According to one interpretation, expressed by Richard Rawson, president and CEO of three small rural Adventist hospitals near Fresno, CA, CMS in December defined '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."
Several rural hospital CEOs interviewed say that's almost impossible for them to achieve.
Rawson says that to finance anesthesiology coverage to meet Medicare's rule would be expensive, at a cost of about $1 million a year on a $30 million to $40 million annual budget. "And that's if they could find anesthesiologists."
According to a survey last year by the California Healthcare Foundation, Kings County, where two of Rawson's hospitals are located, had only two anesthesiologists. That survey said that 22 of the state's 58 counties have five or fewer anesthesiologists. Kings also has a physician shortage, one doctor per 1,324 residents as opposed to the state average of one per 575.
The California Hospital Association supports the opt-out provision and opposes the CMA/CSA lawsuit. Without the provision, says CHA vice president Dorel Harms, many hospitals would be forced into a financial bind.
"They'd have to eliminate the [surgical] service or reduce their financial viability by not getting the Medicare reimbursement, when their margins are so minimal to begin with," Harms says. "It's a matter of money; it's not a matter of supervision."
According to industry surveys, in general, anesthesiologists make about $300,000 to $400,000 per year. Nurse anesthetists average $160,000.
Peggy Wheeler, CHA's vice president for rural healthcare, says that many of the state's 69 designated rural hospitals "really had some difficulties meeting the conditions of participation. They were all either meeting them or just choosing not to get reimbursement under Medicare . . . because it required that the surgeon or anesthesiologist be on site.
"Two-thirds of these rural hospitals use CRNAs almost exclusively," she says. "So a requirement to have physician services meant it would be difficult for them to offer surgical services."