ASA Response To NY Times A-Bomb Editorial On CRNA Supervision: Paradigm Shift?

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ASA Response To NY Times A-Bomb Editorial On CRNA Supervision: Paradigm Shift?

As we said it would, the response to a NY Times Editorial on study data supporting the removal of all remaining Medicare regulations which require supervision of Certified Registered Nurse Anesthetists (CRNA) in order to obtain reimbursement. Remember, these are purely insurance regulations which do not create laws which require CRNA practice to be supervised….only [...]http://feedads.g.doubleclick.net/~a/zWz4k6S8q_lvl-exQdQgOIyNDW8/0/di (http://feedads.g.doubleclick.net/~a/zWz4k6S8q_lvl-exQdQgOIyNDW8/0/da)
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ASA Response To NY Times A-Bomb Editorial On CRNA Supervision: Paradigm Shift?
By lawmed | Published: September 9, 2010

As we said it would, the response to a NY Times Editorial on study data supporting the removal of all remaining Medicare regulations which require supervision of Certified Registered Nurse Anesthetists (CRNA) in order to obtain reimbursement, has heated up. Remember, these are purely insurance regulations which do not create laws which require CRNA practice to be supervised….only laws which allow for Medicare reimbursement for CRNA services if supervised by an MD in states which have not opted out of the requirement. Currently 15 states HAVE opted out and Colorado is on the precipice of being the 16th. The American Society of Anesthesiologists (ASA) has fought a hard turf battle to keep independent CRNA practice to a minimum.

Indeed ‘supervision’ and ‘medical direction’ are terms born of the insurance industry, not of the health care community. Actual state practice laws vary in their requirements from total independent practice in Iowa where CRNAs are considered equal colleagues with physicians under the law, to “collaboration” in Maryland where CRNAs work independent of any physician but collaborate with a designated physician as needed, to states which require supervision but fail to define it in a meaningful way. Such ‘supervision’ states fall short of the insurance definitions of supervision which generally spell out the activities of a supervising or medically directing physician. However only Medicare requires physician supervision in order for a CRNA to get paid for their services (which the physician gets a percentage of), and only in states which have not opted out of the requirement. Other insurance supervision requirements are used to determine whether a physician will be paid part of the anesthesia reimbursement or it will all go to the CRNA.

No state requires that a CRNA be supervised by an anesthesiologist.

As anticipated, the ASA has come out swinging in response to the Editorial. From TheHill.com:

The anesthesiologist lobby is pushing back this week against a New York Times editorial hinting that nurse anesthetists are as qualified as physicians to deliver anesthesia care.

Alexander A. Hannenberg, president of the American Society of Anesthesiologists (ASA), said a shift to certified registered nurse anesthetists (CRNAs) — and away from the better-trained doctors — “is both dangerous and ironic and condemns Americans to the end of improvement in anesthesia.”

Current Medicare rules dictate that CRNAs can’t administer anesthesia services without a physician present — unless states choose to opt out of that requirement (15 have done so in the past decade). Some medical experts say the quality of care is the same in either case, and they’re pushing Medicare to eliminate the physician-supervision requirement.

The Times‘s editorialists on Tuesday hinted that they support that plan.

“From a patient’s point of view, it would seem preferable to have a broadly trained anesthesiologist perform or supervise anesthesia services, but, in truth, the risk is minuscule either way,” the Times wrote on Tuesday. “As health reformers seek ways to curb medical spending, they need to consider whether this is a safe place to do it.”

But the anesthesiologists are quick to argue that the reduction of risk surrounding anesthesia treatments didn’t happen by accident.

“Anesthesia safety has improved so dramatically in the past 20 years precisely because physicians are developing and testing the drugs, techniques and monitors leading to those improvements,” Hannenberg said in an e-mail. “When The New York Times proposes to drop physicians from anesthesia because of those advances, it is both dangerous and ironic and condemns Americans to the end of improvement in anesthesia.”

This debate, it would seem, is far from over.

That last sentence is an understatement logistically, but practically one wonders. How much life is left in the content of the debate since no study has been produced which supports the ASA position convincingly, despite multiple attempts. The safety record of anesthesia is indisputable and no one has been able to show that anesthesiologist involvement is responsible for that safety. Meanwhile CRNAs are the sole anesthesia providers in various surgical settings across the country absent any cries of alarm or indications of increased morbidity or mortality in patients….and this has been the practice for over 130 years. Surely we would have seen some indication of a problem by now? Or is the health care community part of a vast conspiracy supporting nurse anesthetists while ignoring patient safety?

The current statement by the ASA is a noticeable and interesting shift from all of their previous statements which centered on an alleged danger to patients in the current clinical setting when an anesthesiologist is not present, to an apparent argument that research and innovation in anesthesia is carried out by physicians alone and endorsement of CRNA independent practice would put an end to anesthesiologists as well as “improvement in anesthesia.” Leaving aside the incorrectness of the argument that CRNAs are not responsible for improvements in anesthesia, the ASA now seems to argue that the role of the physician anesthesiologist is most important in regards to research and development. Let us be the FIRST to endorse their view. The lack of an ASA rebuttal to the actual findings of the study is stark.

At some point the debate becomes illogical. In this writer’s mind that point passed some time ago.