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The Health Care Financing Administration (HCFA) has removed the longstanding rule that a physician must supervise nurse anesthetists, leading one side on the issue to praise their newfound freedom and the other side to warn of dire consequences. The American Association of Nurse Anesthetists (AANA) hailed the new Medicare rule as "smart health care policy," saying it ensures access to safe, high-quality anesthesia care in medically underserved areas, especially in rural and inner-city hospitals where certified registered nurse anesthetists (CRNAs) often are the sole anesthesia providers.
The rule removes the federal requirement that nurse anesthetists be supervised by physicians when caring for Medicare patients, and defers to the states on the issue. Currently, the nurse practice acts, board of nursing rules and regulations, medical practice acts, and board of medicine rules and regulations in 29 states do not require physician supervision of nurse anesthetists.
The immediate effect of the rule, which became official when it was released in January, is that hospitals and ambulatory surgery centers (ASCs) will be able to receive reimbursement from Medicare without requiring surgeons or other physicians to supervise nurse anesthetists. This is consistent with the current Medicare rule, implemented in 1989, that enables nurse anesthetists themselves to be directly reimbursed by Medicare without a physician supervision requirement.
In addition, removal of the federal supervision requirement means seniors will now be cared for under the same rules and regulations that apply to all other anesthesia patients in their particular state. As stated in the Federal Register, "Under this final rule, state laws will determine which professionals are permitted to administer anesthetics and the level of supervision required, recognizing a state’s traditional domain in establishing professional licensure and scope-of-practice laws."
Larry Hornsby, CRNA, president of the AANA, says the change means all surgical patients can now be confident they will receive the highest caliber of anesthesia care, even if they live far beyond the city limits. "This issue has never been about quality of care, but about access to care," he says. "AANA applauds HCFA for staying the course and ultimately carrying through with its initial plan."
The rule provides hospitals, critical access hospitals, and ASCs greater flexibility when it comes to staffing their anesthesia services, an important consideration for rural and inner-city facilities. Both the American Hospital Association and the National Rural Health Association supported the rule since it was proposed in December 1997.
Hornsby noted that 20 years ago, there were approximately two deaths for every 10,000 anesthetics given. Thanks to advancements in pharmaceuticals, monitoring technology, and anesthesia provider education, the current figure is approximately one death for every 240,000 anesthetics, he says.
The American Society of Anesthesiologists (ASA) sees the issue differently. The ASA is calling on President Bush to reverse what it calls a "grievous and dangerous 11th-hour decision by the Clinton administration that places every Medicare and Medicaid patient having surgery at increased risk of injury or death." The medical organization, representing 36,000 physician members nationwide, charged that the rule change will jeopardize the lives of seniors who undergo surgery by eliminating the requirement for a doctor to supervise if a nurse gives the anesthesia. Neil Swissman, MD, president of the ASA, notes that this requirement has been in effect continuously for the 35 years since the Medicare program was created.
"This action taken by the Clinton administration, with only two days remaining before leaving office, is an affront to everyone in this country — but in particular to our most vulnerable patients, senior citizens — who look to our federal government to establish minimum standards for keeping patients safe," Swissman says. "Instead, the safety net that has protected millions of seniors over the years has been dropped right before the administration leaves town. It is simply incomprehensible that the administration could be so callous."
Swissman says independent researchers, every major surgical association, all 50 state medical societies, and the American Medical Association have supported retaining the rule. During the past year alone, the public decried the proposed rule change by sending more than 75,000 faxes and e-mails to Congress and the White House, and newspapers across the country published editorials supporting patient safety over politics. In Congress, more than 140 senators and representatives supported bills calling for research that would assure safety.
"There is a basic but critical misconception that has clouded this issue from the beginning," Swissman says. "The practice of anesthesiology is not just administering anesthetic agents. It requires continuous medical judgment before the surgery to diagnose the patient and determine the best anesthetics to use during surgery when split-second decisions are made, and even after surgery when recovery of the patient and [his] pain treatment are critical. Nurses are not doctors and should not be expected to make those decisions."
Swissman contends there is no scientific research to support the rule change, and says there are studies that call such action into question as it regards the safety of patients having anesthesia. Last summer, University of Pennsylvania researchers published a paper that reviewed the care of 235,000 Medicare patients and determined there were 25 needless deaths per 10,000 cases when an anesthesiologist was not involved in the care.
"Instead of heeding the warning flags, HCFA chose to disregard the research rather than taking it to the next logical step," Swissman says. "To make it worse, HCFA still has offered absolutely no scientific evidence of its own that this change will maintain the current level of safety."
According to HCFA’s press release on the new rule, the decision was based on its "commitment to decrease regulatory burden by deferring to state licensing laws regulating professional health care practice."
All decisions relating to the supervision of nurse anesthetists will now take place at the state level. Some states require medical direction by an anesthesiologist while others maintain few or no standards at all. That is not the proper way for a federal program such as Medicare to operate, Swissman says.
"There should be one minimum federal standard of care so that seniors are not placed in medical jeopardy based on a patchwork of different regulations that currently exist throughout the country," he says. "For 35 years, no senior, whether in a small town or a big city, ever had to worry if a doctor would be involved in their anesthesia based solely on the state in which they were hospitalized. Now they will."
As recently as 1992, HCFA looked at this proposed rule change and said the anesthesia care of Medicare patients was too risky to leave to unsupervised nurse providers. "Nothing has changed in the training of nurse anesthetists that somehow qualifies them now to assume the medical responsibility of patients," Swissman says. "How can HCFA take a diametrically opposed position today when the only new scientific evidence suggests that doctors should supervise anesthesia nurses?"
The government also takes the position that anesthesia has become so safe that less qualified personnel can administer it. "This misses the point completely," Swissman says. "Anesthesia is safer today than ever before because of the involvement of physicians. The safety figures that HCFA has quoted were based on studies in which an anesthesiologist was involved in every single case."
Anesthesia nurses have two years of technical training vs. 12 years of medical training for physicians. Swissman contends that level of training cannot prepare them for medical emergencies that inevitably arise during surgery. He says the ASA is reviewing all available options to overturn the rule change, which he characterizes as "a parting, potentially lethal gift" from the Clinton administration.