But thanks for joining us today. I'm Brett Morgan. I'm the AANA Senior Director for Education and Practice and I'm thrilled to be able to moderate this panel today. We are here to talk about student ratios for our learners and how we may explore options to optimize those models to help facilitate transition into full-time practice. And so I would like to have my panel introduce themselves to you all and then we'll get started. Okay. Hi. Good afternoon. I'm Laura Bonanno. I am currently the Vice President of the Council on Accreditation and I'm also the Program Director at LSU Health Sciences Center Nurse Anesthesia Program in New Orleans, Louisiana. Hello, everybody. My name is Rachel Davis. I am the Chair of the Education Committee and also the Program Director for the Nurse Anesthesia Program at Baylor College of Medicine. Good afternoon, everybody. My name is Mike Anderson. I'm the Vice President of the AANA and I'm currently the Clinical Coordinator at the University of Iowa, as you can see by my color, so go Hawks. Good afternoon. My name is Lucy New. I am currently a full-time clinician at Atrium Health Cabarrus, but I'll be leaving that role in about a month because I've accepted a faculty position at Wake Forest University Anesthesia Program. Oh, yay. Very touchy mics here. So a little bit of a background on where this talk came from. I would say about six months ago, and it turns out you'll see why probably about six months ago. We started to receive more and more inquiries from educators at the AANA around whether students or learners or residents, whatever term we want to use, could be left alone in the operating room. Well, if you're like me, you probably trained that way pretty early in your training. We were left alone in the operating room when it was appropriate, and so I was kind of dumbfounded by that question because we even have a mechanism by which students' services can be reimbursed by Medicare. So, you know, I simply said, of course, you know, students can be left alone. The COA has standards that would support that, but why are you calling to ask me? And they said, well, time and time again, an anesthesiologist in my facility has said that students cannot be left alone. And of course, my initial reaction is, well, anesthesiologists have nothing to do with what our students can do. That's the COA. But I know the implications in real-life practice, and so you have to navigate. So we decided to start exploring what was going on with that. And so in that exploratory sort of conversation, we decided that we needed to have a conversation with educators about this and sort of where this is coming from and maybe what are some things that you can do to help advocate against it. Many of you know that back in October of 2019, the ASA issued an edited statement about the anesthesia care team. It's not an evidence-based statement. It's simply just their opinion about things, and it's actually rather long. I provided it to you if you want something to read on the plane when you're going home. But there's a section of this statement that speaks to anesthesia learners and who they deem qualified anesthesia personnel. And they call out the fact that, it's not the fact, they call out that in their opinion, nurse anesthesia students, that's what they referred to our learners as, are non-qualified personnel. And so it is not appropriate, and it's actually against their standard of care, to leave them alone in the room if they are participating in a case that is being deemed as part of an anesthesia care team. That's extremely troublesome for us, right? Because first off, nurse anesthesia learners, they are qualified and licensed healthcare providers. They are not medical students. They are not anesthesiology assistant students. They are nurses. And probably most troublesome to us is that the COA is the sole authority for nurse anesthesia education, over nurse anesthesia education, and the ASA does not have the authority to set standards for our educational process. Even more troubling is that if you dig deeper into what this is really about, they know, and this is going to get political, it's just going to have to. They know that our students have a mechanism, or our learners have a mechanism, to be reimbursed for their services, and the other learner types do not. So if they can control the narrative, and they can prevent them from having that opportunity, then they will eventually be, in their minds, seen as the same. So this is part of their agenda, and that's why we wanted to have this conversation, to make sure program faculty really understand what the rules are, and what the authority over CRNA education really says about this issue. Now you're probably, you may not be wondering, but I was wondering why all of the sudden was this coming up again. Well at the ASA's annual meeting in October, they re-released this statement, and not only did they re-release the statement, they excluded the part, all the rest of the anesthesia care team conversation, and they honed in on this. It's a very troubling statement here, because not only does it say, again, that our learners are non-qualified personnel, it also implies that AAs are qualified to teach our students. It doesn't specifically say that, but it implies it. So that explains why, last fall, I started hearing more and more about this. So I think we really have a problem on our hands, and this is why this conversation needs to start happening amongst the educators, and this is why we're here today. How many of you are aware of the Medicare teaching rules? Okay. So I think that one of our priorities at the AANA now is just to help educate educators about that Medicare teaching rule, because there is a mechanism in place for your students, or your residents, for their services to be reimbursed. In fact, Medicare pays CRNAs and anesthesiologists for cases involving student nurse anesthetists or residents who are providing anesthesia services. There is a mechanism for that, and a CRNA can be paid for teaching student nurse anesthetists, and an anesthesiologist can be paid for teaching our learners and physician residents. So our federal reimbursement policy supports this. Why on earth would they not want to get paid for teaching our students? I'm asking these questions, right, and it's going to be part of our conversation today. It is true that Medicare Part B does not pay for student learners, nurse anesthesia learners, but it also doesn't pay for resident care either. So there's no difference in how we're treated in that regard. But I am going to spend a couple minutes going over the anesthesia teaching rules and how they apply to our practice, and then we can get into answering some of the questions that you guys pose to us. So if you have a non-medically directed CRNA who is serving in a teaching role, who is teaching two students, right, or two learners or two residents, ultimately what this says is a CRNA can bill for 100% of that case. Now what they can't do is take on a third case, right? They can't take on a third case, but they can bill for those two cases. But they must be available for the pre and post anesthesia care for both of the cases that they're billing for. That sounds an awful lot like what we do, right? We are involved in teaching our students and helping them in the pre-op area. We definitely follow the patient to the recovery room and afterwards, and we are invested in the teaching experience of our students. And we can bill, using the QZ modifier, 100% for those cases. I don't know about you guys, but there's a tremendous, what you guys know about, but there's a tremendous anesthesia shortage right now, right? Huge anesthesia shortage. Now I'm not necessarily advocating that we put our students in positions of being staff, but there are real opportunities here for us to help with the anesthesia workforce issues that we're seeing and get those really great experiences for our students at the same time. And it's fully billable. Now if a CRNA is medically directed, what does it look like? Well, if a CRNA is medically directed and there are two students, the anesthesiologist can bill for 50% of the service, and the CRNA can bill for each of the rooms with what they call discontinuous time, right? So you can't bill for being in this. They're going to look at your time. How many of you use that model in your clinical training? So you have to be very careful about signing in and out of the room, making sure you're not in two rooms at the same time, that sort of thing, because it's a discontinuous service. You also must be present for the pre- and post-anesthesia care to be able to bill as a CRNA. The anesthesiologist doesn't have to meet that requirement. So we're starting to see some disadvantages at this point for our learners. Now, for anesthesiologists, if they're teaching one nurse anesthesia learner and one physician resident and medically directing a CRNA, right, the first case will bill 50% for the SRNA, the second case will bill 100% for the resident, or the second case will bill 50% for medically directing the CRNA, and that CRNA can bill 50%, right? So they can still bill 100% if they've got a CRNA in the room with that student, right? Now this is where we're really disadvantaged. If the anesthesiologist—oh, I went too far, sorry. If the anesthesiologist is teaching, right, and they have one resident, when they have two residents, they can bill 100% for the two residents. If they have two SRNAs, if they have one SRNA, they can bill 100% for supervising that SRNA directly if they're continuously present, or 50% if they're not, but if they have two SRNAs, they can only bill 50% for each of the services. That's when they're not involving a CRNA in that case. So these Medicare teaching rules, while they do provide a mechanism for us to be reimbursed, the best case scenario is when we're doing so using the QZ modifier, by and large. And if you work in a facility where that's a possibility, that would be what you should advocate for because you're maximizing the reimbursement. If you start to get where the anesthesiologists are providing the direct supervision of our There is a financial disincentive for that. And that's certainly something that I think we need to start. We have been working on it, it has been an advocacy agenda item for many years, but I think we're starting to see now it's becoming increasingly more important.

anesthesia education

nurse anesthesia learners

Medicare teaching rules

QZ modifier

workforce shortages