New anesthesia rule mixes politics, science, and states rights — and continues the controversy
New anesthesia rule mixes politics, science, and states rights — and continues the controversy
Whether you are an anesthesiologist, nurse anesthetist, or member of the Bush administration, the Centers for Medicare & Medicaid Services’ (CMS) final rule on anesthesia services represents an obvious attempt at good science, power politics, or additional support for state self-determination.
But patients are unlikely to be able to tell which factor was at work and how the changes in Medicare conditions of participation regarding anesthesia services will affect them.
The final rule, published Nov. 13, is markedly different from that published just two days before the Clinton administration left office last January. After years of debate between physician anesthesiologists and nurse anesthetists over the need for physician supervision of nurses providing anesthesia services, the Clinton administration decided to side with the nurses and issued a proposal eliminating the physician supervision rule in states where it was not required by state law.
Predictably, the nurse anesthetists cheered, and the physicians cried foul. Implementation of the Clinton proposal was delayed as part of the incoming Bush administration’s review of all last-minute regulations issued by the prior administration.
CMS said that as it reviewed the Clinton proposal and alternatives for implementation, it uncovered two questions that had not been raised and addressed:
- whether states relied on Medicare physician supervision requirements in establishing state scope-of-practice laws and monitoring practices so that eliminating the Medicare requirement could change supervision practices in some states without allowing states to consider their individual situations;
- whether a prospective study or monitoring should be undertaken to assess the impact in those states where certified registered nurse anesthetists (CRNA) practice without physician supervision.
"The literature we reviewed indicated that the anesthesia-related death rate is extremely low, and that the administration of anesthesia in the United States is safe relative to surgical risk. However, in the absence of clear research evidence, it is impossible to definitively document outcomes related to independent CRNA practice," CMS said in its Federal Register notice.
The final rule retains the physician supervision provision, while allowing state governors to submit a written request to opt out of that requirement after consulting with the state boards of medicine and nursing in the affected state on issues related to access and the quality of anesthesia services. In addition, the Agency for Healthcare Research and Quality will design and conduct a prospective study or monitoring effort to assess outcomes-of-care issues relating to CRNA practice and involvement.
Many commentaries on the proposal questioned how consultation with state boards would work if a governor wanted to pursue the opt-out provision and suggested the process might allow one profession to make judgments about the scope of practice of another profession. However, CMS said its intent is to allow governors to make local decisions without being told by a federal agency how to do so. "We purposefully were not prescriptive in detailing processes or steps that should be undertaken," the agency said. "In addition, the particular factors that are pertinent in reaching a sound policy decision will invariably vary from state to state."
Publication of the final rule did not stop the sniping that has gone on for years between nurse anesthetists and anesthesiologists — but increased it.
Deborah Chambers, president of the American Association of Nurse Anesthetists in Park Ridge, IL, says Medicare "got it right the first time [in the Clinton administration rule]. After three years of careful consideration, last January, Medicare proposed removing the federal physician supervision requirement for nurse anesthetists. This was largely due to the fact that anesthesia care is nearly 50 times safer today than 20 years ago, with nurse anesthetists being the primary hands-on providers of anesthesia in this country."
She says one positive element in the Bush administration proposal is that for the first time, states have the opportunity to opt out of the supervision requirement. "While the new rule clearly is not as good for patients as the January proposed rule would have been, nurse anesthetists will work with the new rule to continue ensuring the safest, highest quality anesthetics for our patients, particularly those in rural and medically underserved areas where CRNAs have long been the lifeline between those communities having and not having access to surgical, emergency, and obstetrical care."
Ms. Chambers also said the CMS decision proves there is no safety issue involved because states would not have been given an opt-out opportunity if it would jeopardize patient safety. "The public should not be buffaloed into thinking that what happened here is anything other than a transparent attempt by the White House to keep the medical lobby happy."
However, Barry Glazer, MD, president of the American Society of Anesthesiologists, also in Park Ridge, praised the administration for preserving "an important patient safety measure that has been protecting patients for more than 35 years before it was discarded by the Clinton administration." He expressed concern about the opt-out provision, saying it could be "exploited and abused by those opposed to having a physician involved in every anesthetic." He cautioned that the "opt-out criteria fails to adequately define what specific procedures and protocols a state governor would have to follow to opt out of, or back into, the supervision rule. We expect that any governor considering this option will want to do what is best for the citizens of the state and will base such a decision on sound science, and not political pressure."
While the issue may now be finally resolved at the federal level, the battleground will shift to those states in which CRNAs can practice independently. Governors in those states (and the two sides can’t even agree on how many there are) will certainly come under pressure from nurse anesthetists to exercise the opt-out provision and from physicians to retain a supervision requirement.
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