Should CRNAs Treat Chronic Pain? Q&A With ASIPP Chairman Dr. Laxmaiah Manchikanti

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Laxmaiah Manchikanti, MD, is the chairman of the board and chief executive officer of the American Society of Interventional Pain Physicians and Society of Interventional Pain Management Surgery Centers. He is also a clinical professor of anesthesiology and perioperative medicine at the University of Louisville, and he practices anesthesiology and pain management at several surgery centers.

Dr. Laxmaiah Manchikanti, chairman of the board and chief executive officer of ASIPP and SIPMSASIPP opposes the final rule from The Centers for Medicare and Medicaid Services to allow Medicare funds to pay for certified registered nurse anesthetists to diagnose and treat chronic pain.

The organization has gathered support of approximately 30 members of Congress, who have written CMS asking them to withdraw the regulation, Dr. Manchikanti says. Two senators and one representative also requested a U.S. Government Accountability Office study to evaluate if nurse anesthetists are qualified to perform these procedures or not.

Dr. Manchikanti weighs in on the CMS ruling and its potential effects on anesthesia and pain management.

Q: What was ASIPP's reaction to the final rule by CMS to allow CRNAs to practice chronic pain management?

Dr. Laxmaiah Manchikanti: We at ASIPP call it evidence by proclamation with a poor prognosis and certification by politics. We were disappointed, but even more stunned and appalled. This may be the first time in the history of the United States that CMS will take a position when a certain group of providers are not educated, not experienced and not trained to provide medical care. Several members of Congress overwhelmingly oppose the CMS decision; the General Accountability Office is looking into whether nurse anesthetists are qualified to perform interventional pain management procedures. It is the opinion of many that this rule definitely will not hold up because of the impending GAO study.

Q: What were the main considerations for the rule?

LM: The main considerations are political, rather than focusing on the issue of access. As of now, nurse anesthetists perform only 1 percent of interventional pain management techniques. They also consider all interventional pain management techniques to be blind epidural injections. There is overwhelming evidence that blind epidural injections do not work and further, they can cause serious problems. Epidurals are less than 50 percent of interventional pain management. Access is a nonissue as there are qualified, well trained pain physicians within a 40 to 50 mile radius of every city and county in the United States, with the possible exception of some rural areas in Idaho and the like, which have longer distances to travel, for any type of care.

CMS has ignored taking into consideration these nurses’ lack of training. They have only used as the basis of their decision that student nurse anesthetists’ curriculum in the future will include chronic pain management.

Interventional pain management is a medical discipline with defined interventional techniques that should only be performed by physicians who are well trained and qualified.

Q: What will be the results of this rule for the practice of anesthesia and pain management?

LM: The results of this rule could be devastating. Hospitals are supporting this so that they can have better leverage on well-trained physicians. Some physician groups may be supporting this because of their own special interests as they can start these clinics in their offices and provide everyone with a certain number of epidural injections.

The problem will be that these patients will be started on opioids and will not be followed by these physicians. Further, they will exhaust their number of interventional techniques to be performed. No one will approve any further treatment. Patients will suffer afterwards. The only thing these patients will have are side effects from these inaccurately performed treatments including weight gain, osteoporosis and other issues related to excessive steroid administration and dependency on opioids. The floodgates will be opened for these patients to have future dependency and addiction problems.

Q: The American Society of Anesthesiologists called the ruling dangerous to patient safety and said it could lead to increased cases of fraud. Do you agree? Are there other risks to this measure?

LM: It is not just the American Society of Anesthesiologists. They are accurate in this. The American Society of Interventional Pain Physicians in essence spearheaded this process and the project. The GAO study was requested by ASIPP.

This rule will increase fraud and abuse, controlled substance abuse, addiction and overuse, leading to numerous fatalities. The statistics at present show that 60 percent of the deaths secondary to opioids, deaths which have exceeded the number of motor vehicle injuries, are due to prescribed opioids. It is also interesting to note that the United States uses so much opioids that it if we were to give each person in the United States 5 mg of hydrocodone four times a day, it would last 45 days – that is each and every person in the United States.

There are also major risks related to these procedures. If nurses start performing these procedures in the thoracic and cervical spine, they will cause spinal cord injury and nerve injury.

Q: How do you foresee this measure impacting billing for anesthesia?

LM: In the short run, there should not be any change in billing for anesthesia. However, as time passes on nurse anesthetists will be more empowered in conjunction with the hospitals and together they will try to capture higher revenues. This will affect the insurance companies and they will start fighting back and reducing reimbursement for everyone, including anesthesiologists, physiatrists and everyone else. This is, provided there is any insurance other than Medicare in the future.

Q: Will any further advocacy efforts be made on behalf of your organization to oppose CMS' decision?

LM: We will continue to oppose this rule. As stated, numerous members of Congress are appalled and disappointed at this rule. They continue to oppose it. This will be discussed when the U.S. Department of Health and Human Services' funding comes in front of various committees. Further, the GAO study is on its way. The results will illustrate that these nurses do not have the proper training and we hope the GAO will then make an objective decision. The fact is that there is no training for nurse anesthetists to perform interventional pain management techniques. Their education is only one-third of what a physician’s education and training entails. It will be extremely interesting to note if and when GAO says that these nurses are not qualified and yet they continue doing these procedures. This will be taken into notice by various states and they may start reversing their previous opinions of nurse anesthetists performing anesthesia independently. It may also spread to other professions, such as nurse practitioners and physician assistants.

There are two types of consequences: one is unlimited practice with increasing fraud and abuse and the second one is more restrictions on these groups.

Q: What do you think is at the root of this decision?

LM: The final rule is devastating. It is a travesty. The entire issue boils down to the control of medicine. The medical profession is controlled by various organizations which are not coherent and oppose each other. These include Accreditation Council for Graduate Medical Education and American Board of Medical Specialties.

The first programs recognized by the ACGME were accredited in 1993. The number of ACGME accredited programs and the number of trainees in accredited programs have grown steadily over the past decade, reaching almost 100 programs that train approximately 300 new pain specialists each year; there was, however a decline to 80 to 90 programs since 2006 due to stringent requirements. The ABMS is not controlled by medical groups and established specialty certification.

In contrast, the nursing boards are the same as the nursing society and advocacy organizations, and it is mandatory nurses to have membership. Consequently, no one speaks against the boards because they are the boards. Essentially, 50 percent or more of the nurse anesthetists are categorically opposed to such an expansion. Even then, CMS and some active members of the group are pursuing these aspects. CRNAs would like to do many procedures which are difficult for even physicians to perform safely or comfortably unless they have had extensive training in the procedures. Overall, this is very sad news for the United States, which will ultimately result in decreased quality of care and increased cost of healthcare. Additionally, it may even result in fatalities.

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