HCFA Removes Supervision Requirement for CRNAs
In a move that has brought to a head one of the most hotly debated medical controversies of our time, the Health Care Financing Administration (HCFA) recently decided that certified registered nurse anesthetists (CRNAs) will be able to provide care to Medicare patients without physician supervision in states that allow it, under a rule published in the Federal Register on January 18. At present, 29 states do not require such supervision, although many of the 29 have protocols involving physician collaboration, direction, and limits on prescriptive authority.

The final rule (currently challenged by a 60-day halt for review by the Bush administration) is the latest chapter in a battle that has been waged between the nation's anesthesiologists and CRNAs ever since HCFA proposed eliminating the physician-oversight rule in 1997.

Not surprisingly, CRNAs nationwide are savoring the victory and praising HCFA for what they say is a show of support for poor and rural areas typically underserved by anesthesiologists and served by physicians reluctant to take on the liability that supervision implies. "HCFA has studied this issue since 1997, and stayed the course despite all of the political pressure," says Larry G. Hornsby, CRNA and president of the American Association of Nurse Anesthetists (AANA).

Anesthesiologists such as Neil Swissman, MD, president of the American Society of Anesthesiologists (ASA), however, are arguing that HCFA has ignored the expertise of doctors and disregarded recent studies showing that good advanced-practice nursing does not take the place of the "continuous medical judgment" provided by doctors, as well as related case-cost savings illustrated by such studies. Says Dr. Swissman, "What HCFA has failed to acknowledge is that the practice of anesthesiology is not just administering anesthetics."

Under the new rule, hospitals and ASCs will be able to receive reimbursement from Medicare without requiring surgeons or other MDs to supervise nurse anesthetists. A HCFA fact sheet suggests that the rule, by deferring to the state, simply brings anesthesia-practice rules into line with other Medicare rules. Medicare does not currently require physician oversight of other state-licensed independent practitioners, and a Medicare rule implemented in 1989 enables CRNAs to be directly reimbursed by Medicare without a physician supervision requirement. Linda Williams, an attorney and CRNA in West Virginia who is a past president of the AANA, says, "The requirement should have never been. I could get reimbursed under part-B Medicare for a procedure done without physician supervision, but the hospital couldn't get reimbursed for that procedure. It wasn't logical." Dr. Swissman argues the distinction was understandable. "Payment for a professional service is considered differently than what constitutes an appropriately performed procedure," he says.

Removal of the federal requirement means seniors will be cared for under the same regulations that apply to other anesthesia patients in their particular state. Phil Weintraub, ASA public relations manager, says that a national standard is needed to protect seniors, a particularly vulnerable population. "They're going to be turning seniors into guinea pigs. There has been no research in the last three, five, or 10 years showing that CRNAs, when working independently, can provide the same level of care as anesthesiologists," he says. Mr. Hornsby feels that there is plenty of proof that CRNAs provide essential care. "Nurse anesthetists have been doing this for over 100 years; we didn't start putting seniors to sleep yesterday," he offers. "We are the sole anesthesia providers in 70 percent of rural hospitals...and our medical malpractice premiums have decreased by 52 percent in the past 10 years." He feels that the ASA's apparent concern for the aged, in this instance, is so much hot air. "I think that it's a shame that senior citizens are being used as a pawn in what has become a political argument. Anesthesiologists are using the media to scare this population needlessly. CRNAs administer 65 percent of all anesthetics delivered each year, and anesthesia is safer than it's ever been."

Though Mr. Weintraub does point out that CRNAs are "sorely needed and appreciated" for what they do, he feels that anesthesiologists, who have the training to evaluate patients during all phases of the surgery process, are not getting the respect they deserve. "Anesthetics are safer than ever before because anesthesiologists have been at the forefront of developing monitoring equipment and safer agents, and setting standards," he says.

Meanwhile, the battle continues-the ASA is calling on Secretary of Health and Human Services Tommy Thompson to review the decision, having presented the secretary with a report last month, on the day the Senate confirmed his appointment.