Medicare Reimbursement Professional Aspects MSNA 699 SRNA Project Summer 2007 Brian Brister Gary Boutwell Errica McGregor Janet Pilkington D.J. Rawlinson.

Medicare Medicare ReimbursementReimbursement

Professional AspectsProfessional Aspects

MSNA 699MSNA 699

SRNA Project Summer 2007SRNA Project Summer 2007Brian BristerBrian Brister

Gary BoutwellGary Boutwell

Errica McGregorErrica McGregor

Janet PilkingtonJanet Pilkington

D.J. RawlinsonD.J. Rawlinson

Brian WatsonBrian Watson

The issue / The The issue / The problemproblem Medicare Medicare

Reimbursement and its Reimbursement and its impact on CRNA impact on CRNA

practicepractice

Brief Description and Brief Description and HistoryHistory

• Medicare was established in 1965 with Medicare was established in 1965 with the the enactment of Medicare and enactment of Medicare and Medicaid legislation.Medicaid legislation.• Originated as a health insurance Originated as a health insurance program for the program for the elderly paid for by elderly paid for by Social Security Taxes.Social Security Taxes.• Initially only provided insurance services Initially only provided insurance services for for physician's and hospitalization. Now physician's and hospitalization. Now provides provides reimbursement for other reimbursement for other healthcare providers to healthcare providers to include CRNA’s.include CRNA’s.

History (cont.)History (cont.)

• 1976: AANA sought to receive 1976: AANA sought to receive direct reimbursement from direct reimbursement from Medicare.Medicare.

• 1983: Prospective Payment System 1983: Prospective Payment System was devised to contain hospital cost was devised to contain hospital cost and allowed many outpatient and allowed many outpatient procedures to be reimbursed.procedures to be reimbursed.

History (Cont)History (Cont)

• The Omnibus Reconciliation Act of 1987The Omnibus Reconciliation Act of 1987 required Medicare to implement a separate required Medicare to implement a separate payment within the professional services payment within the professional services sector for CRNA reimbursement. sector for CRNA reimbursement. – Went into effect January 1Went into effect January 1stst, 1989., 1989.

• Prior to 1989, anesthesia reimbursement was Prior to 1989, anesthesia reimbursement was limited to the services provided by a limited to the services provided by a physician.physician.– Medicare BMedicare B, is the division responsible for CRNA , is the division responsible for CRNA

reimbursement.reimbursement.

• Prior to this act, CRNA’s were reimbursed Prior to this act, CRNA’s were reimbursed by Medicare Part A, which is the division by Medicare Part A, which is the division responsible for hospital or institutional responsible for hospital or institutional reimbursements. reimbursements.

Divisions of MedicareDivisions of Medicare

• Medicare Part AMedicare Part A

- Payment for hospitals and ambulatory - Payment for hospitals and ambulatory care facilities under Medicare. care facilities under Medicare.

- Requires CRNA’s to work under the - Requires CRNA’s to work under the direct supervision of MDA’s as a direct supervision of MDA’s as a condition for reimbursement from condition for reimbursement from Medicare.Medicare.

Divisions of MedicareDivisions of Medicare

• Medicare Part BMedicare Part B

- CRNA reimbursement.- CRNA reimbursement.

- Payment for Medical direction and - Payment for Medical direction and Medical supervision. ( Seven Medical supervision. ( Seven conditions of TEFRA must be met).conditions of TEFRA must be met).

CRNA Medicare BillingCRNA Medicare BillingRequirementsRequirements

Only a Certified nurse anesthetist can billMedicare directly. (140.1.2 of the MedicareClaims Manual)What does Medicare require to bill forservices?1. Certification2. Recertification - Req. by AANA, assumedcomplete by CMS3. NPI (National Provider Identifier)

ReimbursementReimbursement• “ “ Today, reimbursement for CRNA services is Today, reimbursement for CRNA services is

many times ignored, overlooked, or assumed, many times ignored, overlooked, or assumed, all of which can result in a negative economic all of which can result in a negative economic impact upon CRNAs within the healthcare impact upon CRNAs within the healthcare marketplace. Today’s healthcare spending is marketplace. Today’s healthcare spending is highly scrutinized; therefore, no highly scrutinized; therefore, no reimbursement opportunities can be left reimbursement opportunities can be left untapped, including those present in the untapped, including those present in the system for the services of CRNA’s. system for the services of CRNA’s. The future The future of the profession relies on the ability of of the profession relies on the ability of CRNAs to accurately understand the CRNAs to accurately understand the healthcare marketplace. CRNAs must be healthcare marketplace. CRNAs must be able to identify their worth, understand the able to identify their worth, understand the reimbursement process, and assist their reimbursement process, and assist their employer or secure for themselves through employer or secure for themselves through private practice the proper portion of today’s private practice the proper portion of today’s healthcare dollar that is due for the services healthcare dollar that is due for the services they providethey provide.” (1).” (1)

Medicare FACTSMedicare FACTS

• CRNAs first nonphysician provider to be directlyreimbursed by Medicare Part B

• Approx. 27 million anesthetics are provided by

CRNAs in the U.S. annually• Medicare reimburses anesthesia $2.4bn /

yr• – $1.7bn for anesthesiology• – $657mn for nurse anesthesia• – Up 25% from 2005 level of $1.9bn

CMS, 2007 PFS final rule [CMS-1321-FC & CMS-1317-F], 11/1/2006

Issue related to the Issue related to the practice standards / practice standards /

guidelinesguidelines

Medicare uses the TEFRA conditions Medicare uses the TEFRA conditions simply to determine if an simply to determine if an

anesthesiologist has been adequately anesthesiologist has been adequately involved in the administration of an involved in the administration of an

anesthetic to justify paying the anesthetic to justify paying the anesthesiologist. anesthesiologist.

Issue related to the Issue related to the practice standards / practice standards / guidelines (cont.)guidelines (cont.)

• Medicare has no requirement of Medicare has no requirement of anesthesiologist supervision and will anesthesiologist supervision and will reimburse CRNAs who are not reimburse CRNAs who are not supervised by any physician if they supervised by any physician if they meet the appropriate requirements.meet the appropriate requirements.

• Due to the seven conditions of Due to the seven conditions of TEFRA, five Standards of Practice TEFRA, five Standards of Practice for the nurse anesthetist apply to for the nurse anesthetist apply to Medicare reimbursement.Medicare reimbursement.

1. Preanesthetic evaluation 1. Preanesthetic evaluation of the patientof the patient

• Performing and documenting a pre-Performing and documenting a pre-anesthetic assessment and evaluation anesthetic assessment and evaluation of the patient, including requesting of the patient, including requesting consultations and diagnostic studiesconsultations and diagnostic studies

• Selecting, obtaining, ordering, or Selecting, obtaining, ordering, or administering pre-anesthetic administering pre-anesthetic medications and fluidsmedications and fluids

• Obtaining informed consent for Obtaining informed consent for anesthesiaanesthesia

2. Prescription of the 2. Prescription of the anesthesia plananesthesia plan

• Developing and implementing an Developing and implementing an anesthetic plananesthetic plan

3. Personal participation in the 3. Personal participation in the most demanding procedures in this most demanding procedures in this plan, especially those of induction plan, especially those of induction

and emergenceand emergence

• Developing and implementing an anesthetic Developing and implementing an anesthetic planplan

• Selecting and initiating the planned anesthetic Selecting and initiating the planned anesthetic technique which may include: general, technique which may include: general, regional, and local anesthesia and intravenous regional, and local anesthesia and intravenous sedationsedation

• Managing emergence and recovery from Managing emergence and recovery from anesthesia by selecting, obtaining, ordering, or anesthesia by selecting, obtaining, ordering, or administering medications, fluids, or administering medications, fluids, or ventilatory support in order to maintain ventilatory support in order to maintain homeostasis, to provide relief from pain and homeostasis, to provide relief from pain and anesthesia side effects, or to prevent or anesthesia side effects, or to prevent or manage complications. manage complications.

4. Following the course of 4. Following the course of anesthesia administration at anesthesia administration at

frequent intervalsfrequent intervals• Selecting, obtaining, or Selecting, obtaining, or

administering the anesthetics, administering the anesthetics, adjuvant drugs, accessory drugs, adjuvant drugs, accessory drugs, and fluids necessary to manage the and fluids necessary to manage the anesthetic, to maintain the patient's anesthetic, to maintain the patient's physiologic homeostasis, and to physiologic homeostasis, and to correct abnormal responses to the correct abnormal responses to the anesthesia or surgeryanesthesia or surgery

5. Ensure all procedures not personally performed are performed

by a qualified individual

The Standard of Practice that matches that would be:

 • All eleven Standards apply - because

the CRNA is performing the anesthesia

6. Remain physically available for the 6. Remain physically available for the immediate diagnosis and treatment of immediate diagnosis and treatment of

emergenciesemergencies• Responding to emergency situations by Responding to emergency situations by

providing airway management, providing airway management, administration of emergency fluids or administration of emergency fluids or drugs, or using basic or advanced cardiac drugs, or using basic or advanced cardiac life support techniqueslife support techniques

• Selecting, obtaining, or administering the Selecting, obtaining, or administering the anesthetics, adjuvant drugs, accessory anesthetics, adjuvant drugs, accessory drugs, and fluids necessary to manage the drugs, and fluids necessary to manage the anesthetic, to maintain the patient's anesthetic, to maintain the patient's physiologic homeostasis, and to correct physiologic homeostasis, and to correct abnormal responses to the anesthesia or abnormal responses to the anesthesia or surgerysurgery

7. Providing indicated 7. Providing indicated postanesthesia carepostanesthesia care

• Releasing or discharging patients Releasing or discharging patients from a post-anesthesia care area, from a post-anesthesia care area, and providing post-anesthesia and providing post-anesthesia follow-up evaluation and care follow-up evaluation and care related to anesthesia side effects or related to anesthesia side effects or complicationscomplications

Plan of ActionPlan of Action

““As long as there is government As long as there is government there will always be a need for a there will always be a need for a

plan of action.”plan of action.”- - Gary Boutwell July 11,2007Gary Boutwell July 11,2007

Increase funding for Increase funding for educationeducation

• In 2006 the educational fund was $3 In 2006 the educational fund was $3 million. million. • In 2008 our plan is to increase nurse In 2008 our plan is to increase nurse anesthesia anesthesia educational funding to $4 educational funding to $4 million which will million which will provide more provide more nurse anesthesia educational nurse anesthesia educational programs and increase grants which programs and increase grants which will will

support existing programs by support existing programs by escalating escalating enrollment. enrollment. • Supporting more graduates to Supporting more graduates to practice in practice in medically underserved medically underserved areas.areas.

Change Teaching Change Teaching Rules!Rules!

• It is fundamental that Medicare It is fundamental that Medicare treat nurse treat nurse anesthetists and anesthetists and anesthesiologists the same anesthesiologists the same to insure to insure educational equal opportunityeducational equal opportunity• Equality in teaching Equality in teaching anesthesiologists, nurse anesthesiologists, nurse anesthetists, residents and student anesthetists, residents and student

anesthetists.anesthetists.• Medicare cuts in pay = Medicare cuts in pay = discouragement in discouragement in providing providing educational services.educational services.

How Does This Funding Help?

• Grants help establish, strengthen CRNA

educational programs• Traineeships provide some funding for second-year

students• 105 Accredited Nurse Anesthesia programs• Total CRNA educational funding -- $3-4million/yr• Over 2,000 graduates in 2006, more than doubled

since 2000

Past ActionsPast Actions

• Take ActionTake Action - It has been proven - It has been proven effective in the past.effective in the past.

• HR 3617HR 3617• S 1356S 1356• HR 6111HR 6111• ResultsResults: CRNA’s are treated as : CRNA’s are treated as

equal healthcare providers.equal healthcare providers.

Medicare Agency Final rule provisions of interest to

CRNAs Finalizes 13.7% Cut in 2007 Part B Anesthesia

Payment; No Change in Anesthesia Teaching Rules

• There is no change in the Medicare anesthesia payment teaching rules in the final rule– Legislation introduced in Congress, the "Medicare Academic

Anesthesiology and CRNA Payment Improvement Act" (HR 6184), would fix problems in the Medicare anesthesia payment teaching rules for both CRNAs and anesthesiologists. This legislation is supported by AANA.

• CMS is applying changes in evaluation and management (E/M) code values to those anesthesia services where E/M constitutes a portion of the service – CMS proposed in its proposed rule to modestly increase the anesthesia work value to reflect the increased work valued for the E/M codes where there were increases in the work for those E/M codes.

• CMS included two new CPT codes for anesthesia – The codes, 00625 and 00626 (anesthesia spine

transthoracic with and without ventilator, respectively) would have base units set to 13 for 2007. CMS accepted AMA Relative Value Update Committee (AMA RUC) recommendations for these codes.

• CMS made value changes to other CPT codes outside anesthesia services– such as for certain surgical services, which may

impact demand for certain anesthesia services.

Medicare Agency Final rule provisions of interest to

CRNAs (cont.)

Act Now!Act Now!• Thanks to action in 2006 (HR 6111); 5% of Thanks to action in 2006 (HR 6111); 5% of

approximately 14% planned Medicare cuts approximately 14% planned Medicare cuts for 2007 was reversed. for 2007 was reversed.

• This relief is only temporary (last for 1 This relief is only temporary (last for 1 year).year).

• Without congress’ action and HR6111 the Without congress’ action and HR6111 the 2007 anesthesia conversion factor would 2007 anesthesia conversion factor would have decreased from $17.76 (2006) to have decreased from $17.76 (2006) to $15.33 not experienced since before 1992.$15.33 not experienced since before 1992.

• Without further action cuts will resume in Without further action cuts will resume in 2008 and so on, could be as much as 40% 2008 and so on, could be as much as 40% by 2012.by 2012.

• We need a long term solution; CMS – will We need a long term solution; CMS – will continue to assess and call for budget continue to assess and call for budget adjustments.adjustments.

Get involved!Get involved!

• Maintain AANA active membership – Maintain AANA active membership – • Support the AANA monetarily –Support the AANA monetarily –• Communicate with Congress about these Communicate with Congress about these

extreme cuts, using AANA online eAdvocacy, extreme cuts, using AANA online eAdvocacy, www.aana.com

• Remember to note effects on patients’ access Remember to note effects on patients’ access to healthcare services –to healthcare services –

• Meetings with legislators in local communities-Meetings with legislators in local communities-• Recruit CRNAs to support AANA – Recruit CRNAs to support AANA – • Get to know the AANA, stay informed, stay in Get to know the AANA, stay informed, stay in

touch with AANA DC –touch with AANA DC –• Get to know your legislatures- they can Get to know your legislatures- they can

influence every aspect of your job, particularly influence every aspect of your job, particularly your paycheck.your paycheck.

Why is it important?Why is it important?

• How will anesthesia professionals, How will anesthesia professionals, anesthesia groups, hospitals and offices anesthesia groups, hospitals and offices deal with cuts in anesthesia reimbursement deal with cuts in anesthesia reimbursement per-service? per-service?

• Answer?Answer?• Two fundamental choices: increase Two fundamental choices: increase

revenues, or decrease costs.revenues, or decrease costs.• Majority of CRNAs assign their billing Majority of CRNAs assign their billing

rights to an employing group, hospital, or rights to an employing group, hospital, or facilityfacility

• CRNAs’ should learn and know their own CRNAs’ should learn and know their own economic value in the practice setting – the economic value in the practice setting – the revenues a CRNA’s work produces.revenues a CRNA’s work produces.

Do you know your worth?Do you know your worth?• Medicare Anesthesia Economic Value CalculatorMedicare Anesthesia Economic Value Calculator

• X = A * C * D * EX = A * C * D * E• Y = B * C * D * EY = B * C * D * E• Z = X - YZ = X - Y

U.S. Averages 100% Medicare /Sample Personal FiguresU.S. Averages 100% Medicare /Sample Personal Figures

A = Medicare 2006 average anesthesia CF A = Medicare 2006 average anesthesia CF $17.77 / $17.77 $17.77 / $17.77

B = Medicare 2007 average anesthesia CF (est.) $16.23 B = Medicare 2007 average anesthesia CF (est.) $16.23 / $16.23 / $16.23

C = Average units / case C = Average units / case 12 / 1212 / 12

D = Average # cases / year D = Average # cases / year 900 / 900900 / 900

E = Fraction of cases that are Medicare E = Fraction of cases that are Medicare 0.35 / 1.000.35 / 1.00

X = CRNAs' Medicare practice economic value, 2006 $67,170.60 X = CRNAs' Medicare practice economic value, 2006 $67,170.60 / $191,916.00/ $191,916.00Y = CRNAs' Medicare practice economic value, 2007 Y = CRNAs' Medicare practice economic value, 2007 $61,349.40 / $175,284.00$61,349.40 / $175,284.00

Z = Impact of Medicare cuts on above values $5,821.20 Z = Impact of Medicare cuts on above values $5,821.20 / $16,632.00/ $16,632.00

How to ACT?How to ACT?

• Through AANA: guide legislators to Through AANA: guide legislators to introduce appropriate bill.introduce appropriate bill.

• In our case a bill reversing Medicare In our case a bill reversing Medicare cuts.cuts.

• CRNA’s act by writing there CRNA’s act by writing there appropriate members of congress, to appropriate members of congress, to pass said bill.pass said bill.

• State associations and others write State associations and others write letters of support.letters of support.

ASA’s actionsASA’s actions

• ““Teaching Rules” - which effect Teaching Rules” - which effect reimbursement of students providing reimbursement of students providing anesthesia (nurse anesthesia students anesthesia (nurse anesthesia students and residents in anesthesia).and residents in anesthesia).

• Introducing bills specific to Introducing bills specific to anesthesiologist and residents.anesthesiologist and residents.

• HR 5246HR 5246• HR 5348 StarkHR 5348 Stark• S2990 VitterS2990 Vitter• These bills have not been adopted These bills have not been adopted

ResourcesResources

• Meetings – local, state, and federal.Meetings – local, state, and federal.• AANA – website: AANA – website: www.aana.com• AANA News Bulletin AANA News Bulletin • CMS websiteCMS website• Alabama Association of Nurse Alabama Association of Nurse

Anesthetist - Anesthetist - www.ala-crna.org• Realize AANA has a DC office.Realize AANA has a DC office.

Proposed alternative andProposed alternative andtimetable for resolutiontimetable for resolution

Issues for Lobbying Capitol Hill

• Educating Legislators About CRNAs• Keeping Medicare Strong• Equity in CMS Anesthesia Teaching

Rules• Nurse Anesthesia Education Funding

Get involved NOW !!Get involved NOW !!

• Attend the 2007 AANA midyear Attend the 2007 AANA midyear assembly in Denver, CO.assembly in Denver, CO.

• Let your voice be heard!!Let your voice be heard!!• As Washington looks for answers to

healthcare financing, access and quality issues CRNAs must leave a strong, positive impression with legislators for our issues & the others to come.

Current status of Medicare Current status of Medicare problemproblem

• The Washington Environment In Government: – New Democratic Congress – Jockeying to succeed President Bush In Policy: – Budget running enormous deficits, short- and long-term Focus: War, healthcare, budgets

• The Washington Environment In healthcare:

the public’s second-highest issue interest – Fiscal challenges – Part B cuts – Pay-for-performance / quality reporting / health I.T. Insurance reforms:

Singlepayor, employer mandate, tax incentives

Obstacles to big initiatives

Current status of Medicare Current status of Medicare problemproblem

Who Matters in Government?

• The people who make the rules• The people who enforce the rules• The people who pay for things

Why Do They Matter to CRNAs?

• Congress’ Committees of Jurisdiction– Medicare-writing: House Ways & Means,

Senate Finance, House Energy & Commerce

– Funding: House and Senate Appropriations

– Education & Other Health: House Energy &Commerce, Senate Health Education Labor & Pensions

CRNAs Make A Difference

• •CRNAs are ensuring clinical excellence– Accreditation, cert, recert, practice

standards• CRNAs develop expertise in policy areas

– Meetings, training, committees, advisory panels

• We have gotten organized– AANA, CRNA-PAC

• • We are applying what we know in Washinton D.C.

Today!

Medicare Payment Trends

• 2004 : +1.5%• 2005 : +1.5%• 2006 : No change• 2007 : 8% (not -14% as originally

proposed)• 2008 : - 10%• 2009-2012: - 25-30%

Medicare Payment Trends

• Cuts will come unless Congress acts• Medicare payment drives other

payments– Government programs like

Medicaid– Federal employee benefits (FEHBP,

TRICARE/Champus)• Unlike in 2007, all Part B providers are

inthe same boat

CRNA Education Message

Congress should request:

• $4 million for Nurse Anesthesia Education

• $76 million for advanced education nursing

• •$200 million in total for nurse education

The BIG MessageThe BIG Message

• Medicare anesthesia payment got cut in 2007• Future Medicare payment cuts of up to 35-40%

in five years would destroy the Medicareprogram for our seniors

• Congress should enact legislation to reverseMedicare Part B physician fee schedule cutsthat are scheduled for 2008 and beyond.

• Continue to include CRNAs in the developmentof pay-for-performance quality measures

You Make the Difference!

For Our Patients, Practice and ProfessionYour DC Office:• Frank Purcell, Sr Dir, Federal

Govt Affairs• Brian R. Bullard, Assoc Dir,

Federal Govt Affairs• Pamela Kirby, Assoc Dir, Federal

Regulatory & Payment Policy• Shari Dexter, Political Affairs Mgr• Candi Richardson, Senior

Administrative Assistant

QuestionsQuestions

1.1.What act required Medicare to implement a What act required Medicare to implement a separate payment within the professional separate payment within the professional services sector for CRNA reimbursement? What services sector for CRNA reimbursement? What year did it go into affect?year did it go into affect?

2. What part of Medicare is the division 2. What part of Medicare is the division responsible for CRNA reimbursement?responsible for CRNA reimbursement?

3. 3. True/False True/False    The 7 conditions of TEFRA apply    The 7 conditions of TEFRA apply to CRNA reimbursement and directly correlate to CRNA reimbursement and directly correlate with most of the CRNA Scope of Practice.with most of the CRNA Scope of Practice.

• True/FalseTrue/False    In order for the CRNA to be     In order for the CRNA to be reimbursed by Medicare, he must be supervised reimbursed by Medicare, he must be supervised by a physician.by a physician.

QuestionsQuestions

4. What governmental group/committee 4. What governmental group/committee is established for approving or is established for approving or denying federal program funding?denying federal program funding?

5. Why does the educational fund for 5. Why does the educational fund for nurse anesthesia need to be nurse anesthesia need to be increased from 3 million to 4 million?increased from 3 million to 4 million?

6. How will anesthesia professionals, 6. How will anesthesia professionals, anesthesia groups, hospitals, and anesthesia groups, hospitals, and offices deal with cuts in anesthesia offices deal with cuts in anesthesia reimbursement per-service?reimbursement per-service?

ReferencesReferences

1.1.Foster SD, Faut-Callahan M. Foster SD, Faut-Callahan M. A professional A professional Study and Resource Guide for the CRNA.Study and Resource Guide for the CRNA. Park Park Ridge, IL: AANA Publishing Inc; 2001 : 180-181, Ridge, IL: AANA Publishing Inc; 2001 : 180-181, 288, 358.288, 358.

2.2.Culpepper TL. Culpepper TL. History of Nurse Anesthesia, History of Nurse Anesthesia, PowerPoint / LecturePowerPoint / Lecture.. Samford University, Ida V. Samford University, Ida V. Moffett School of Nursing, Department of Nurse Moffett School of Nursing, Department of Nurse Anesthesia; June 12, 2007: pg.4, slide 3. Anesthesia; June 12, 2007: pg.4, slide 3.

3.3.Nagelhout JJ, Nagelhout JJ, Zaglaniczny KL. Nurse Anesthesia. 3rd ed. Philadelphia, PA; Saunders; 2005: 1249-1263.

4.AANA Professional Manual for CRNAs (www.aana.com)

ReferencesReferences

5.5. Scope and Standards for Nurse Anesthesia Scope and Standards for Nurse Anesthesia PracticePractice. Park Ridge, III: American Association of . Park Ridge, III: American Association of Nurse Anesthetists; 1996.Nurse Anesthetists; 1996.

6.6. American Association of Nurse Anesthetists - American Association of Nurse Anesthetists - Office of Federal Government AffairsOffice of Federal Government Affairs. . www.aana.comwww.aana.com. . Apr. 2007.Apr. 2007.

7.7. American Association of Nurse Anesthetists - American Association of Nurse Anesthetists - Office of Federal Government AffairsOffice of Federal Government Affairs. . www.aana.comwww.aana.com. . Mar. 2007.Mar. 2007.

8.8. Blumenreich GA. Blumenreich GA. Standards of Care and the ASA Standards of Care and the ASA Medical Direction Statement.  Medical Direction Statement.  AANA Journal, Vol. 72 AANA Journal, Vol. 72 (No. 2);(No. 2); 2004. 2004.

ReferencesReferences

9.9. Purcell, FJ.Purcell, FJ. Government Relationship and Federal Government Relationship and Federal IssuesIssues. AANA Mid-year Assembly PowerPoint . AANA Mid-year Assembly PowerPoint Presentation. May-June 2007. Presentation. May-June 2007. www.aana.com. Accessed . Accessed and permission granted July 20, 2007.and permission granted July 20, 2007.

10.10. Purcell, FJ. Purcell, FJ. Analysis of Federal Issues.Analysis of Federal Issues. AANA Mid- AANA Mid-year Assembly PowerPoint Presentation. May-June year Assembly PowerPoint Presentation. May-June 2007. www.aana.com. Accessed and permission granted 2007. www.aana.com. Accessed and permission granted July 20, 2007.July 20, 2007.

11.11. Purcell, FJ. Purcell, FJ. CRNAdvocacy 101: How CRNAs’ CRNAdvocacy 101: How CRNAs’ Action Affects CRNAs’ Patients, Practice & Profession. Action Affects CRNAs’ Patients, Practice & Profession. AANA Mid-year Assembly PowerPoint Presentation. AANA Mid-year Assembly PowerPoint Presentation. May-June 2007. www.aana.com. Accessed and May-June 2007. www.aana.com. Accessed and permission granted July 20, 2007.permission granted July 20, 2007.