The Issue Of Physician Supervision Of Nurse Anesthetists Since That Time, Aana Has Supported The Rule Change For The Following Reasons

1. It would place the regulation of healthcare professionals where it belongs - at the state level. The proposed rule defers to state law on the issue of physician supervision of nurse anesthetists, advocating states' rights over federal government regulation in healthcare matters. We are mystified that the anesthesiologists would oppose CRNAs being regulated by the states. At the same time, if the anesthesiologists oppose the removal of a Part A requirement, would they support similar federal restrictions being imposed on anesthesiologists?

2. It promotes flexibility. The deferral to state law gives hospitals and ambulatory surgical centers greater flexibility in the use of anesthesia providers and improving operating room efficiency without affecting quality of care. The proposed rule is supported by the American Hospital Association and the Federation of American Health Systems.

3. It may help to remedy ongoing cases where anesthesiologists deny care. The proposed rule would ensure patient access to safe, high-quality anesthesia care, particularly in rural and inner-city hospitals. This is particularly critical given what has transpired in rural and underserved areas. In Los Angeles, an anesthesiologist refused to provide an epidural to a Medicaid patient in labor unless she could provide a cash payment. The indigent patient could not pay cash and was forced to undergo a delivery without anesthesia. In 1998, a story in the Los Angeles Times reported the case of Mrs. Ozzie Chavez who was told she would have to pay $400 cash in order to get an epideral during her labor. Though she was on MediCal, she offered to pay with a credit card or check but was denied and had to endure a painful delivery because the anesthesiologist demanded cash. According to the news story, this anesthesiologist had denied epidurals to a number of Medicaid patients as well. Interestingly, in the April 2000 issue of the American Society of Anesthesiologists Newsletter, Christine A. Doyle, M.D. writes that "the 'Northridge labor epidural incident' here in California was brilliantly converted by the California Society of Anesthesiologists (CSA) from an apparent disaster into a vehicle for achieving the first increase in Medi-Cal (Medicaid) reimbursement for obstetrical anesthesia in over 10 years." So much for compassion; instead the theme for anesthesiologists seems to be "show me the money." In Utah, it was reported in the Salt Lake Tribune (July 2, 1998) that Kelly DeFeo, a CRNA, volunteered to provide help for children at a school-based clinic in Ogden but was denied the ability to do so since McKay-Dee Hospital - the hospital which apparently cooperated with the clinic refused to allow her privileges. She was barred from volunteering because the hospital policy required anesthesiologist supervision. At least at that time, no anesthesiologist volunteered to provide the services nor was the policy changed so that the CRNA could provide the anesthesia. A few years ago in Montana and Wyoming, anesthesiologists refused to allow nurse anesthetists to provide epidurals even though it is within the scope of practice of CRNAs to do so. This denied numerous women epidurals themselves because there were apparently not enough anesthesiologists who were willing to provide the service. The result was that many women were being denied access to epidurals. (Great Falls Tribune, "Epidurals still not available," by Carol Bradley, September 3, 1995; Casper Star Tribune, "Nursing ethics group says epidural access at WMC depends on knowing 'right person'", by Tom Morton, 1993; Denver Post, "Montana women seek deliverance", by Carol Bradley, July, 1995). As these cases demonstrate, it is critically important to ensure access to anesthesia, particularly when anesthesiologists are either unavailable or unwilling to provide certain services in rural or underserved urban areas.

4. The rule addresses liability concerns. It eliminates the misperception some surgeons have that they are liable for the actions of CRNAs due to the federal supervision requirement. We have had many reports from CRNAs around the country about anesthesiologists who have dissuaded surgeons from working with CRNAs or hospitals from employing CRNAs inferring that somehow they are automatically liable for the actions of the CRNA by virtue of the supervision requirement. This assessment, of course, is not legally correct as the surgeon or other physician may rely upon either the CRNA or the anesthesiologist for the anesthesia portion of the case, unless the surgeon or other physician decides to become involved in the delivery of anesthesia. This perception of liability has been artfully used by some anesthesiologists to evict nurse anesthetists from their positions.

5. Finally, the rule recognizes CRNAs and affords them the opportunity to practice within their scope. It recognizes CRNAs for what they are: healthcare professionals who generally have a graduate-level education, who administer 65 percent of all anesthesia in the United States and are the sole anesthesia providers in two-thirds of all rural hospitals. Further, it recognizes that anesthesia care is safer today than it has ever been due to advancements in technology, pharmacology, and provider education.

For all of these reasons, the HCFA rule would enhance competition by providing flexibility in the marketplace, while ensuring continued access to high quality health care. To delay its implementation would only delay the improvements in the marketplace that we believe this rule will bring.

HCFA has made a careful, clinical decision and is under no obligation to further study this issue.