A provision buried in the Affordable Care Act already prohibits reimbursing certified registered nurse anesthetists at a lower rate than physicians for the same work. It just has never been enforced.
Jeff Tieder, MSN, CRNA, clinical assistant professor at the University of Tennessee at Chattanooga, joined Becker’s to discuss how closing that gap, could do more to stabilize ASC coverage than any other single fix.
Editor’s note: This interview was edited lightly for clarity and length.
Question: If you could fix one piece of the reimbursement picture to keep anesthesia coverage sustainable in the ASC setting, what would it be?
Jeff Tieder: Fixing the payment disparity that undervalues CRNA services relative to the physician fee schedule.
Administrators see that they’ll only collect 85% of the physician reimbursement rate when a CRNA provides care, and that creates this underlying anxiety: if only we could get that extra 15%. But here’s the bigger issue — neither one is generating enough to pay their own salary. We’re already paying stipends regardless of whether it’s a physician or a CRNA. So the delta between 85% and 100% is relatively small compared to the overall picture.
But a broader reimbursement policy that stopped pretending anesthesia is somehow different depending on who delivers it would affect day-to-day ASC operations, demonstrate the value of CRNAs, and give administrators the confidence that they are collecting as much as they possibly can.
The frustrating thing is there’s actually a non-discrimination provision in the ACA that technically prohibits reimbursement discrimination based on provider degree. But the Office of the Inspector General has never issued the final ruling to enforce it. So this law exists, and it just doesn’t get applied. If someone on either side of the aisle would say, ‘This was passed by Congress, let’s enforce it,’ it would stop being political. The big physician groups would collect more money; CRNAs would be reimbursed at the same rate for the same work. It would help everyone, except the insurance companies, and that’s probably why it hasn’t moved.
As for where the needle is heading — if I had a crystal ball, I’d say we’ll see more of that 85% model, because it’s a way for insurance companies to reduce reimbursement. They tried to cap anesthesia payments altogether, and state law pushed back pretty hard on that. So they’ll find other ways. Insurance companies are in the business of collecting premiums, not paying out distributions. And this is one way that works. The cost will ultimately be borne by ASCs, and then passed on to patients. That’s the biggest predictor I see.
That said — anesthesia is still a great career choice. If I were starting over today, I’d still choose it. I think there are 30 to 40 years of solid opportunity ahead, unless there’s some massive disruption nobody can see coming. Five years from now we’ll have a much clearer picture — we’ll be in the middle of the physician shortage, but we’ll also have graduated the first full cohorts from all these new CRNA programs. Supply will be better, the market will have settled into a rhythm. It may be a little more regionally competitive in places like the Southeast, but overall we’ll be in a much better spot to evaluate where things actually stand.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
