California Nurse Anesthetists Allowed to Work Solo

Yael Waknine

June 29, 2012

June 29, 2012 — A ruling this week by the California Supreme Court has ended years of legal wrangling, leaving certified registered nurse anesthetists (CRNAs) free to continue providing access to care in medically underserved populations despite increasing physician concerns for patient safety.

The court upheld former Governor Arnold Schwarzenegger's 2009 decision to opt out of the 47-year-old federal Medicare facility reimbursement rule requiring physician supervision of CRNAs, denying review of a lawsuit filed by the California Medical Association opposing the ruling.

At this time, there are 40 US states with no physician supervision requirement for CRNAs written into their nursing or medical laws or regulations. Of these states, 33 do not require supervision according to state hospital licensing laws or regulations.

California is 1 of 17 states that have decided to opt out of the federal regulation requiring physician supervision to obtain reimbursement for Medicare patients undergoing anesthesia.

In 2001, the Bush administration gave state governors the right to opt out as long as they ascertained that opting out is consistent with state law, informed the state boards of medicine and nursing of their intent to opt out, and determined that opting out is in the best interest of the state's citizens.

Other states that have chosen to opt out are Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, Montana, South Dakota, Wisconsin, Colorado, and Kentucky.

The Training Issue

Jane C.K. Fitch, MD, a former nurse anesthetist, told Medscape Medical News, "I became an anesthesiologist after I realized I did not know all I needed to know to take comprehensive care of my patients." Dr. Fitch is now first vice president of the American Society of Anesthesiologists.

"The differences in length of education and training, as well as the differences in depth of knowledge, do not allow CRNAs to learn as much detail or gain as much experience and training as is needed to practice independently. That is why it is not in the best interest of patient safety to have [nurse anesthetists] practice without physician supervision," Dr. Fitch emphasized.

To administer anesthesia, bachelor-degreed registered nurses must have at least 1 year of acute care nursing experience before completing a 2- to 3-year master's degree program and passing the national CRNA board certification exam.

In contrast, anesthesiologists must first obtain a 4-year medical degree, complete a 4-year anesthesiology residency program, and pass a comprehensive oral and written exam. Subspecialization can be done through a 1- to 3-year fellowship.

However, Debra Malina, CRNA, DNSc, MBA, asserts that CRNAs are as equally capable as physicians in administering anesthesia. Dr. Malina is president of the American Association of Nurse Anesthetists.

"National studies have confirmed that anesthesia care provided by CRNAs is as safe as [that] provided by anesthesiologists, and more cost-effective," Dr. Malina said in an interview with Medscape Medical News, calling the federal supervision requirement, which is not required under state law, "outdated, cumbersome, and most of all, unnecessary."

Scope of Care

In a recent news article, Bob Egelko of the San Francisco Chronicle quoted Curtis Cole, lawyer for the California Society of Anesthesiologists, as saying that the studies are misleading because "nurse anesthetists don't do the hard cases, like cardiac surgery."

Dr. Malina strongly disagrees, saying, "It is easy to prove that CRNAs provide anesthesia care for every type of surgery, regardless of physician supervision, including cardiac, transplants, brain surgery, back surgery, joint replacement, you name it. There are no limitations on what types of cases CRNAs are involved in, what types of anesthetics they can provide, the facilities where they can work, etc."

Even so, the scope of care a physician can provide can be crucial.

According to Dr. Fitch, the need for physician supervision has never been more vital because of the critical nature of anesthesia, the unpredictable responses of patients, and America's older and sicker patient population.

Most anesthesiology-related adverse events are related to a patient's comorbidities or to the specifics of the surgery or procedure, which are more knowledgably addressed by the surgeon or interventional physician, Dr. Fitch explained. Only a minority of anesthesiology-related adverse events are related to the anesthetic.

Costs and Access to Care

However, Dr. Malina asserted that the federal rule has nothing to do with patient safety and everything to do with a requirement for reimbursement, because supervision already was not required at the state level. She added that CRNAs ensure valuable access to surgical, obstetrical, trauma, and pain management services for millions of Americans in rural and other medically underserved areas.

"Taking into consideration all 3 components — access, safety, and cost-effectiveness — in an era of tremendous economic concerns, particularly with regard to our healthcare system, the ability to opt out of a needless federal requirement and put the healthcare decision making in states' hands is a very appealing option," Dr. Malina said.

Dr. Fitch disagrees, noting that cost and access are frequently cited as motivations to pursue CRNA independent practice.

"Cost is not the issue because there is no difference in payment from Medicare for CRNAs or anesthesiologists. Nor is access to anesthesia services impacted, as where there is the need for surgery or a procedure requiring anesthesia, there is always a physician present," Dr. Fitch said.

"For CRNAs who want independent practice, please do what I did and prepare yourself to provide comprehensive care of your patients by becoming a physician. It is not in the best interest of patient safety to seek legislative or regulatory shortcuts to achieve that goal. The ability to practice the critical care specialty of anesthesiology should only be granted through the proper medical education and training, and not through legislation or regulation," Dr. Fitch concluded.


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