Medicare dropping supervision requirement for nurse anesthetists

Despite the vehement objections of anesthesiologists, the Health Care Financing Administration (HCFA) is poised to drop a Medicare requirement that nurse anesthetists with advanced training be supervised by a physician when administering anesthesia in a hospital setting.

HCFA administrator Nancy-Ann DeParle has notified Congress that the change, the most controversial among many changes proposed to hospital regulations (drawing more than 30,000 comments), will be announced in the Federal Register before June.

To anesthesiologists who have lobbied heavily against the proposal over the two years since its initial introduction, the issue is patient safety and the risk that comes when physicians do not supervise nurses during the administration of anesthesia for surgery. The issue is not directly an economic one since Medicare reimburses both nurse anesthetists and anesthesiologists the same amount for the same services.

Having failed to convince HCFA not to change the requirement, the anesthesiologists are turning to Congress and seeking legislation to prevent HCFA from making the change. Sponsors of the Safe Seniors Assurance Study Act say the bill is needed because it appears to them that HCFA has not sufficiently reviewed current data or carried out new studies to ensure that seniors will be safe if the requirement for physician supervision of nurse anesthetists is removed.

"It is obvious now that all concern for patient safety has been lost to bureaucracy," says Ronald A. MacKenzie, DO, president of the American Society of Anesthesiologists in Washington, DC. "HCFA has said that it has made this proposal based on reasoning that anesthesia is relatively safe’ now and that there is no evidence to compare the differences between anesthesiologists’ care and nurses’ care. That reasoning is dangerously flawed. If HCFA goes ahead and removes this safeguard, seniors stand to lose not only a critical Medicare benefit, but, even more frightening, people will die."

Nonsense, say officials of the Park Ridge, IL-based American Association of Nurse Anesthetists (AANA), representing certified registered nurse anesthetists.

"Senior citizens will be just as safe as they’ve always been," says Jan Stewart, CRNA, the association president. "This decision removes the supervision requirement for a hospital to be paid by Medicare. It doesn’t affect providers. I think that if you walk down a hospital corridor six months after this takes effect, you won’t see any difference. This is not a change in practice, just in billing. I think the opposition has blown it all out of proportion. Doctors may believe there is some control slipping away from them, but they never really had it."

Historically, nurse anesthetists were the initial providers of anesthesia during surgery, according to AANA director of practice Sandra Tunajek. For many years, they worked under surgeons, until the physician specialty of anesthesiology came about. Over the years, many state boards of nursing looked at what nurses were doing, assumed a physician would be present during any operation in which anesthesia is used, and decided there was no need for a state requirement for physician supervision of the nurse anesthetist.

As a result, 29 states — Alaska, California, Colorado, Delaware, Hawaii, Idaho, Illinois, Iowa, Kentucky, Maine, Maryland, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New York, North Carolina, North Dakota, Oregon, Pennsylvania, South Carolina, Texas, Utah, Vermont, Washington, and Wyoming — plus the District of Columbia, Puerto Rico, and the Virgin Islands have no supervision or direction requirement concerning nurse anesthetists in nurse practice acts, board of nursing rules and regulations, medical practice acts, board of medicine rules and regulations, or their generic equivalents.

Nurse anesthetists currently administer 65% of all anesthesia in hospitals, and 70% of all anesthesia in rural hospitals, according to Ms. Tunajek. For many rural hospitals, nurse anesthetists are the only professionals available to provide anesthesia, and HCFA’s decision is motivated by a desire to recognize that situation officially and give hospitals more flexibility in determining a provider mix that meets their particular needs, she adds. The change also is responsive to federal government initiatives to defer to state law on such issues.

And the move recognizes a trend that has been under way for some time regarding advanced practice nurses, Ms. Tunajek says. Medicare already reimburses nurse midwives, and both the armed forces and Veterans Affairs have policies for advanced nurse practitioners.

The AANA has no plans to seek changes in state laws in the remaining 21 states, according to Ms. Stewart, because "we try not to meddle in state affairs, and the local level is the correct place to determine practice regulations."

Although the change has no direct impact on physicians, it "may ease the minds of some surgeons who believed erroneously that they had some liability for the actions of nurse anesthetists," Ms. Stewart adds.

Payment policies differ

Payment policies for nurse anesthetists vary depending on the payer and state, according to Ms. Tunajek. "Basically, third-party payers will pay nurse anesthetists, although in some states, Medicaid will not pay us. Medicare pays nurse anesthetists directly at the same rate as an anesthesiologist if the nurse anesthetist works alone without an anesthesiologist being present. The largest component of Medicare’s payment usually goes through an anesthesia care team."

In hospitals where anesthesiologists supervise nurse anesthetists, the physicians usually monitor several operating rooms simultaneously, with a nurse anesthetist present in each room continuously. While the anesthesiologists do not talk about it, some observers have raised the possibility that behind their vehement objections lies a fear that hospitals will use the change as an excuse to cut back on the number of anesthesiologists.

"Could it happen?" asks Ms. Stewart. "I suppose it’s possible. But I have a hard time imagining that any hospital would decide now to drop anesthesiologists."

Contact Mr. MacKenzie at (202) 289-2222 and Ms. Stewart and Ms. Tunajek at (847) 692-7050.