Medicare opt-out provision triggers scope-of-practice debate

When Narendra Trivedi, MD, instructs young anesthesiology residents, he seeks to impress upon them the importance of their broad medical school training. In the operating room, they have to be prepared for any emergency.

"I tell them, 'You are not only an anesthesiologist, you are an internist,' " said Dr. Trivedi, president of the California Society of Anesthesiologists. "Many times the situation is so critical that if you don't react right away, you might not have time. The patient's life is at risk."

Having a physician trained to quickly diagnose and respond to complications that can arise while a patient is under anesthesia is critical for patient safety, say the American Medical Assn., American Society of Anesthesiologists and other physician organizations.

But within the last nine years, 16 states have opted out of a federal rule requiring physician supervision of certified registered nurse anesthetists administering anesthesia medication at Medicare-participating hospitals.

Governors and nursing groups from the 16 states say taking the exemption enables them to provide anesthesia services in communities that have a hard time attracting physicians, and without the higher cost of an anesthesiologist.

"It really allows local facilities more flexibility in the provision of their anesthesiology services, particularly in the rural and underserved areas," said Paul Santoro, CRNA, president of the American Assn. of Nurse Anesthetists.

Some physician organizations have challenged the opt-outs.

In 2007, the Wisconsin Medical Examining Board concluded that nurse anesthetists were exempt from supervision if they are advanced practice nurses who can prescribe medication under state law. The decision came in response to a petition from the Wisconsin Society of Anesthesiologists opposing the exemption.

More recently, a California Superior Court judge ruled on Oct. 8 to allow nurse anesthetists to work independently, saying there is no state statute requiring supervision. The ruling came after a lawsuit filed against Gov. Arnold Schwarzenegger by the California Medical Assn. and the California Society of Anesthesiologists.

Colorado is the latest state to opt out of the Medicare provision and face a court challenge. On Sept. 28, the Colorado Medical Society and Colorado Society of Anesthesiologists sued Gov. Bill Ritter Jr. The case is pending.

The exemption is contrary to state law, as well as Colorado courts that have repeatedly found surgeons liable for operating room personnel, the lawsuit says. "It appears that Gov. Ritter's intent is to substitute nurses for physicians," said Randall Clark, MD, spokesman for the Colorado Society of Anesthesiologists.

But the Colorado Assn. of Nurse Anesthetists said the lawsuit has no merit. "The opt-out was consistent with state law and in the best interests of Colorado citizens," said Jennifer Harenberg, CRNA, the association's president, in a statement.

Ongoing debate

Physicians receive extensive training in medical school that equips them to deal with a variety of medical emergencies, said Jerry A. Cohen, MD, American Society of Anesthesiologists president-elect.

"While nurse anesthetists are well prepared to deliver the technical aspects of anesthesia, the unusual and more complex events that may arise during an operation require the depth of knowledge provided by a medical education and four to five years of residency before the years of experience that follow," he said.

But Santoro with the AANA said nurse anesthetists are part of a medical team, and work with the surgeon in emergencies. He cited an AANA-funded study in the August Health Affairs that analyzed surgery-related death rates and complications and found no difference in 14 states that had opted out of the Medicare provision. "This issue does not remove the surgeon from the care of the patient," he said.

However, another study in the journal Anesthesiology in July 2000 found that the presence of an anesthesiologist prevented more than six excess deaths per 1,000 cases in which an anesthesia or surgical complication occurred. That study was funded by the Agency for Healthcare Research and Quality.

In October, the Institute of Medicine released a report recommending state and federal governments to remove barriers and allow advanced-practice nurses to practice to the full extent of their training. However, the debate about what that training qualifies them for continues.

"We support nurses acting within their scope of practice, but we are concerned that when they become wholly independent of physician oversight, they are no longer functioning as nurses but are indeed acting as physicians without the necessary training to do so," Dr. Cohen said.