Currently, 15 states have fully opted out of the federal requirement for physician supervision of anesthesia, and one — Colorado — has opted out for specific hospitals. Mark Warner, MD, new president of the American Society of Anesthesiologists, discusses why states should not opt-out of the rule and what the ASA is doing to help address the provider shortage in rural areas.
1. Expansion of pain management practices by nurses could harm patients. According to Dr. Warner, some states which have opted out of the rule have seen a growth in nurses establishing pain management practices, a practice technically allowed but not intended by the opt-out option. "It's not really what the opt-out is all about because the opt-out is only related to anesthesia services," Dr. Warner says. "Pain medicine is really a medical practice, and nurses are not training in pain procedures."
Dr. Warner says nurses pursuing pain management practice may take weekend courses, a level of training he calls "insufficient." He says New Hampshire, South Dakota and Iowa, in particular, have seen boards of nursing taking the opt-out as "a license from the government to go ahead and expand the practice of nurses." He says some nurses are performing procedures — such as implanting equipment and catheters into the spine — that his physician colleagues at Mayo Clinic wouldn't do if they weren't trained in pain medicine.
Dr. Warner gives Iowa as an example, where nurses "perform dangerous pain procedures on the spine using a radiographic technique called fluoroscopy." He says the x-ray technique exposes patients to harmful radiation, and nurse training programs do not cover the use of fluoroscopy.
2. Anesthesiologists are finding it more difficult to work in critical access rural hospitals. In opt-out states, Dr. Warner says anesthesiologists are finding it increasingly difficult to work in rural, critical access hospitals. "There is a small loophole in federal payment rules that allows some very small hospitals to charge directly for full anesthesia costs if the care is delivered by nurses," he says. "There is no similar loophole payment for physicians, [meaning] a perverse financial incentive exists for these hospitals to discourage the upgraded and expanded care that anesthesiologists could bring to their rural areas." Because of the loophole, an administrator of a small, rural access hospital would be inclined to staff CRNAs because the hospital will make more money with nurses than with anesthesiologists. In effect, he says the loophole incentivizes small hospitals to discourage anesthesiologists from practicing at small facilities — thus limiting the number of anesthesia providers who are attracted to understaffed areas.
He says the loophole will eventually result in a two-tier system of healthcare. In small rural areas, anesthesia could be provided exclusively by CRNAs, while urban areas receive the benefits of anesthesiologists, especially "for those who are quite ill and need intensive care services."
3. Surgeons are no more likely to work in rural areas following a state opt-out. According to Dr. Warner, one of the major issues cited by nurses who support state opt-outs — and repeated by governors — is that the change will recruit more surgeons to rural, critical access hospitals. He says data and general experience suggests that rural areas are still hard-pressed to recruit surgeons, possibly because surgeons in rural areas prefer to work with physician colleagues. "The thought was that if the nurses were independent, the surgeons would not have to supervise them and wouldn't have the medical legal liability for an error made by a CRNA," he says. "But in opt-out states, surgeons are still being held responsible from a medical legal standpoint, so surgeons are still reluctant to go into these areas."
4. ASA would like the payment of full anesthesia costs for nurses applied to physician anesthesiologists. Dr. Warner says the American Society of Anesthesiologists is working in Washington, D.C., to apply to the loophole that allows payment in full of anesthesia costs to physician anesthesiologists as well as nurses. "It's not the fact that the loophole is bad, it's that it doesn't apply equally to anesthesia providers," he says. "We'd be able to get more anesthesiologists interested in working in rural areas." He says expanding the loophole would also benefit critically ill patients in rural areas, because those patients would not necessarily have to be transferred to a large, urban hospital for treatment. "There are a lot of patients who could be kept in [rural, critical access hospitals] if they had anesthesiologists who are trained in critical care," he says.
5. Opt-out provision has mostly not resulted in an increase of nurses to rural areas. With a few exceptions, Dr. Warner says the opt-out provision has not increased the number of nurses who move to rural areas to provide anesthesia. "These nurses want to be in metropolitan areas just like physicians," he says. "It's interesting because the opt-out has not accomplished anything it was supposed to do, and it has actually created an odd disincentive for physicians to move to rural areas." He says the shortage of anesthesia providers should clearly be addressed by the federal government — but based on recent data and general experience, the opt-out is not the answer.
Learn more about the American Society of Anesthesiologists.
1. Expansion of pain management practices by nurses could harm patients. According to Dr. Warner, some states which have opted out of the rule have seen a growth in nurses establishing pain management practices, a practice technically allowed but not intended by the opt-out option. "It's not really what the opt-out is all about because the opt-out is only related to anesthesia services," Dr. Warner says. "Pain medicine is really a medical practice, and nurses are not training in pain procedures."
Dr. Warner says nurses pursuing pain management practice may take weekend courses, a level of training he calls "insufficient." He says New Hampshire, South Dakota and Iowa, in particular, have seen boards of nursing taking the opt-out as "a license from the government to go ahead and expand the practice of nurses." He says some nurses are performing procedures — such as implanting equipment and catheters into the spine — that his physician colleagues at Mayo Clinic wouldn't do if they weren't trained in pain medicine.
Dr. Warner gives Iowa as an example, where nurses "perform dangerous pain procedures on the spine using a radiographic technique called fluoroscopy." He says the x-ray technique exposes patients to harmful radiation, and nurse training programs do not cover the use of fluoroscopy.
2. Anesthesiologists are finding it more difficult to work in critical access rural hospitals. In opt-out states, Dr. Warner says anesthesiologists are finding it increasingly difficult to work in rural, critical access hospitals. "There is a small loophole in federal payment rules that allows some very small hospitals to charge directly for full anesthesia costs if the care is delivered by nurses," he says. "There is no similar loophole payment for physicians, [meaning] a perverse financial incentive exists for these hospitals to discourage the upgraded and expanded care that anesthesiologists could bring to their rural areas." Because of the loophole, an administrator of a small, rural access hospital would be inclined to staff CRNAs because the hospital will make more money with nurses than with anesthesiologists. In effect, he says the loophole incentivizes small hospitals to discourage anesthesiologists from practicing at small facilities — thus limiting the number of anesthesia providers who are attracted to understaffed areas.
He says the loophole will eventually result in a two-tier system of healthcare. In small rural areas, anesthesia could be provided exclusively by CRNAs, while urban areas receive the benefits of anesthesiologists, especially "for those who are quite ill and need intensive care services."
3. Surgeons are no more likely to work in rural areas following a state opt-out. According to Dr. Warner, one of the major issues cited by nurses who support state opt-outs — and repeated by governors — is that the change will recruit more surgeons to rural, critical access hospitals. He says data and general experience suggests that rural areas are still hard-pressed to recruit surgeons, possibly because surgeons in rural areas prefer to work with physician colleagues. "The thought was that if the nurses were independent, the surgeons would not have to supervise them and wouldn't have the medical legal liability for an error made by a CRNA," he says. "But in opt-out states, surgeons are still being held responsible from a medical legal standpoint, so surgeons are still reluctant to go into these areas."
4. ASA would like the payment of full anesthesia costs for nurses applied to physician anesthesiologists. Dr. Warner says the American Society of Anesthesiologists is working in Washington, D.C., to apply to the loophole that allows payment in full of anesthesia costs to physician anesthesiologists as well as nurses. "It's not the fact that the loophole is bad, it's that it doesn't apply equally to anesthesia providers," he says. "We'd be able to get more anesthesiologists interested in working in rural areas." He says expanding the loophole would also benefit critically ill patients in rural areas, because those patients would not necessarily have to be transferred to a large, urban hospital for treatment. "There are a lot of patients who could be kept in [rural, critical access hospitals] if they had anesthesiologists who are trained in critical care," he says.
5. Opt-out provision has mostly not resulted in an increase of nurses to rural areas. With a few exceptions, Dr. Warner says the opt-out provision has not increased the number of nurses who move to rural areas to provide anesthesia. "These nurses want to be in metropolitan areas just like physicians," he says. "It's interesting because the opt-out has not accomplished anything it was supposed to do, and it has actually created an odd disincentive for physicians to move to rural areas." He says the shortage of anesthesia providers should clearly be addressed by the federal government — but based on recent data and general experience, the opt-out is not the answer.
Learn more about the American Society of Anesthesiologists.