The lawsuit filed by 40,000 California doctors last week to halt nurse anesthetists' newly obtained ability to administer anesthesia without physician supervision opened the floodgates of fury.
The vitriol was reflected in dozens of heated—and some quite nasty—comments beneath HealthLeaders Media's online story, and on the Wall Street Journal's Health Blog. There's a lot at stake in a scope of practice fight: Authority, responsibility, and billings for Medicare patients.
Physicians said nurse anesthetists aren't as well trained, and aren't as safe as anesthesiologists.
Nurse anesthetists retorted by calling doctors a lot of names, like "idiot," and said the doctors' litigation was merely an effort to protect their turf, and increase their bargaining power in contract negotiations with hospitals.
Blood pressure all around is clearly elevated.
Beneath the din, however, is the underlying crux of the issue: the impact of the physician shortage on rural hospitals, which struggle to find and contract with primary care or specialty doctors willing to work in their areas, and especially at contract rates the poorer, smaller hospitals can afford.
Let's dig into this. If it's a safety issue, as doctors suggest, then let's see the studies to prove it. So far, I've seen none.
Physician groups have long been conscious of the problems rural areas have in recruiting doctors, a challenge made more difficult in California, where hospitals are prohibited from hiring them directly. Perhaps the doctors should realize they can't have it both ways.
Physicians can't insist on one hand that they want to resolve the problem of rural physician shortages, and then try to block this rule in California. It seems like an effort to strengthen the need for their services in places where far too few of them want to practice.
In California, the conflict began with little publicity last year when Gov. Schwarzenegger sent federal officials a letter making California the 15th state to "opt out" of a Medicare rule that requires a physician to be "immediately available" to supervise a nurse anesthetist's administration of anesthesia to a Medicare patient. Without that opt-out, Medicare wouldn't pay if a hospital had no physician supervising the certified registered nurse anesthetist (CRNA).
Two large California physician groups last week petitioned San Francisco Superior Court to force the governor to withdraw the letter, citing procedural issues as well as patient safety concerns, if CRNAs are allowed to work unsupervised.
The groups involved in the petition are quite influential; they are the California Medical Association, which represents 35,000 of the state's 125,000 doctors, and the 4,000-member California Society of Anesthesiologists.
In the years before Schwarzenegger signed up for the opt out, small rural hospitals had managed to get around the rule because they could usually find a doctor—often the surgeon who came later—to sign off on supervision, regardless of whether he or she actually witnessed the nurse anesthetist's administration.
"Prior to the opt-out, the surgeon would basically sign a paper that met the requirement of the supervision," explains Richard Rawson, president and CEO of Adventist's Hanford Community Medical Center near Fresno and two other small hospitals in California's San Joaquin Valley.
"Surgeons really didn't really like to do it, because they weren't really anesthesiologists, but that's in essence how it happened across the state in most rural hospitals," he says.
Hospital officials and nurse anesthetists tell me that practice of signing off on something they didn't witness is what happens in many rural facilities in non-opt out states. Or else, as sometimes happens, the hospital or the nurse anesthetist don't bill Medicare for the services provided to that patient.
Rawson is quite worried about what might happen if the doctors are successful with their lawsuit. He says a new Medicare "clarification" that took effect in December tightens the stipulation that an anesthesiologist—not just any physician—would have to witness the CRNA's procedure and be "immediately available."
He forwarded a document from Adventist administrators, which says CMS is defining the phrase, " ‘immediately available' as it relates to supervision of certified registered nurse anesthetists or anesthesia assistant (AA) to mean the anesthesiologist is physically located within the same area as the CRNA or AA (e.g., in the same operative suite, same labor and delivery unit, or same procedure room); not otherwise occupied in a way that prevents the anesthesiologist from immediately conducting hands-on intervention, if needed."
Officials with the National Association of Nurse Anesthetists, say the Adventist interpretation of the CMS rule is incorrect, and that supervision from any physician would suffice.
But in any case, more intense coverage from anesthesiologists would cost each of his hospitals $1 million a year, and for two of them, that's 3% of their $30 million annual budget, he says. "If you need anesthesiologists, if you can find them, you have to pay whatever they cost—and those costs are spiraling out of control," he says.
It's impractical for a small rural hospital, such as his 64-bed Hanford Community Hospital, 57-bed Selma Community Hospital or 49-bed Central Valley General Hospital to pay for an anesthesiologist to be present long before a patient needs surgery, long before the surgeon arrives.
Bottom line, Rawson says: if the doctors get their way, two of his facilities would have to stop providing surgery, and the third would have to cut back surgery by nearly half. For the most part, that surgical volume is what keeps the hospital viable.
With the new interpretation, he says, Medicare "applies the standard to bread and butter cases where there's no benefit at all in having an anesthesiologist."
"If they win the lawsuit, we can't go back to the way it was," he says. The tighter restrictions, he says, "would be devastating."
Keep in mind that the 14 other opt-out states are largely rural: Alaska, Iowa, Idaho, Kansas, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Washington and Wisconsin. California is the first largely urban state to opt-out.
Mark Odden, a CRNA in Iowa, the first state to exercise the opt-out nearly 10 years ago, works with a company that provides nurse anesthetist services to 13 rural hospitals as far as 75 miles away from Manchester.
If Iowa didn't have the opt-out, Odden says, those hospitals "would have to hire anesthesiologists to travel to all those hospitals." Practically speaking, the patients are mostly older and on Medicare or are uninsured and they "would have to go elsewhere."
"We handle farming accidents or a drug overdose. And we're the first line people who are called," Odden says. "We can do the resuscitation and complications that come, and sometimes it's just me and a another nurse practitioner, taking care of a massively damaged patient while we wait for a helicopter."
Just recently, he says, nurse anesthetists helped saved a life of a teenager with asthma, who came in to a 29-bed hospital when there was no doctor around. The CRNA had to intubate the patient because he was so unstable. "We had to do ground transport to a hospital in bad weather, 70 miles away to the University of Iowa," Odden says.
Now, tensions among hospitals, doctors and nurse anesthetists are raw over this issue. But eventually, common sense and practicality must prevail. For many hospitals that already struggle to have trained, licensed professionals available to treat patients, removing the option that a CRNA can practice without physician oversight could be devastating both to the patients and to the facilities where they practice.
Physicians need to show proof of the cause of their disdain for the use of CRNAs. Perhaps they can point to some real evidence that patient safety is increased when they are there. If they can't, they should accept the probability that patient care can and should be—especially in rural areas—a shared, cooperative responsibility.
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