Congress To Legislatively Mandate Yet Another Study, Which Could Cost More Than $15 Million, Is Simply A Tactic To Delay HCFA

On March 9, 2000, HCFA informed the American Association of Nurse Anesthetists (AANA) and the American Society of Anesthesiologists (ASA) that it intends to move forward with its proposal to remove the federal requirement that nurse anesthetists must be supervised by physicians. It is expected that HCFA will publish this rule sometime this summer. Clearly the Secretary determined that the voluminous available data was sufficient for her to make her decision.

Regardless of all the available evidence, ASA first began pressing Congress in 1998 for another national anesthesia outcomes study. It is interesting that they were comfortable with the amount of data available in 1994, when the draft proposed rule was first circulated, as they expressed no concerns at that time. It has only been since 1998, once the publication of a final rule appeared to be a possibility, that their concerns about lacking data emerged. AANA has consistently opposed a mandated national study for the following reasons:

1. No previous study has shown a significant difference in the quality of anesthesia care provided by nurse anesthetists and anesthesiologists. Various studies have been done over the years and AANA has compiled a synopsis summarizing the studies - all of which indicate that there is no difference in outcomes. We do not need yet another study to show us what we already know-that CRNAs provide high quality care that promotes access to health services.

2. In 1990, the Centers for Disease Control examined anesthesia outcomes and concluded that morbidity and mortality rates in anesthesia were too low to warrant a multi-million dollar national study.

3. In 1994, a legislatively mandated study by the Minnesota Department of Health determined there are no studies that conclusively show a difference in patient outcomes by type of anesthesia provider.

4. The ASA's appeal to Congress to legislatively mandate yet another study, which could cost more than $15 million, is simply a tactic to delay HCFA from implementing its proposal to remove supervision. The anesthesiologists have had ample time to perform a study but it was not until HCFA proposed this rule that they suggested any study was necessary. In fact, the anesthesiologists have always heretofore touted the safety of anesthesia, but only now suggest the dangers of anesthesia in order to reinforce their political message.

5. There is no way to objectively study nurse anesthesia outcomes while the supervision requirement is still in place. And we believe this is well known by the ASA. Quite simply, if any study were to be performed under the current regulatory scenario, and it were shown that CRNAs were safe anesthesia providers, the anesthesiologists would simply argue that it was due to supervision, thereby creating an obvious "Catch 22."

The anesthesiologists have frequently changed their tune about this regulation. As for the HCFA rule, Congress should listen to what the ASA had said earlier in this battle:

"ASA believes issues relating to treatment of Medicare patients, including anesthesia care, are best dealt with in the context of thoughtful dialogue among the affected parties, and ultimately through the reliance on rule-making process by HCFA, the agency charged by law with the responsibility." (Letter to Congress, May 23, 1995)
They clearly believed that HCFA should be responsible, not Congress, for making this regulatory decision. They reiterated this position a second time in their own Newsletter:

"…[the issue] belongs there (with HCFA) and not in Congress." (ASA Newsletter, November 1995, Vol. 59, No. 11, p. 5)
Nevertheless, when HCFA appropriately used the regulatory rule-making process as ASA suggested, and decided to propose a deferral to state law on the issue of physician supervision of nurse anesthetists, ASA quickly changed its mind and ran straight to Congress to get it reversed.

Even the ASA's own website and their lobbying materials argued in favor of state regulation. Their materials stated in part:

"ASA believes that the qualifications of members of a particular class of health professionals may vary significantly from state to state and that state legislatures and licensing bodies are in the best position to determine the appropriate scope of practice in their jurisdictions."