States Opting out of Physician Monitored practice

  1. So have all of you been keeping up on the CRNA supervision issue? What are your thoughts.

    Personally I am excited to be joining the field at this time. Two states have excersized their right to pursue non-physician monitored practice for CRNA's. The states are Iowa and Nebraska. I can see this happening in much more needy states in the near future.

    I am happy about this, but the Anesthesiologists I work with are not very thrilled.

    Cruise on over to to read some of the press releases. There are some interesting figures in the Nebraska release, such as

    According to a news release disseminated to Nebraska media by the governor's office, approximately 69 of the state's 85 acute care hospitals rely solely on nurse anesthetists to provide safe anesthesia care to patients.

    As always, Nebraska's CRNAs will work closely with surgeons, obstetricians, and other doctors in the delivery of safe, high-quality patient care. In 1999, the Institute of Medicine published a report stating that anesthesia care today is nearly 50 times safer than it was 20 years ago. CMS echoed that statement in the Federal Register last January. CRNAs provide 65 percent of all anesthesia care delivered each year in the United States.
    And finally

    The first state to opt out of the supervision requirement was Iowa, which made the move in December 2001. In that state, 91 of 118 hospitals rely solely on nurse anesthetists to provide anesthesia care.
    Nows is definately the time to become a CRNA.


    BTW all of this is in the application stage. But it looks like it will pass regardless of what the ASA (american Society of Anesthesiologists has to say.
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    About nilepoc

    Joined: Aug '01; Posts: 660; Likes: 148


  3. by   meandragonbrett
    Personally I think it's great. It gives the CRNAs who are wanting more autonomy what they want. Hopefull more states will start allowing the CRNAs to be unsupervied during medicare(?) caid(?) cases. I think that this will help to expand the role and the profession of CRNAs everywhere. just my .02cents worth

  4. by   lgcv
    The issue of supervision at the federal level (CMS previously HCFA) concerns only reimbursement under part B of Medicare to hospitals. So the hospital is not reimbursed for the medicare pt. who receives anesthesia services from a non-supervised CRNA in states that have not opted out. Many states do not have a supervision requirement see AANA web site.
    The ASA has used this requirement to scare surgeons into believing that they will be held liable for the actions of a nurse anesthetist if something goes wrong. This is the reason their has been a push by the AANA to remove this ruling. It really has very little effect on the practice of most CRNAs.
  5. by   nilepoc
    Idaho just opted out three days ago. This seems to be a trend.

    details at

  6. by   lgcv
    Gov. Jesse Ventura Removes Physician Supervision
    for Nurse Anesthetists

    Park Ridge, Ill. - Gov. Jesse Ventura has informed the Centers for Medicare & Medicaid Services (CMS) that Minnesota is opting out of the federal physician supervision requirement for nurse anesthetists because it is in the best interest of citizens. The opt out is effective immediately.

    Minnesota is the fourth state after Iowa, Nebraska, and Idaho, to opt out from the federal requirement, as permitted in a November 13, 2001 rule published in the Federal Register [66 FR 56762-56769]. The rule allows a governor to notify CMS in writing of a state's desire to opt out (be exempt from) the supervision requirement after the governor meets the following prerequisites: consults with the state's boards of medicine and nursing, determines that opting out of the requirement is consistent with the state law, and decides that it is in the best interest of the state's citizens.

    In his letter to CMS, Gov. Ventura added that his office consulted with the medical and nursing boards, the attorney general and various other interested parties regarding this matter and concluded that the exemption is consistent with Minnesota state law.

    "Opting out of the supervision requirement will truly benefit the citizens of Minnesota," said Lisa Citak, president of the Minnesota Association of Nurse Anesthetists. "CRNAs have long provided safe anesthesia care to patients of all ages , for all types of procedures, and in every setting in which anesthesia care is delivered. MANA applauds Gov. Ventura for recognizing this and for taking action."

    MANA has long been an advocate of patient rights. In February of this year, MANA appealed and won the reversal of a lower court's decision, and is now able to proceed with a $1 billion Medicare fraud lawsuit. Citak said that MANA's case will result in long-overdue changes for patients. She said that, until now, anesthesia billing has been an invisible service in hospitals, driven by the billing practices of anesthesiologists rather than what works best for patients and payors. MANA's lawsuit will throw light on the billing practices for anesthesia services.

  7. by   stevierae
    I am an operating room nurse; have worked all over the country for over 25 years. Don't want to ruffle any feathers; I have worked with some awesome CRNAs, and have also worked with some anesthesiologists "supervising" them who could not even start an IV, let alone intubate. I chose a CRNA for my last surgery and for my child's surgery. But, I knew there was also an awesome anesthesiologist assigned to that CRNA to supervise.

    Howvever, I have also been in situations where something went totally, unexplainedly wrong: a tension pneumothorax caused by a CRNA knocking a bleb off while intubating with a double lumen tube in preparation for a scheduled thoracotomy; as the patient went into PEA, and developed massive subcutaneous emphysema, the CRNA literally froze, never having seen this before, and uncertain as to how to proceed.

    Luckily, there WAS an anesthesiologist who was supervising (though not in the room) when he came in, he just looked, said calmly, "Looks like a tension pneumo. Here, gimme an 18 g IV catheter." He then stuck the IV catheter in an intercostal space and released some of the air, while we got a chest tube and a pleurevac, and the patient returned to NSR once that was done.

    Now, that could have happened to anyone; it could have happened to the anesthesiologist. But, what if the anesthesiologist hadn't recognized the situation for what it was? If the CRNA HAD been functioning as an independent practitioner that day, who would have come to his aid? He would have been SOL. Even the thoracic surgeon did not recognize what was going on, at least not immediately, so how do you know another CRNA would have?

    Another time, right after we started a thoracotomy and gained exposure, the thoracic surgeon said, "Let down the left lung." The CRNA said, "I've never been taught how to do that." Again, lucky there was an anesthesiologist who came and bailed him out.

    Yet another time, different hospital, thoracotomy: Surgeon: "Let down the lung." CRNA: "You're kidding, right? For that I would need a double lumen tube." Surgeon: "You mean, you didn't put in a double lumen tube?!" CRNA: "Well, you didn't ask for one..."

    I promise you I am not making these stories up. I have been in hospitals where the anesthesiologists said words to this effect: "So, they want to function as independent practitioners, do they? Well, don't count on ME to bail any one of them out when they get into trouble..." so the poor circulator is left alone to deal with what might be a dangerous patient care situation.

    Now, don't flame me!!! Like I said, there are some awesome CRNAs out there. I also understand the need for autonomy; I get tired of being micromanaged in the OR, instead of being left to run my own room as I see fit, which is, after all, what a good circulator (and her scrub, and the rest of the team) is SUPPOSED to do; or being told by managers who don't scrub how I am supposed to set up my back table and mayo stand. I just don't see whay a CRNA would want to be put into a situation where no help is forthcoming, should there be an emergency.
    Last edit by stevierae on Apr 25, '02
  8. by   kmchugh
    This is not really a new issue. Generally, you'll find CRNA's practicing independently in the rural hospitals, where MDA's don't want to go. The "supervision" issue, as I see it is less about patient safety and more about another untapped financial resource for MDA's. There have actually be propositions to have MDA's "distance supervise" CRNA only practices. This neatly alleviates the problem of having to move somewhere you don't want to live while allowing you the option to get some of the "take" from the rural practices. I think if you look, many of the states that have already opted out are states with large rural areas and populations. The have to opt out, so that the rural hospitals can continue to operate.

    Stevierae makes some good points, but they have less to do with the educational path taken by the anesthesia provider, and more to do with the experience of the provider. I know several CRNA's who are very good at what they do, and can practice independently. All could easily handle the situations described by Stevierae. By the same token, I know MDA's fresh out of residency who would have frozen in much the same way as he described the CRNA reacting. Until you have done it (not just been there as the OR nurse) you have no idea how frightening anesthesia can be. As a new practitioner, there is NO WAY I would want to try independent practice, though I have been offered such jobs. But who's to say how I'll feel in five years, or ten?

    One other point, the MDA supervision issue is ONLY a medicare issue. Private insurers can and do pay direct to CRNA's who are practicing independently.

    Kevin McHugh
  9. by   nilepoc
    I agree with Kevin, I can see the point of both sides of the arguement, but I think it is basically an issue of money and billing.

    Why I am happy to see the supervision inssue around is to see that it is nice that Anesthetists are being accepted in some states as valued practitioners of medicine. By being allowed independant practice, you are not removing the support system that exists in every OR I have been in. No matter the credential of the practitioner, I have seen them helping each other. I very rarely have seen only one anesthesia provider in the room for an induction. Maybe this observation is specific to my area, but I am pretty sure that it is not. Kevin correct me if I am wrong.
  10. by   stevierae
    You have never seen just a single anesthesia provider in the room during induction? When I have worked in private practice hospitals, rural hospitals, and California Kaiser hospitals, that seemed to be the norm. Only if a CRNA specifically requested help (maybe, during the pre-op interview, he found out the patient had had a multi-level C-spine fusion, or had sleep apnea or was obese, so he anticipated a difficult induction,) either from another CRNA or an anesthesiologist, BEFORE bringing the patient in the room, AND there happened to be someone available (that is, not tied up in his own room, or in L&D, or in the ICU) would he ordinarily get someone. That is my experience in places where CRNAs have become independent practioners. They had their own rooms; the anesthesiologists had their own rooms. And, like I mentioned, some of those anesthesiologists could get really passive-aggressive about providing help to those CRNAs who got into trouble, when they were opposed to their independent practioner status in the first place, for whatever reason. You are correct; some of those anesthesiologists were upset about losing the hefty fee they would have earned--no, earned is perhaps not the right word; COLLECTED is more accurate-- for just "being there" and not doing any of the real work. Some anesthesiologists are very greedy; so what else is new? The point I am making is--I just don't understand why a CRNA would be willing to work for LESS money than anesthesiologists, especially knowing that, if an UNANTICIPATED emergency arises during induction, there just might not be anyone willing or available to come to their aid. Aren't anesthesia departments experiencing the same low staffing levels and cutbacks as the OR nurses are, even with safe staffing laws in place?
    Last edit by stevierae on Apr 26, '02
  11. by   lgcv
    New Hampshire Becomes Fifth State to Opt Out of Federal Anesthesia Requirement

    Governor cites quality care, rural access as reasons
    for removing supervision requirement

    Park Ridge, Ill. - Stating that failure to remove the federal physician supervision requirement for nurse anesthetists "may severely limit the ability of rural hospitals to treat emergencies and provide other services that require anesthesia care," New Hampshire Governor Jeanne Shaheen today informed the Centers for Medicare & Medicaid Services (CMS) that her state was opting out of the federal requirement. The opt-out is effective immediately.

    New Hampshire becomes the fifth state to remove the federal physician supervision requirement since CMS published its anesthesia care rule granting states the ability to seek such an opt-out.

    The CMS rule, published in the Federal Register [66 FR 56762-56769] on November 13, 2001, allows a governor to notify CMS in writing of the state's desire to be exempt from the supervision requirement for nurse anesthetists after the governor meets the following prerequisites: consults with the state's boards of medicine and nursing, determines that opting out of the requirement is consistent with state law, and decides that it is in the best interests of the state's citizens.

    In her letter to CMS, Shaheen stated that "after consulting with the state Boards of Nursing and Medicine on issues of patient safety and access to anesthesia services in our rural communities, I have determined that exercising this exemption is in the best interest of New Hampshire citizens." The governor added that it has been the public policy of her state since 1991 to permit Certified Registered Nurse Anesthetists (CRNAs) to practice independently of physician supervision.

    "After careful review and consultation with New Hampshire citizens, practicing health professionals, and administrators of hospitals, I am confident that exemption from this federal Medicare regulation will provide significant long-term benefits to the citizens of New Hampshire," Shaheen wrote to CMS.

    In addition to her concerns about ensuring access to care in rural hospitals--concerns that were legitimized by input from medical staff and administrators of numerous rural facilities throughout New Hampshire--Shaheen cited two other reasons for seeking the opt-out.

    Shaheen informed CMS that the numerous surgeons and other physicians she consulted who work closely with CRNAs in New Hampshire's rural communities praised the quality of care provided by nurse anesthetists and urged her to request the exemption from the federal requirement.

    The governor also indicated in her letter to CMS that she was influenced by New Hampshire's long-held belief that decentralized decision making leads to the best decisions possible. By removing physician supervision for nurse anesthetists, administrators and medical staffs of the state's hospitals and ambulatory surgical centers will be able to staff their surgical and anesthesia departments to best meet the needs of their patients.

    As always, New Hampshire's CRNAs will continue to work closely with surgeons, obstetricians, and other doctors in the delivery of safe, high-quality patient care. In 1999, the Institute of Medicine published a report stating that anesthesia care today is nearly 50 times safer than it was 20 years ago. CMS echoed that statement in the Federal Register in January 2001. CRNAs provide 65 percent of all anesthesia care delivered each year in the United States.

    "Governor Shaheen's decision reflects an understanding that CRNAs and physicians are partners in care--each brings to the patient the necessary knowledge and skills to provide safe anesthesia care," said Gordon Kempe, CRNA, president of the New Hampshire Association of Nurse Anesthetists. "CRNAs consult with physician colleagues as needed and have maintained an exemplary safety record."

    "This is a great decision for the citizens of New Hampshire, many of whom live in rural communities and rely on CRNAs to provide safe anesthesia care for surgeries, delivering babies, and emergency healthcare," said Deborah Chambers, CRNA, president of the 28,000-member American Association of Nurse Anesthetists. "In New Hampshire, CRNAs have long provided the majority of the anesthesia care to patients of all ages, for all types of procedures, and in every setting in which anesthesia care is delivered."

    Nurse anesthetists have been practicing for more than 100 years, giving them the longest history of any anesthesia provider. They are critical care nurses with a graduate degree in anesthesia. Graduates of nurse anesthesia programs must pass a national certification examination to become a CRNA, and must complete 40 hours of continuing education every two years to continue practicing as a CRNA.