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Buoyed by a presidential extension of the implementation date for a controversial rule allowing state professional practice laws and hospital bylaws to determine which licensed professionals can administer anesthesia, the Park Ridge, IL-based American Society of Anesthesiologists (ASA) is lobbying Tommy Thompson, secretary of Health and Human Services, to rescind the rule that was approved by the Clinton administration Jan. 18, just two days before leaving office.
"We are getting information to
the new administration," Philip Weintraub, ASA spokesman, tells State Health Watch. He says Mr. Thompson has received a comprehensive outline of reasons why the rule should be rescinded.
The anesthesiologists have long opposed the proposal that would allow nurse anesthetists to administer anesthesia to Medicare and Medicaid patients without being supervised by a physician.
"States and hospitals can always exceed basic Medicare rules," says ASA president Neil Swissman, MD, "but seniors should not have to worry about their Medicare coverage based on where they live or where they travel. In the name of patient safety, we are urging the secretary to conduct a thorough review of all available and verifiable data on this subject. This is a significant opportunity to overturn a grave mistake, one that was based on politics and not on science."
Meanwhile, those on the other side, represented by the American Association of Nurse Anesthetists (AANA), also in Park Ridge, IL, hailed the new rule as "smart health care policy because it will ensure access to safe, high-quality anesthesia care in medically underserved areas, especially in rural and inner-city hospitals where certified registered nurse anesthetists are often the sole anesthesia providers."
An association spokesman said, as a result, hospitals and ambulatory surgery centers will be able to receive reimbursement from Medicare without requiring surgeons or other physicians to supervise nurse anesthetists.
"All surgical patients can now rest assured that they will receive the highest caliber of anesthesia care, even if they live far beyond the city limits," says AANA president Larry G. Hornsby, CRNA.
"The issue has never been about quality of care but about access to care. AANA applauds HCFA [the Health Care Financing Administration] for staying the course and ultimately carrying through with its initial plan," he says.
For its part, HCFA said its decision to allow certified registered nurse anesthetists to practice without supervision where state laws permit is consistent with the agency’s commitment to decrease regulatory burden by deferring to state licensing laws regulating professional health practice.
The final rule was proposed in 1997 in an effort to restructure and refocus Medicare's conditions of participation for hospitals so they focus on outcomes rather than regulating processes.
"The final rule recognizes the states’ traditional domain in establishing professional licensure and scope-of-practice laws," a HCFA fact sheet says.
"It does not prohibit, limit, or restrict in any way the practice of medicine or prevent anesthesiologists from administering anesthesia or supervising another professional. The new rule allows an appropriate level of regulatory flexibility without compromising patient health or safety. Research has demonstrated that a variety of factors contribute to the unprecedented safety record for anesthesia administration that now exists in this country.
"Advances in medical knowledge, implementation of practice guidelines, better drugs, and safer equipment all have contributed to better quality care," the fact sheet states.
HCFA says that according to the 1999 Institute of Medicine report on medical errors, the number of deaths from errors in administering anesthesia has dropped from two deaths per 10,000 patients receiving anesthesia in the 1980s to approximately one death per 200,000 to 300,000 patients today — a 40- to 60-fold improvement.
"There is no evidence that CRNA [certified registered nurse anesthetist] independent practice would cause adverse outcomes," the HCFA statement claims. "There also is no evidence that states are any less concerned with ensuring the quality of care and safety of their citizens than is the federal government, or that states have been unsuccessful in overseeing other health care professional practice."
Speaking for the anesthesiologists, Mr. Swissman says there has been a "basic but critical misconception that has clouded this issue from the beginning — that the practice of anesthesiology involves only the administration of anesthetic agents." Rather, he says, it "requires continuous medical judgment before surgery to diagnose a patient and determine the best anesthetics to use, during surgery when split-second decisions are made, and after surgery when recovery of the patient and pain treatment are critical. Nurses are not doctors and should not be expected to make those critical decisions."
Mr. Swissman also points out that there is no scientific research to support the rule change and that a study by the University of Pennsylvania in the summer of 2000 reviewed the care of 235,000 Medicare patients and determined that 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," he 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," Mr. Swissman adds.
Expecting that argument from the anesthesiologists, HCFA says the University of Pennsylvania study "is not relevant to the issue involved in this rule. It did not compare CRNA practice with nonanesthesiologist physician supervision to CRNA practice without physician supervision. It does not provide sound and compelling evidence to support maintaining federal preemption of state law."
As the press release bickering over turf continues, the nurse anesthetists have tried to stake out the high ground.
"Despite the difficult and sometimes personal debate between AANA and ASA over the issue," a release issued when the rule was approved says, "AANA leaders sounded a note of confidence that the rule marks the beginning of a new era of cooperation.
"Mr. Hornsby cast his sights on the future and called on ASA to work with the nurse anesthetists and other health care practitioners to make anesthesia even safer."
Mr. Hornsby was quoted as saying, "We hope this will put an end, once and for all, to the federal supervision debate. We urge ASA to work with AANA on important health care issues confronting anesthesia providers and to work together for the common good of patient safety."
Mr. Swissman later said that despite the fact that the only new evidence supports the current involvement of a physician, "HCFA caved in to political pressures and issued this inappropriate, dangerous new rule."
[Contact the ASA at (847) 825-5586 and the AANA at (847) 692-7050, ext. 3043.]