Nurse anesthetists say they practice safely without physician supervision

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Nurse anesthetists across the country are vehemently defending their ability to administer anesthesia to Medicare patients without physician supervision, saying there's never been a study showing the practice to be unsafe, as alleged by two large physician groups who filed a lawsuit last week.

On the contrary, several representatives of the American Association of Nurse Anesthetists (AANA) say studies have shown that certified registered nurse anesthetists (CRNAs) perform the service with equal safety, or even more safely, than anesthesiologists.

"It's fine for an anesthesiologist to sit in Los Angeles and say this can't go on; but it's another thing to create a policy that says you can't take care of an accident victim until a surgeon wanders in with his glorious presence," says Dan Simonson, a member of the AANA board and a nurse anesthetist and researcher in Spokane, WA.

"This is not about patient safety. It's about access to care," he says.

Nurse anesthetists say that if they were not allowed to independently administer medication to stop pain or cause a loss of consciousness to prepare a patient for surgery, many patients—especially those in rural areas especially would not get emergent care within the time they need it. A supervising physician cannot always be on-site and ready to "immediately [conduct] a hands-on intervention, if needed," as Medicare payment rules require, AANA officials say.

Today, nurse anesthetists in those states give pain relief to women going into labor who may never see a physician. They start sedation for patients undergoing brain surgery, heart operations, and many other procedures, and do so safely, AANA officials add.

The nine-year controversy reverberated nationally last week when the large and influential California Medical Association and the California Society of Anesthesiologists went to San Francisco Superior Court in an effort to rescind the ability of nurse anesthetists to work independent of physician or anesthesiology supervision.

They sued California Gov. Arnold Schwarzenegger, who last year signed a letter to the Centers for Medicare and Medicaid Services "opting out" of the requirement that a physician supervise all CRNAs. In doing so, he joined 14 states—all with large rural populations—whose governors had exercised the opt-out provision, which took effect in 2001. The 14 states are: Alaska, Iowa, Idaho, Kansas, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Washington, and Wisconsin.

The CMA and CSA said in their lawsuit the governor ignored protocol, which their complaint said required him to check with the state's nursing and medical licensing boards, which he did not do.

But their real concern is patient safety, according to CMA General Counsel Francisco Silva.

Former CMA president and San Diego anesthesiologist Robert Hertzka, MD, told HealthLeaders Media last week that nurse anesthetists didn't have sufficient training to practice solo. He said that even in the states that have opted out, hospital policies or medical staffs rarely allow CRNAs to work without a surgeon of physician's presence.

Wanda Wilson, executive director of the AANA, called Hertzka's comments "an insult to the thousands of diligent, responsible, and intelligent" instructors who educate nurse anesthetists, "many of whom are anesthesiologists themselves."

As a practical matter, in California and other states, many CRNA and hospital officials say, Medicare rules are frequently overlooked by rural hospitals because they are so impossible to follow all the time. For example, the Centers for Medicare and Medicaid Services' rules require "supervision" that's "immediately available," but those words have been subject to interpretation.

How close to the nurse anesthetist does the supervising physician, perhaps the anesthesiologist, need to be? Is it OK if he or she is in the building but doing another procedure? What if he or she is in the car, and will arrive in 20 minutes?

Over the years, CMS has tried to narrow down those definitions.

According to one interpretation, expressed by Richard Rawson, president and CEO of three small rural Adventist hospitals near Fresno, CA, CMS in December defined 'immediately available' "as it relates to supervision of certified registered nurse anesthetists or anesthesia assistant (AA) to mean the anesthesiologist is physically located within the same area as the CRNA or AA (e.g., in the same operative suite, same labor and delivery unit, or same procedure room); not otherwise occupied in a way that prevents the anesthesiologist from immediately conducting hands-on intervention, if needed."

Several rural hospital CEOs interviewed say that's almost impossible for them to achieve.

Rawson says that to finance anesthesiology coverage to meet Medicare's rule would be expensive, at a cost of about $1 million a year on a $30 million to $40 million annual budget. "And that's if they could find anesthesiologists."

According to a survey last year by the California Healthcare Foundation, Kings County, where two of Rawson's hospitals are located, had only two anesthesiologists. That survey said that 22 of the state's 58 counties have five or fewer anesthesiologists. Kings also has a physician shortage, one doctor per 1,324 residents as opposed to the state average of one per 575.

The California Hospital Association supports the opt-out provision and opposes the CMA/CSA lawsuit. Without the provision, says CHA vice president Dorel Harms, many hospitals would be forced into a financial bind.

"They'd have to eliminate the [surgical] service or reduce their financial viability by not getting the Medicare reimbursement, when their margins are so minimal to begin with," Harms says. "It's a matter of money; it's not a matter of supervision."

According to industry surveys, in general, anesthesiologists make about $300,000 to $400,000 per year. Nurse anesthetists average $160,000.

Peggy Wheeler, CHA's vice president for rural healthcare, says that many of the state's 69 designated rural hospitals "really had some difficulties meeting the conditions of participation. They were all either meeting them or just choosing not to get reimbursement under Medicare . . . because it required that the surgeon or anesthesiologist be on site.

"Two-thirds of these rural hospitals use CRNAs almost exclusively," she says. "So a requirement to have physician services meant it would be difficult for them to offer surgical services."