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Nurse Anesthetists' Scope of Practice Challenged Again in CA

 |  By cclark@healthleadersmedia.com  
   February 03, 2011

California physicians are appealing the latest court decision that upheld the right for nurse anesthetists to administer anesthesia without physician supervision, an issue that has pitted nurses and doctors against each other in a nationwide turf battle. 

Under Medicare rules, state governors can opt out of federal requirements that a physician must supervise nurse anesthetists when they insert anesthesia drugs in federally reimbursed patients. Former Gov. Arnold Schwarzenegger exercised that option in June of 2009, one of 16 governors to waive the rule to date.

The governor did so on the basis that in many rural and underserved areas of California, physicians are too busy, unavailable, too expensive, or too far away to perform or supervise the procedure, especially during patient emergencies, leaving some hospitals no option to send their patients elsewhere.

Additionally, there has been no official study suggesting that nurse anesthetists' administration of anesthesia without supervision has caused harm.

But the California Medical Association and the California Society of Anesthesiologists disagreed and challenged Schwarzenegger's decision on Feb. 2 last year.

Late last year, however, a San Francisco Superior Court refused to block the governor's decision, and nurse anesthetists were free to proceed with independence.

Now the CMA and CSA are fighting back with an appeal of the court's refusal, and say they will take it to the California Supreme Court if necessary.

"Nurse anesthetists can be helpful and they are very helpful and they can administer anesthesia," says Long Do, attorney representing the two physicians groups. "But they're not trained and not capable of reacting to any number of problems that can come up when patients are given anesthesia.

"I'm not a medical doctor, and I can't tell you what could go wrong, but a number of complications could arise because of a reaction to whatever drug that could be administered, or something related to the surgery itself. Whatever it was, a trained physician, however, would be capable of reacting to that and making sure the patient received good care."

Do says that the physicians' issue is that California law does not allow that scope of practice liberty for nurse anesthetists. That's simply a legal distinction, and not one up for interpretation by the governor, or either the Medical Board of California or the California Board of Registered Nursing, neither of which has weighed in on the issue.

California is one of 16 states that allow nurse anesthetists to practice without physician supervision, nearly all of them largely rural. They are Alaska, Iowa, Idaho, Kansas, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Washington and Wisconsin. Last year, Colorado became the 16th. New Jersey would have been the 17th, after the governor of that state also opted out, but that decision was blocked by the New Jersey legislature.

But Do says that in many of those states, there are strict limits on what types of procedures are okay for nurse anesthetists to administer anesthesia drugs without physician supervision.

"We certainly haven't seen evidence or statistics that in states where this rule was lifted that there are severe consequences," Do acknowledges.  

"But I believe that in those states, a lot of what's going on is more routine surgeries or routine procedures where nurses are administering anesthesia. There's a lot of that going on in California as well, but it's the fact that there's no limit and no restriction that would govern or guide how surgeries are to be performed in California. In any kind of surgery there does not have to be a physician, even in any kind of surgery – even for open heart surgery."

California is the first largely urban state to opt-out of the Medicare requirement.

Last year, several representatives accused the CMA and the anesthesiologists of simply being protective of their revenue stream, and for being paternalistic about the practice of medicine.

Phil Recht of Mayer Brown LLP, attorney for the California Association of Nurse Anesthetists, said in an interview Wednesday that the San Francisco judge's decision "made a point of saying that (the physicians) presented no evidence whatsoever to demonstrate any safety problems, nor did they rebut CANA's claims that there were no safety problems. There have been no safety related incidents in any opt-out state since opt-outs were first initiated years ago. And in our view, this is just a red herring argument."

Recht added that the physicians' challenge is "anti-consumer," and one that has become "a national story."
In that context, he said, physician groups in other states that are fighting nurse anesthetists' ability to administer anesthesia without physician supervision are "struggling to hold on to the anachronistic ways of the past." The fact that there is a physician shortage, and a growing need for patients to access healthcare services, means that "expanding the role of nurses is a logical option and progression for our healthcare system."

In January, after the October San Francisco Superior Court decision was issued in writing, it released this statement hailing that opinion:

"(This) ruling goes a long way toward ensuring that our patients have access to the safest, most cost-effective delivery of anesthesia available," said Elizabeth Wong, CANA President and a practicing California Registered Nurse Anesthetist. "This decision ensures that hospitals in underserved and economically disadvantaged areas will have the flexibility they need to remain viable."

She added that safety "has not been an issue for the 16 states that have the opt-out in place. There has not been a single reported quality of care incident in those states since the rule was first adopted 10 years ago in 2001. Further, a recent highly publicized study conducted by the Lewin Group, an independent national healthcare consulting firm, confirmed that CRNAs offer a quality, safe, and cost-effective alternative to physician specialists."

James Hindale MD, president of CMA, said, "Nurses can be an integral part of a medical tem if they work hand in hand and under the guidance of physicians, as they have for many decades.

"But nurses are not trained to react to the myriad potential complications that can arise in the administration of anesthesia. Patients place thorough trust in their physicians when they must undergo surgery. Requiring physician supervision is one important element of ensuring the best quality of care."

The California Medical Association represents more than 35,000 physicians, while the California Society of Anesthesiologists represents about 4,000 physician anesthesiologists.

 
See Also:

CA Court Rejects Nurse Anesthetists Supervision Petition

Doctors Sue to Stop Nurse Anesthetists from Administering Anesthesia

Nurse Anesthetists Say They Practice Safely Without Physician Supervision

Nurse Anesthetists Battle Overlooks Rural Doctor Shortage

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