March 20th, 2012
By Jennifer Olin, BSN, RN
Controversy has raged in California for several years now as nurse anesthetists and physicians duke it out for CRNA independent practice. Last week, the First District Court of Appeal in San Francisco ruled that nurses who are trained as anesthetists do not need a doctor’s supervision to work in California hospitals.
This ruling is especially important for hospitals in rural areas of California where physician coverage is at a premium. As in much of the country, nurses trained in anesthesia delivery, provide anesthesia care under a doctor’s orders but without direct supervision. Physicians maintain that their direct supervision is necessary to guarantee patient safety.
In fact, CRNAs are the primary providers of anesthesia care across rural America, enabling healthcare facilities in these medically underserved areas to offer obstetrical, surgical, and trauma stabilization services. In some states, CRNAs are the sole providers in nearly 100 percent of the rural hospitals. They have been the main providers of anesthesia care to U.S. military personnel on the front lines since WWI, including current conflicts in the Middle East.
Hospitals, their representative organizations, along with nurses and their organizations have long argued that if physician supervision is always required that healthcare becomes more expensive and less available.
Federal law denies Medicare reimbursements to hospitals that allow nurses to give anesthesia without supervision. In 2001, the Centers for Medicare and Medicaid Services (CMS) published a rule allowing states to be exempt from Medicare's physician supervision requirement for nurse anesthetists after appropriate approval by the state’s governor, in consultation with the state’s medical board.
In June 2009, then California governor Arnold Schwarzenegger joined governors in 15 other states in opting out of the federal regulation requiring participating Medicare hospitals to ensure that physicians supervise nurse anesthetists. Schwarzenegger said he opted out to increase access to anesthesia services in rural and underserved areas.
Anesthesiologists (CSA) filed a lawsuit challenging the Schwarzenegger’s decision to opt out of the supervision requirement. However, a San Francisco Superior Court judge refused to block Schwarzenegger's decision and allowed nurse anesthetists to continue practicing independently.
A study published on the Health Affairs website in 2010 focused on an analysis of Medicare data for 1999–2005. Researchers Brian Dulisse and Jerry Cromwell both health economists, found no evidence that opting out of the oversight requirement resulted in increased inpatient deaths or complications.
The pair looked at inpatient mortality and complication rates from 481,440 hospitalizations covered by Medicare in both opt-out and non-opt-out states. They looked at three different ways anesthesia can be provided — by CRNAs working with no supervision, by anesthesiologists working alone and by both working in a team.
There was no evidence that “patients are exposed to increased surgical risk if nurse anesthetists work without physician supervision,” they wrote. The researchers did find that anesthesiologists tended to work on more complex cases than did nurse anesthetists, and they controlled for that factor in their analysis.
“We recommend CMS return to its original intention of allowing nurse anesthetists to work independently of surgeon or anesthesiologist supervision without requiring state governments to formally petition for an exemption,” they said. “This would free surgeons from the legal responsibilities for anesthesia services provided by other professionals. It would also lead to more cost-effective care as the solo practice of certified registered nurse anesthetists increases.”
Now, to be fair, the study was funded by the American Association of Nurse Anesthetists (AANC).
The court ruling also aligns with recommendations made in the IOM's Initiative on the Future of Nursing committee's report “The Future of Nursing: Leading Change, Advancing Health" by allowing nurse anesthetists to serve patients without physician oversight.
As reported in the San Francisco Chronicle, “The law explicitly authorizes nurses to administer medications ‘ordered by … a physician’ and does not require in-person supervision, said Presiding Justice Ignazio Ruvolo in the 3-0 ruling, which upheld a December 2010 decision by a judge in San Francisco. He said the state Board of Registered Nursing, which regulates the profession, had reached the same conclusion.
The other states that have followed suit and opted out of direct physician supervision for CRNAs include: Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, South Dakota, Wisconsin, Montana and Colorado.
At this time, according to their attorney, the CMA and CSA have not decided whether or not to appeal this latest court decision.