CRNAs Are The Sole Anesthesia Provider In At Least 65% Of Rural Hospitals, Which Translates Into Anesthesia Services For Millions

In the administration of anesthesia, CRNAs perform virtually the same functions as physician anesthetists (anesthesiologists) and work in every setting in which anesthesia is delivered including hospital surgical suites and obstetrical delivery rooms, ambulatory surgical centers, health maintenance organizations' facilities, and the offices of dentists, podiatrists, ophthalmologists, and plastic surgeons. Today, CRNAs administer approximately 65% of the anesthetics given to patients each year in the United States. CRNAs are the sole anesthesia provider in at least 65% of rural hospitals which translates into anesthesia services for millions of rural Americans. CRNAs have been a part of every type of surgical team since the advent of anesthesia in the 1800s. Until the 1920s, anesthesia was almost exclusively administered by nurses. In addition, nurse anesthetists have been the principal anesthesia provider in combat areas in every war the United States has been engaged in since World War I. CRNAs provide anesthesia services in the medical facilities of the Department of Defense, the Public Health Service, the Indian Health Service, the Department of Veterans Affairs, and countless other public and private entities. The most substantial difference between CRNAs and anesthesiologists is that prior to anesthesia education, anesthesiologists receive medical education while CRNAs receive a nursing education. However, the anesthesia part of the education is very similar for both providers, and both professionals are educated to perform the same clinical anesthesia services. CRNAs and anesthesiologists are both educated to use the same anesthesia processes and techniques in the provision of anesthesia and related services. The practice of anesthesia is a recognized specialty within both the nursing and medical professions. Both CRNAs and anesthesiologists administer anesthesia for all types of surgical procedures, from the simplest to the most complex, either as single providers or in a "care team setting". There are currently 87 accredited nurse anesthesia education programs in the United States lasting between 24-36 months, depending upon the university. As of 1998, all programs offer a master's degree level for advance practice nurses, and these programs are accredited by the Council of Accreditation of Nurse Anesthesia Educational Programs which is recognized by the U.S. Department of Education. THE PROPOSED HCFA RULE PROMOTES COMPETITION AND ACCESS TO ANESTHESIA
As you know, HCFA issued a proposed rule in December, 1997 that would defer to state law on the issue of physician supervision of nurse anesthetists. Since that time, AANA has supported the rule change for the following reasons: 1. It would place the regulation of healthcare professionals where it belongs - at the state level. The proposed rule defers to state law on the issue of physician supervision of nurse anesthetists, advocating states' rights over federal government regulation in healthcare matters. We are mystified that the anesthesiologists would oppose CRNAs being regulated by the states. At the same time, if the anesthesiologists oppose the removal of a Part A requirement, would they support similar federal restrictions being imposed on anesthesiologists?  2. It promotes flexibility. The deferral to state law gives hospitals and ambulatory surgical centers greater flexibility in the use of anesthesia providers and improving operating room efficiency without affecting quality of care. The proposed rule is supported by the American Hospital Association and the Federation of American Health Systems.  3. It may help to remedy ongoing cases where anesthesiologists deny care. The proposed rule would ensure patient access to safe, high-quality anesthesia care, particularly in rural and inner-city hospitals. This is particularly critical given what has transpired in rural and underserved areas. In Los Angeles, an anesthesiologist refused to provide an epidural to a Medicaid patient in labor unless she could provide a cash payment. The indigent patient could not pay cash and was forced to undergo a delivery without anesthesia. In 1998, a story in the Los Angeles Times reported the case of Mrs. Ozzie Chavez who was told she would have to pay $400 cash in order to get an epideral during her labor. Though she was on MediCal, she offered to pay with a credit card or check but was denied and had to endure a painful delivery because the anesthesiologist demanded cash. According to the news story, this anesthesiologist had denied epidurals to a number of Medicaid patients as well. Interestingly, in the April 2000 issue of the American Society of Anesthesiologists Newsletter, Christine A. Doyle, M.D. writes that "the 'Northridge labor epidural incident' here in California was brilliantly converted by the California Society of Anesthesiologists (CSA) from an apparent disaster into a vehicle for achieving the first increase in Medi-Cal (Medicaid) reimbursement for obstetrical anesthesia in over 10 years." So much for compassion; instead the theme for anesthesiologists seems to be "show me the money." In Utah, it was reported in the Salt Lake Tribune (July 2, 1998) that Kelly DeFeo, a CRNA, volunteered to provide help for children at a school-based clinic in Ogden but was denied the ability to do so since McKay-Dee Hospital - the hospital which apparently cooperated with the clinic refused to allow her privileges. She was barred from volunteering because the hospital policy required anesthesiologist supervision. At least at that time, no anesthesiologist volunteered to provide the services nor was the policy changed so that the CRNA could provide the anesthesia. A few years ago in Montana and Wyoming, anesthesiologists refused to allow nurse anesthetists to provide epidurals even though it is within the scope of practice of CRNAs to do so. This denied numerous women epidurals themselves because there were apparently not enough anesthesiologists who were willing to provide the service. The result was that many women were being denied access to epidurals. (Great Falls Tribune, "Epidurals still not available," by Carol Bradley, September 3, 1995; Casper Star Tribune, "Nursing ethics group says epidural access at WMC depends on knowing 'right person'", by Tom Morton, 1993; Denver Post, "Montana women seek deliverance", by Carol Bradley, July, 1995). As these cases demonstrate, it is critically important to ensure access to anesthesia, particularly when anesthesiologists are either unavailable or unwilling to provide certain services in rural or underserved urban areas. 4. The rule addresses liability concerns. It eliminates the misperception some surgeons have that they are liable for the actions of CRNAs due to the federal supervision requirement. We have had many reports from CRNAs around the country about anesthesiologists who have dissuaded surgeons from working with CRNAs or hospitals from employing CRNAs inferring that somehow they are automatically liable for the actions of the CRNA by virtue of the supervision requirement. This assessment, of course, is not legally correct as the surgeon or other physician may rely upon either the CRNA or the anesthesiologist for the anesthesia portion of the case, unless the surgeon or other physician decides to become involved in the delivery of anesthesia. This perception of liability has been artfully used by some anesthesiologists to evict nurse anesthetists from their positions.