Colorado Physicians Sue to Require Physician Supervision of Nurse Anesthetists

September 30, 2010

September 30, 2010 — A long-simmering turf war between anesthesiologists and certified registered nurse anesthetists (CRNAs) across the country erupted this week into a legal battle in Colorado.

As it is with healthcare in general, the conflict centers on matters of quality and quantity — quality of care for patients, quantity of dollars for providers.

The Colorado Medical Society and the Colorado Society of Anesthesiologists yesterday sued Colorado Gov. Bill Ritter Jr. over his decision, announced earlier in the week, to opt out of a Medicare requirement that a CRNA must work under physician supervision for his or her work to be reimbursed. The Centers for Medicare and Medicaid Services gave states this option in 2001, and Colorado is the sixteenth state to exercise it. Most are Western and Great Plains states, where remote rural hospitals may lack an anesthesiologist to supply the supervision.

In their lawsuit, filed in a state circuit court, the Colorado physicians contend that Gov. Ritter's opt-out decision "will diminish patient safety" and violate the state's "captain of the ship" doctrine, which puts surgeons in charge of operating room personnel. Seeking a reversal of the governor's action, the Colorado physicians also contend that the opt-out is contrary to state law, which they say classifies administration of anesthesia by a nurse as a "delegated medical function."

CRNAs counter that patient care does not suffer when members of their profession work without physician oversight.

"The evidence shows that physician supervision does not have an impact on quality of care," Paul Santoro, CRNA, and president of the American Association of Nurse Anesthetists (AANA), told Medscape Medical News.

Other states than Colorado that have bailed out of the physician supervision requirement for CRNAs are Alaska, California, Idaho, Iowa, Kansas, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Washington, and Wisconsin. Colorado's opt-out is confined to critical-access hospitals and specified rural hospitals.

Santoro said the opt-out rule does not automatically eliminate physician oversight. Rather, each hospital is free to set its own standards for how CRNAs function in light of its needs. "Right now we have a one-size-fits-all regulation," said Santoro, referring to the Medicare supervision requirement.

"We Think It's Jeopardizing Patient Safety"

A spokesperson for the American Society of Anesthesiologists (ASA) told Medscape Medical News that the opt-out decision by Colorado's governor was worth fighting in court.

"We think the opt-out is jeopardizing patient safety, and we'll continue to say so," said Richard Dutton, MD, executive director of the association's Anesthesia Quality Institute.

Anesthesiologists, said Dr. Dutton, have more training than CRNAs, a much broader perspective on patient care, and the ability to rescue an anesthetized patient when a simple case in the hands of a CRNA goes haywire. "This is constantly done in the [operating room] and emergency department," he said.

The solution to providing anesthesia services in underserved areas is to hire more anesthesiologists, not allow CRNAs to work unsupervised, Dr. Dutton said. "We don't think states should sanction a lower level of care for rural patients."

CRNAs, Anesthesiologists Disagree About Health Affairs Article

The debate over the quality of care delivered by unsupervised CRNA seemed to tilt in favor of the nurses with research published in the journal Health Affairs last month. The authors, 2 economists at the Research Triangle Institute in Waltham, Massachusetts, reported that allowing CRNAs to work independently had little or no effect on mortality and morbidity rates. The authors recommended that the Centers for Medicare and Medicaid Services eliminate its supervision requirement altogether.

The ASA was quick to point out that the study was funded by the AANA and was therefore less credible. However. Santoro told Medscape Medical News that his group had no say-so in either the methodology or conclusions of the study and that it had to withstand peer review before its publication in the nation's premiere journal for healthcare policy.

"All professional associations, including the ASA, commission research," he noted.

However, the ASA's criticism goes a little deeper. Dr. Dutton said that the Health Affairs study relied partly on Medicare claims to compare the performance of anesthesiologists practicing solo, unsupervised CRNAs, and CRNAs either directed or supervised by anesthesiologists. However, these claims do not always accurately indicate what category of clinician performed anesthesia, according to Dr. Dutton. He also said the study did not adequately account for anesthesiologists and supervised CRNAs tackling tougher cases than unsupervised CRNAs.

Salary Differential Is Debated

Some of the controversy in the CRNA debate centers on economics. CRNAs, who are mostly salaried employees, earn about $150,000 a year, according to the AANA. Anesthesiologists in group practices, in contrast, took home a median $424,000 in 2009, according to the Medical Group Management Association. The AANA's Santoro said this compensation differential makes it less expensive for cash-strapped hospitals to use independent CRNAs than those supervised by an anesthesiologist.

Dr. Dutton of the ASA said anesthesiologists earn about 20% to 30% more than CRNAs — and work that many more hours a week as well.

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