Docs slam new report urging end of physician supervision for nurse anesthetists

The nation's anesthesiologists are pushing back — and hard — against a new report urging repeal of Medicare rules that require physician supervision of certified registered nurse anesthetists (CRNAs).

The report, sponsored by the American Association of Nurse Anesthetists (AANA), an industry group, found that patients fare just as well when CRNAs treat them unsupervised as when physicians oversee the process.

"We don't find any statistical differences for CNRAs working alone," said Jerry Cromwell, senior fellow at the Research Triangle Institute (RTI) and co-author of the report, which appeared in the latest issue of Health Affairs. 

Cromwell has joined the AANA in calling on the Centers for Medicare and Medicaid Services (CMS) to repeal the physician supervision requirement.

But don't try to convince Alexander A. Hannenberg. The president of the American Society of Anesthesiologists (ASA) said this week that the RTI report is nothing but "purchased junk science" reminiscent of the tobacco industry finding that cigarettes are safe. In a phone interview Monday, Hannenberg argued anesthesiologists provide valuable medical services that the lesser-trained CRNAs simply can't, and he has a laundry list of things he said undermine the RTI findings. 

First, Hannenberg noted, the RTI report was based on claims data — not outcomes data — meaning the RTI researchers would have no way to distinguish between complications derived from the anesthesia and those resulting from the surgery or pre-existing conditions. Using that data, therefore, it's impossible to reach definitive conclusions about anesthesia-related mortality and complication rates, Hannenberg said. 

"It's a non-sequitur."

Second, because anesthesia-related deaths occur once per 200,000 to 300,000 treatments, according to the Institute of Medicine (IOM), the approximately 480,000 claims that RTI researchers examined were "completely inadequate" for comparing anesthetic treatments administered by CRNAs working alone and those being supervised, Hannenberg argued.  

"You need a mammoth sample in order to draw that kind of conclusion," he said.

And third, Hannenberg argued, because anesthesiologists tend to see the sicker, more complex patients, equivalent health outcomes suggest CRNAs aren't providing the same level of care.

"I would submit that that is an indictment of the care," he said, "because [the outcomes] shouldn't be the same."

At issue are current rules under which Medicare won't reimburse hospitals and ambulatory surgery centers for anesthesia treatments provided by CRNAs in the absence of a physician supervisor. 

In 2001, though, the Centers for Medicare & Medicaid Services (CMS) started allowing states to opt out of the supervision requirement — an option that 15 states have exercised since then.

The RTI study was designed to compare the outcomes of patients receiving anesthesia care in opt-out states, versus those treated by CRNAs in states where physician supervision is mandatory. 

The results, as Hannenberg's comments indicate, have by no means ended the hotly disputed debate over which model is superior.

Read more on the AANA's arguments here.