Medicare payments to CRNAs irk anesthesiologists, again

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Alexandra Wilson Pecci, for HealthLeaders Media, November 6, 2012

Another battle in the war between anesthesiologists and advanced practice nurses is under way.

The final rule on physician fees for 2013 allows Medicare to pay Certified Registered Nurse Anesthetists for services to the full extent of their state scope of practice.

Specifically, CMS says this applies to "anesthesia and related care [which] includes medical and surgical services that are related to anesthesia and that a CRNA is legally authorized to perform by the state in which the services are furnished."

According to the American Association of Nurse Anesthetists (AANA), nurse anesthetists have been getting paid by Medicare for their services for more than 20 years. But a challenge came in early 2011 when Medicare contractor Noridian decided to stop reimbursing CRNAs.

"This policy really restores reimbursement," Christine Zambricki, DNAP, CRNA, FAAN, senior director of federal affairs strategies at AANA, tells HealthLeaders Media. "It was necessary for the Medicare agency to make a strong policy."

Zambricki describes Noridian's quick decision to stop reimbursing CRNAs as "going rogue," since CRNAs had been being reimbursed by Medicare for years.

"It's very disappointing that something like this could take place when the goal in our healthcare system is to...really remove burdens to healthcare providers," she says. "This is a case study in the opposite."

She's not alone in her thinking. Obviously, CMS agrees with AANA's position, since it restored reimbursements, but other organizations showed their support as well. In April, state hospital associations in Missouri, Iowa, Kansas, and Nebraska wrote a letter to Acting CMS Administrator Marilyn Tavenner arguing that rural hospitals, especially critical access hospitals, rely on CRNAs to provide care.

"It is very troubling that Medicare contractors are able to change the policy at their discretion without a public comment period or at minimum, education to providers," the letter said.

"The creation of a "black box" policy has the potential to create real hardship and access problems for many of the most vulnerable Medicare beneficiaries who reside in the rural areas of our states."

The non-profit advocacy group, AARP, also weighed in on the issue in a September letter to Tavenner, saying, "Without the availability of CRNAs' pain management services, many Medicare patients—particularly in rural areas—would either be forced into nursing homes for this chronic care or go without the treatment and greatly suffer."

Zambricki also adds that the CMS decision is consistent with Institute of Medicine recommendations.

"It's a wonderful example with the federal government making healthcare policy that's consistent with some of the best thinking" about medical care, she says.

Despite support for the ruling from a variety of organizations, there is a predictable outlier: The American Society of Anesthesiologists, which says the "policy jeopardizes patient safety, lowers the quality of health care and increases the risk for fraud and prescription drug abuse."

It argues that the Medicare contractors stopped paying CRNAs because it "concluded the assessment skills required for the diagnosis and treatment of chronic pain are not part of nurses' training curricula. By contrast, anesthesiologists' extensive medical training also includes a rotation in pain care during residency training, and those choosing to specialize in pain medicine must complete a minimum one year multidisciplinary pain fellowship."

If this refrain sounds familiar, that's because it is. The American Academy of Family Physicians released a report in September, arguing that despite the primary care shortage in the United States, "substituting NPs for doctors cannot be the answer. Nurse practitioners are not doctors, and responsible leaders of nursing acknowledge this fact."

"The interests of patients are best served when their care is provided by a physician or through an integrated practice supervised directly by a physician," report said. "We must not compromise quality for any American, and we don't have to."

Despite losing their reimbursements for nearly two years (the new rule won't go into effect until January 1st and doesn't allow for retroactive payments), Zambricki says some nurse anesthetists have continued to provide services for free, knowing how much their patients rely on them.

She says one CRNA she talked with had more than 800 unpaid bills, but never stopped taking care of his Medicare patients, reasoning, "I can't stop taking care of them; they're my neighbors."

"They really made the sacrifice," Zambricki says. "And they really hoped that this would be remedied."

Source: HealthLeaders Media