One Step Forward, One Step Back: Physician supervision requirements are troublesome for CRNAs.

American Journal of Nursing [Vol. 103, No. 1, pp. 91-4], January 1, 2003

“It’s a wash,” says Sally Bass Witkowski, CRNA, BSR, when asked about the recent flip-flop Medicare rulings on physician supervision of certified registered nurse anesthetists (CRNAs) in hospitals.... “A lot of time, energy, and money were spent by people on both sides of the argument, and for what? Nobody’s job changed.”

“It’s a wash,” says Sally Bass Witkowski, CRNA, BSR, when asked about the recent flip-flop Medicare rulings on physician supervision of certified registered nurse anesthetists (CRNAs) in hospitals…. “A lot of time, energy, and money were spent by people on both sides of the argument, and for what? Nobody’s job changed.”

On January 18, 2001, as one of the numerous “midnight” regulations of the Clinton administration, the federal requirement for hospital physician supervision of nurse anesthetists was dropped. But on November 13, 2001, just before the January ruling was to go into effect, it was reversed by the Bush administration.

The November ruling requires physician supervision of CRNAs in hospitals receiving Medicare reimbursement. The ruling compromises by permitting state governors to request a waiver to opt out of the requirement, if deemed in the best interest of the state’s residents. The governor may do so only after consulting the state’s boards of nursing and medicine, and after determining if opting out is consistent with state law. To date, six states have opted out of the requirement — in order, Iowa, Nebraska, Idaho, Minnesota, New Hampshire, and New Mexico.

Although nurse anesthetists are legally allowed to provide anesthesia in all 50 states, some states require that they do so with supervision. However, 31 states don’t require physician supervision of CRNAs. This is specified though the states’ nursing and medical practice acts, the rules of their nursing and medical boards, and their hospital licensing laws: all three must be in accordance in order to secure exemption from the new ruling.

How the Rulings Effect Practice

“In my judgment, the supervision rulings do not affect practice or the quality of anesthesia care,” said Sandi Peters, CRNA, former president of the Texas Association of Nurse Anesthetists. “I practice in three rural hospitals. In one practice site Im employed as a staff anesthetist; in the other two I independently contract. The physician who supervises me is usually a surgeon who likely has hd no advanced anesthesia training. Physician supervised or not, my practice is the same at all three hospitals.”

“Physician supervision of nurse anesthetists has absolutely nothing to do with practice or patient safety,” says Ira Gunn, MLN, CRNA, FAAN, who for nearly 50 years has practiced anesthesia and worked extensively with state legislatures, the Congress and administrative bodies regulating the nurse anesthesia profession. The 30,000-member American Association of Nurse Anesthetists (AANA) established a professional advocacy award in her name. “It has to do with politics, turf, control and income. It’s a holdover from the days of the ‘captain-of-the-ship’ legal doctrine, which became obsolete long ago in most jurisdictions.”

Gunn clarified a common misperception about who exactly “supervises” CRNAs. “People assume that physician supervision rulings are about anesthesiologists supervising nurse anesthetists. That isn’t true. Physician supervision rulings refer to any physician, including those without advanced anesthesia training. In practice it’s likely a surgeon,” said Gunn. “The American Society of Anesthesiologists (ASA) successfully campaigned to convince surgeons that they were liable for CRNAs. Nothing could be further from the truth. CRNAs carry their own medical malpractice insurance. Nurse anesthetists are trained by nurses, credentialed by nurses, and regulated by nurses. The profession is independent of medicine.”

Peters agrees. “ASA’s misleading information made surgeons feel that they would be liable for any mishap if they didn’t supervise CRNAs. The surgeons I work with haven’t had advanced anesthesia training, and many tell me they don’t feel qualified or comfortable supervising my anesthesia care.”

“In another twist on the subject, HCFA (the federal Health Care Financing Administration) never defined ‘supervision,’” Peters continues. “In practice, it could mean anything from a physician being somewhere in the building to one looking over the old ether screen and asking the CRNA if everything’s okay. So, there’s no consistency. Supervision is meaningless in real-life practice.”

“The Bush administration reversal was deeply disappointing to practicing CRNAs,” Peters says, “because it meant an opportunity was lost to lose unnecessary encumbrances to practice. It also places a procedural burden on state governors to opt out.”

Deborah Chambers, CRNA, MHSA, past president of AANA, says, “The AANA believes that CMS (Centers for Medicare & Medicaid Services) got it right the first time with the January 2001 rule on supervision. But since the November 13 ruling is in place, the AANA will work with that rule to ensure safe, high-quality anesthesia care for all Americans. We are confident that governors will make the right decisions for the citizens of their states by choosing to opt out of the requirement.”

Witkowski, too, is disappointed in the latest ruling. “It promotes a phony hierarchy of providers, granting physicians greater status and economic reward. It’s demoralizing to the ‘underlings,’ the dedicated people who do the work. It makes them feel beaten down and leave the profession, contributing to the shortage of anesthesia providers. What’s worse, rulings like these drive up prices and limit access,” she says.

A question of Geography

Access to health care is a challenge in U.S. rural areas, as most healthcare providers prefer to practice in urban areas. Thus, the Clinton administration’s January 2001 ruling was strongly supported by the both the American Hospital Association and the National Rural Health Association. Small wonder, as CRNAs are the sole providers of anesthesia in many inner-city hospitals and in more than 65% of rural hospitals, according to the AANA. [http://www.aana.com/crna/ataglance.asp]

Rodney Lester, PhD, CRNA, president of the AANA, understands the critical role CRNAs play in meeting the healthcare needs of rural communities. “If it weren’t for CRNAs, people living in rural and medically underserved areas simply wouldn’t be able to maintain access to the services they need requiring anesthesia—for example, trauma stabilization, diagnostic procedures, and emergency surgeries related to obstetrics, orthopedics, and a myriad of acute conditions,” Lester says.

Hospital medical bylaws reflect this geographic difference in access to services. In the 29 states where physician supervision of CRNAs is not required by law, the medical bylaws of rural hospitals typically don’t require supervision.  However, urban hospital bylaws, which are far more restrictive, tend to require physician supervision. As Witkowski explains, “Some bylaws in urban hospitals with plenty of physician coverage can be so limiting that [CRNAs] wouldn’t be able to make any independent judgments at all. CRNAs would do well to read their hospital’s bylaws and address those that are too restrictive.”

The Future of Physician Supervision

The future of the physician supervision requirement is anyone’s guess. Publicly, the ASA frames physician supervision of CRNAs in terms of patient safety rather than interprofessional turf, and it hailed the Bush ruling as a major victory. But from Gunn’s perspective, “CRNAs have always worked collaboratively with physicians, so supervision is neither necessary nor appropriate.”

Some believe the new ruling may be a violation of the original Medicare Act. Glen Maxey (D-Austin), a healthcare consultant who represented Travis County in the Texas legislature from 1991 to 2002, believes the January ruling shouldn’t have been rescinded. “When Medicare was passed in 1965,” Maxey says, “a fundamental principle of the program was that it wouldn’t interfere with state law regarding the regulation of healthcare professionals. Since the January 2001 ruling would have deferred to the states on supervision, it should have been allowed to stand.”

Toni Inglis, MSN, RN, CNS, FAAN, is a lifelong Austin resident and retired editor and neonatal intensive care nurse. She writes a monthly opinion column for the Austin American-Statesman editorial page.