Anesthesiologists moved one step closer to their goal of maintaining supervisory control of anesthesia care when the US Department of Health and Human Services published a proposed rule in the Federal Register July 5 retaining the long-standing requirement of physician supervision of CRNAs when they are administering anesthesia to Medicare and Medicaid patients.
The proposed rule overturns a measure to remove physician supervision of anesthesia care that President Clinton approved during his last week in office. That measure was to take effect March 19, but the Bush White House, reviewing this and other regulatory rulings of the previous administration, delayed its implementation. That delay was hailed as a victory for anesthesiologists lobbying to retain the physician supervision requirement. HHS is expected to implement the proposed rule in November, although no specific date has been set.
The latest HHS rule includes two key provisions. First, state governors can opt out of the physician supervision rule for hospitals and surgical centers after consulting with state boards of medicine and nursing, and provided that waiving the rule does not contradict state law. Second, the HHS's Agency for Health Research and Quality will conduct a prospective study to assess the outcomes of anesthesia care involving nurse anesthetists.
No one is quite sure just how such a study might be conducted. The ideal study would compare nurse anesthetists and anesthesiologists working independently. "The only concern that we have with a study is it needs to be fair and equitable," says Debbie Chambers, CRNA, MHSA, the new president of the American Association of Nurse Anesthetists. "It needs to be an objective study, and that would be difficult with the supervision rules in place."
The nurse anesthetists argue that the physician supervision requirement limits patient access to surgical care in places where anesthesiologists are scarce, particularly rural areas. Physician supervision does not require an anesthesiologist's imprimatur per se; but surgeons may be unwilling to accept the added liability and responsibility of overseeing anesthesia care.
That's a problem in states like Iowa, where nurse anesthetists provide all of the anesthesia care in 91 of the state's 117 hospitals, according to Bill Miller, CRNA, of Harlan, Iowa (pop. 5,360). "The surgeons are saying they will not do cases here because they don't want to supervise these people," says Mr. Miller. "We've had 22 surgeons in the state, that I know of, who have terminated their privileges at these small hospitals."
Meanwhile, the anesthesiologists are delighted with the recent turn of events. What a difference a new presidential administration makes, not to mention an all-out lobbying blitz by the American Society of Anesthesiologists. "I am pleased only because it protects our senior citizens," says ASA President Neil Swissman, MD, repeating the ASA's claim that nurse anesthetists are less safe than anesthesiologists. "This is not about anesthesiologists, it's not about nurse anesthetists. This is truly about patient safety."
If the HHS's safety study shows no significant difference in outcomes of anesthesia care by different providers, that's an argument he may eventually have to discard. No timetable or format has yet been established for the study. The good news for patients is that every study to date shows that anesthesia care is safer than ever, no matter whether it is provided by an anesthesiologist or a nurse anesthetist.