5 Issues in the CRNA Supervision Debate: Anesthesiologists Weigh in

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The debate over whether certified registered nurse anesthetists should be allowed to administer anesthesia without physician supervision is among the most contentious issues in anesthesia care today. The conflict stems from a 2001 Medicare and Medicaid regulation change that allows states to "opt out" of a requirement that nurse anesthetists be supervised. So far, 17 states have chosen to waive the requirement.

Proponents of the opt-out say that it will improve access to medical care for patients in rural and medically underserved areas. Critics argue that the opt-out could harm patients because nurses and anesthesiologists receive distinctly different medical training.

Three anesthesiologists — Meena Desai, MD, of Nova Anesthesia Professionals in Villanova, Pa.; Thomas Wherry, MD, of Surgery Center of Maryland in Silver Spring; and Randall Maar, MD, of Children's Hospital Colorado in Aurora and a member of the ASA Board of Directors — lend their opinions on five of the most contentious issues in the CRNA supervision debate.

1. Will the opt-out improve access to rural care?

According to Dr. Maar, a common argument in the debate is that removing the CRNA supervision requirement will enable more nurses to practice in rural hospitals, thus increasing medical care in underserved areas where anesthesiologists are scarce. "This is not true in Colorado," he says. "There are just as many — if not more — anesthesiologists than nurse anesthetists affected in the hospitals. At least five of the rural hospitals [in Colorado] are anesthesiologists-only. I want to know how the government is improving access in those hospitals when they're already fully staffed by anesthesiologists."

2. How does physician/CRNA education affect the debate?

According to Dr. Desai, the discrepancy in medical training and education received by CRNAs and Anesthesiologists accounts for differing and poorer quality of care and is often overlooked by the public and government officials. "There is a huge difference in education, which matters for leadership," she says. "CRNAs get two and a half years of medical education, while Physician Anesthesiologists have eight. There are definitely differences in the quality of care. I think that the public, and perhaps elected officials, are misled into thinking otherwise."

Dr. Maar agrees. "A flawed argument is that nurses are the equivalent of physicians and are a perfectly acceptable substitute for anesthesiologists," he says. "Nurses are not physicians. There's a great difference in the education and training of a nurse as compared to a physicians. Anesthesia care is extraordinarily complex, and when one examines all the component portions of an anesthetic, there is no question that there needs to be medical decision making as the essential element of that anesthesia care."

3. How will patient safety be affected by the opt-out?

According to Dr. Maar, the most significant issue in the CRNA debate is the impact of the lack of supervision on patient safety. "We know from the Silber study [Jeffrey H. Silber et al. Anesthesiologist Direction and Patient Outcomes. Anesthesiology. 2000 Jul; 93(1):152-63] that as the degree of supervision is lessened, patients do worse," he says. "Our primary motivation to challenge these opt-out decisions is to not allow the 30 years of hard work that anesthesiology has done to improve patient care in the OR to be rolled back."

Anesthesia care begins well before anesthesia and surgery, Dr. Maar says. Anesthesiologists are responsible for medical decisions made on the patient's condition for the procedure, whether additional testing is required, whether changes in therapy are warranted and whether the surgery should be performed at all. "All of those are medical decisions that only a physician should make," he says.

According to Dr. Desai, the increasing complexity of anesthesia care necessitates that Anesthesiologists have to be perioperative physicians handle the complexity of anesthesia cases. "[Anesthesiologists and CRNAs] have worked together as a care team for a very long time, but they are not perioperative physicians and they do need to be supervised," she says. "Anesthesia has changed into a perioperative specialty — it involves preselection, intraoperative and postoperative phases to make the surgical process safe. I do not believe the education of CRNAs allows them to do patient selection carefully, as they don't have the breadth of medical knowledge required."

Dr. Desai adds that CRNAs are typically not trained to lead in an emergency or disaster situation. "Because of that, patients can suffer harm in an unsupervised situation," she says.

4. Does opting out help to cut costs?

Proponents of the CRNA opt-out argue that it will allow hospitals to cut costs associated with recruiting anesthesiologists and draw from a larger pool of available CRNAs, particularly as hospitals expand or add additional services in different locations. "It gives the hospital or contracted anesthesia group an alternative to provide anesthesia service in a more cost-effective way, and it gives more flexibility," says Dr. Wherry.

Dr. Desai, however, believes that current reimbursement standards prevent the CRNA opt-out from being cost-effective. "CRNAs get paid per case exactly the same as anesthesiologists do," she says. "It's a complete fallacy that there is a cost saving to the medical system." In rural hospitals, she adds, CRNAs are paid a differential under a Medicare incentive to attract more nurses to scarcely populated, medically underserved areas.  In the opt-out, I believe we are trading poor quality of anesthesia service for the same dollar amount.  Additionally, access to care is not a problem, as a physician is always present for surgery and can be the physician supervisor of the nursing staff.  

5. Can the opt-out improve staffing flexibility?

Dr. Wherry says that in Maryland, CRNAs have worked independently for years. The state requires the CRNA have a collaboration agreement with a physician, and the physician is not required to be an anesthesiologist.

CRNAs have been directly reimbursed by Medicare since 1989 through Part B of Medicare, he adds. "CRNAs often sign over their billing rights to a group or a hospital, and it is important to keep in mind CRNAs and anesthesiologists are reimbursed through Part B of Medicare," Dr. Wherry says.

Dr. Wherry then lays out the issue of "opt out" and Medicare Part A. The opt out issue applies to reimbursement to inpatient hospitals, critical access hospitals, and ambulatory surgery centers for the care they provide to beneficiaries through Part A of Medicare, he says. In order for hospitals to be reimbursed by Medicare, they must be compliant with CMS's conditions for participation. There are also conditions for participation for critical access hospitals and ambulatory surgery centers. Each of these conditions calls for the CRNA to be supervised by the operating physician or an anesthesiologist unless the state’s governor has "opted out" of the supervision requirement. Part A of Medicare does not provide any reimbursement to the surgeon or anesthesiologist who provides supervision for the CRNA in order for the facility to be compliant with Medicare Part A conditions for participation.

In states that have not opted out, the facility can comply with Medicare Part A conditions for participation by the surgeon supervising the CRNA, he says.

"Really, all states do with the opt-out is remove a technicality and a political barrier, but it's not going to change the overall practice," he says. "So it might give a group in opt-out states a certain comfort level in the hospital rules and regulations. CRNAs can then work without any supervision, and it takes away any stress that the surgeon may be feeling that they're somehow responsible."

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