Further review of the Bush administration's delay of and proposed changes to an important bipartisan Medicare anesthesia care rule reveals that the administration's action ``hurts patients, hospitals, and healthcare,'' charged Larry G. Hornsby, a Certified Registered Nurse Anesthetist (CRNA) and president of the 28,000-member American Association of Nurse Anesthetists (AANA).
``We have now closely examined this delay and the administration's proposed changes,'' said Hornsby. ``Our initial reaction was that this was a terrible decision, but we decided to give sufficient thought to consider its ramifications. We have found that our initial reaction was right on target -- this is an awful decision: for patients, for healthcare facilities and professionals, and for state governments. For our patients' sakes, we're urging President Bush to reverse course.''
On May 18, Health and Human Services (HHS) published a notice in the Federal Register delaying for 180 days the Medicare anesthesia final rule that would have removed the federal physician supervision requirement for nurse anesthetists and deferred to the states on the issue. The final rule was just days away from being implemented.
In addition to the delay, HHS has been directed by the White House to consider the following: first, allowing state governors to apply to HHS to waive the physician supervision requirement in their individual states, an unfair burden to place on these elected officials; and second, conducting a study of CRNA practices.
As part of the decision that led to publication of the final rule in the January 18, 2001 Federal Register, the Health Care Financing Administration (HCFA) considered conducting a study on anesthesia care provided by CRNAs with and without physician supervision. HCFA concluded in the final rule that a study would not be feasible or wise. In addition, HCFA noted: ``Our decision to change the Federal requirement for supervision of CRNAs applicable in all situations is, in part, the result of our review of the scientific literature which shows no overarching need for a Federal regulation mandating any model of anesthesia practice, or limiting the practice of any licensed professional.''
``HCFA's final rule was supported by hospitals, nurses, physicians, healthcare advocates, rural health advocates, and Republicans, Democrats and Independents in Congress and in America's statehouses,'' said Hornsby. ``It was approved by HCFA, HHS and the Office of Management and Budget, based on the facts, after seven years of consideration. Neither the president's last-minute delay nor the proposed changes are justified, as the final rule attests.''
Decision Purely Political
Even though public opinion surveys name nurses as one of America's most widely respected professions in healthcare or any other field, ``What appears to be driving the White House actions is politics, pure and simple,'' said Hornsby. ``It certainly is not the quality of care provided by CRNAs, given our 100-year history of safety, especially when compared with other providers.'' Hornsby ticked off the following facts:
-- HCFA wrote in its January 18 final rule that "There is no indication that physician supervision of a CRNA affects patient outcomes";
-- Nurse anesthetists provide two thirds of all U.S. anesthetics;
-- The Institute of Medicine reports that anesthesia is nearly 50 times safer than 20 years ago;
-- Nurse anesthetists meet the most stringent continuing education and recertification requirements in anesthesia care, requirements that physician anesthesiologists lack entirely; and
-- The U.S. government's National Practitioner Data Bank reports an astonishing 576 percent more anesthesia malpractice claims against doctors than against nurses.
``We recognize that organized medicine's long-running campaign to defame nurse anesthetists has secured the delay of the Medicare anesthesia final rule,'' said Hornsby. ``But here's what the doctors' self-serving efforts will cost the American public: Many hospitals will close. When this delay costs one patient access to important healthcare services, it will be one hurt patient too many.''
The May 18 proposed changes are schizophrenic in concept and application. On the one hand they would allow states to determine supervision requirements and on the other hand they would give the federal government the final say through the HHS secretary. A close examination of the proposal's specifics reveals that it harmfully politicizes healthcare decisions.
``Our position all along has been that states should decide the scope of practice of healthcare professionals through their state laws, regulations and professional boards of licensure,'' said Hornsby. ``To some degree, the rule that HHS is being told to consider supports this position and flies in the face of the anesthesiologists' efforts to eliminate any possibility of nurse anesthetists working without physician supervision.
``However, these systems come with checks and balances and accountability that would be upended and politicized by the White House's proposal to give governors decision-making authority, but with the condition that their decisions could still be overruled by a federal agency,'' he added.
Citing hospitals' support for the original final rule deferring to states on anesthesia care regulation, Hornsby said, ``Attaching a flighty gubernatorial waiver option to a Medicare reimbursement regulation imposes enormous uncertainty and risk on hospital staffing, financial, and patient care decisions.''
Study Would Discriminate Against Nurse Anesthetists
Hornsby also criticized the Bush-proposed anesthesia-care study because it appears it would examine ``CRNA practices'' only and not the practices of anesthesiologists.
``Why favor one qualified licensed healthcare professional group over another? In suggesting further 'study' of CRNA practices, perhaps HHS should also study anesthesiologists to determine the extent of Medicare fraud in 'medical direction' cases,'' said Hornsby. ``Perhaps an inquiry should be made as to why many anesthesiologists are not board certified or why they are not required by their profession to meet the continuing education and recertification requirements demanded of and met by nurse anesthetists.''
Noting that the Bush administration's delay and proposed changes address political issues and not patient safety, Hornsby said, ``We believe the administration was duped by the anesthesiologists into taking the irresponsible action of overturning a lawful and safe final rule. We urge the administration to reverse course, reject the approach to a proposed rule that jeopardizes patient access to critical healthcare services and discriminates against nurse anesthetists, and permit the Medicare anesthesia final rule to take effect.''
About the American Association of Nurse Anesthetists
Founded in 1931 and located in Park Ridge, Ill., AANA is the professional organization for approximately 28,000 Certified Registered Nurse Anesthetists (CRNAs). As advanced practice nurses, CRNAs administer 65 percent of the 26 million anesthetics delivered in the United States each year. CRNAs practice in every setting where anesthesia is available and are the sole anesthesia providers in more than two thirds of all rural hospitals.