals where 100% of anesthesia claims used the QZ code. Yet 47.5% of those hospitals have physician anesthesiologists on the staff. How could the CRNA's claim to be doing 100% of the anesthesia when nearly half of the hospitals have anesthesiologists present? Was there no time when the CRNA's consulted with a physician anesthesiologist or been supervised by one even for very difficult cases? Therefore reliance on the billing code alone is insufficient to determine who is responsible for anesthetizing the patient.

Perhaps the only way to find cases where the CRNA is working unsupervised is to develop another billing modifier just for that situation. Maybe the ASA can use some of their political clout in Washington to make this happen. Otherwise the assistance that physician anesthesiologists give to the nurses in difficult cases goes unrecognized and makes them look better than they should.

By the way, Dr. Abouleish's study was sponsored by the ASA.

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