Medicare/Medicaid Agency's Proposal Places Patients at Risk

MEDICARE/MEDICAID AGENCY'S PROPOSAL PLACES PATIENTS AT RISK

FOR IMMEDIATE RELEASE

CONTACT:
Denise M. Jones
Philip S. Weintraub
(847) 825-5586
[email protected]

In a move that may seriously endanger the anesthesia care of millions of Americans under Medicare or Medicaid, the U.S. Department of Health and Human Services Health Care Financing Administration (HCFA) is proposing to do away with a 3-decade-old regulation for physician oversight of anesthesia care for surgery. If this regulatory change is enacted, nurses with as little as two years' technical training will be allowed to practice without any physician supervision when giving anesthesia to a Medicare or Medicaid patient in a hospital or ambulatory care center.

Currently the HCFA regulations state that nurse anesthetists can give anesthesia "under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed." That requirement would be eliminated by HCFA in favor of the various states' regulations -- only about half of which clearly require physician supervision.

"Patients, including those who receive health insurance benefits from Medicare and Medicaid, are entitled to the safest possible medical care," according to William D. Owens, M.D., an anesthesiologist in St. Louis, Mo., and president of the American Society of Anesthesiologists. "This proposed change would allow lesser-trained nurses to be independent providers of anesthesia for the more than 38 million American seniors plus the disabled and the nation's poor."

While optimal anesthesia care involves a one-to-one relationship between anesthesiologist and patient, there are situations that necessitate nonphysician personnel to perform technical functions under the direction of an anesthesiologist or other qualified physician. "Certain aspects of anesthesia care may be delegated to other properly trained nonphysician personnel. These nonphysicians with the anesthesiologists who medically direct them compose the anesthesia care team," Dr. Owens said.

This proposal represents an about-face for HCFA. HCFA's support of physician supervision of nurse anesthetists has been in effect since 1966. As recently as 1992, HCFA reaffirmed its position stating, "In consideration of the risks associated with anesthesia procedures, we believe it would not be appropriate to allow anesthesia administration by a nonphysician anesthetist unless under supervision by either an anesthesiologist or the operating practitioner."

No clinical study has been published suggesting it is now safe, or safer than in 1992, to eliminate the requirement of physician supervision. To the contrary, a recent outcome study of 6,000 Medicare patients undergoing two common surgical procedures found that patient outcomes were substantially improved in hospitals with Board-certified anesthesiologists on staff. Furthermore, a 1996 review of the literature, undertaken at the initiative of the Minnesota legislature, concluded that the increase in the number of physicians engaged in the practice of anesthesiology is primarily responsible for the dramatic improvement in patient safety over the past two decades.

Nurse anesthetists are trained to assist anesthesiologists and other physicians in the delivery of anesthesia care. Their level of training typically includes a two-year training program after they have become registered nurses. Anesthesiologists are doctors who go through four years of medical school and up to four or five years of an in-hospital internship, residency and specialist training in the medical specialty of anesthesiology. "Nurses do not have, nor should they be expected to have, the level of education or training necessary to medically assess patients before, during or following surgery. More than one-third of nurse anesthetists don't even have a bachelor's degree," Dr. Owens said.

Regulatory changes are often driven by the need to contain or cut back spending in government-funded programs. But that is not true in this case. Under existing Medicare rules, there is no difference in cost to the patient or the program whether a patient receives anesthesia care from a medically supervised or an unsupervised nurse anesthetist, and the same is true under many state Medicaid programs. Furthermore, anesthesiologists' medical services actually represent a cost savings over nurse anesthetists because they can provide more complete medical care without additional physician consultations being necessary.

An article in The New England Journal of Medicine, published Oct. 16, 1997, notes that when anesthesiologists direct the assessment and preparation of patients for surgery, requests for additional and costly presurgical consultations are reduced by three-quarters. In addition, cancellations of surgeries due to unresolved medical or laboratory problems are reduced by 88 percent, and the costs of laboratory tests are cut by 59 percent with anesthesiologists' involvement. "Anesthesiologists don't add to the cost of health care. They are an added value to health care," Dr. Owens said.

"Our nation's seniors, who comprise the largest group of Medicare and Medicaid recipients, are often the most medically compromised patients undergoing the riskiest surgical procedures. Their medical care should not be placed exclusively in the hands of a nurse," he said.

"Seniors have the power to stop this irresponsible federal proposal in its tracks," Dr. Owens continued. "The government is required to consider all public comments on the proposal received by February 17, 1998. Comments can be mailed to HCFA at P.O. Box 7517, Baltimore, MD 21207-0517."

# # #

Founded in 1905, the American Society of Anesthesiologists is a scientific and educational association of anesthesiologists that was organized to advance the practice of anesthesiology and to improve the quality of care of the anesthetized patient. It is the largest organization of anesthesiologists in the world with more than 34,000 members.

Facts on the Practice of Anesthesiology