Certified Registered Nurse Anesthetists (CRNAs) are among the APRN groups that are an important part of this solution. They are not, however, seeking "expanded practice" or a new scope of practice or reimbursement mechanisms. CRNAs, as they have throughout history (preceding anesthesiologists), administer anesthesia in the same places and utilize the same techniques as their physician counterparts and do so cost effectively, with no compromise in quality of care, according to two recent studies in the peer-reviewed  journals “Health Affairs” and “Nursing Economics”.

These facts have historically lead to an almost continuous turf battle, all centered on reimbursement. The current environment serves only to promote a new intensity to this conflict, as organized medicine feels increasingly threatened. The evidence is clear, patient safety is not an issue. It never has been.

As part of a compromise that led to CRNAs being the first advanced nursing group to obtain direct reimbursement from federal agencies in the 1980s, a novel billing scheme emerged. This system allowed anesthesiologists to recoup double the revenue by “medically directing” (sometimes referred to as “supervising”) as many as four CRNAs, than they would by personally administering an anesthetic. To bill for this “medical direction” the anesthesiologist must meet seven criteria. Failing to meet even one of these criteria makes a claim submitted for “medical direction” fraudulent. Recently a $1.2M settlement was reached between the University of California-Irvine and the federal government over exactly this type of fraudulent billing. This is the tip of the iceberg.


Now, even in light of this settlement (or perhaps more correctly, because of this settlement), the American Society of Anesthesiologists (ASA) wishes to relax the federal rules for reimbursement. Instead of meeting the current requirement for being “immediately available”, a patient in the operating room could have an anesthesiologist who is farther away than that–a specific distance or time “impossible to define”, and this would still be considered “supervising.” This is all too reminiscent of the situation in Minnesota in the 1990s when anesthesiologists were billing for medical direction–from the golf course! This led to a $10M+ settlement and institution of corporate integrity policies. (Perhaps it’s time for ASA to review those policies?) Yet, everything old is new again when trying to protect one's turf.

To make this whole issue even more absurd are two recent studies published in the journal “Anesthesiology,” the official publication of the ASA, and “Anesthesia & Analgesia.” In one, communications with “supervising” anesthesiologists were evaluated revealing that less than 2 percent of such communications originated from those being “supervised” in the OR. In the other, the authors revealed significant lapses in the ability to meet the accountability rules as the number of “medically directed” CRNAs increased – lapses which occurred 99 percent of the time! The study also identified a 22-minute delay when anesthesiologists try to meet the guidelines in order to properly bill for medical direction. With Medicare anesthesia provider reimbursement at a rate of $1.43 per minute, and perhaps millions of such delays every year, the waste of Medicare dollars adds up very quickly, even when the criteria can be met. But this is only a small part of the inherent economic fiasco. While patients waits for an anesthesiologist, the standard Operating Room charges are also accumulating at a rate of $25-50 per minute!

In contrast with the above, and with a philosophy similar to the IOM report, the United States Air Force recently updated its policies for the provision of anesthesia services. The policy states that collaboration among anesthesia providers, independent of specific training background, is the preferred practice model. Unlike the civilian market, there is no financial incentive or profit motive involved in providing anesthesia services to our military heroes and their families, just the desire to provide safe and efficient care.

The solution to this problem is exquisitely simple. The president, via his HHS Secretary, must eliminate reimbursement for medically directed anesthesia claims other than those incurred when teaching students or residents. All anesthesia professionals privileged to relieve pain and suffering should actually administer anesthetics. As a society we simply cannot afford to have highly trained anesthesiologists, whose residencies are financed by taxpayers, “supervising”. If a procedure requires multiple anesthesia providers due to surgical acuity or complexity, the current regulations provide for full reimbursement. The system currently incentivizes inefficiency without any gain in quality or safety, and potentially pays for services not rendered. This change eliminates the waste of millions or even billions of taxpayer-supported health care dollars and the submission of fraudulent claims. This would force anesthesia departments to become more efficient and allow all Americans to receive the same high level of care as our military heroes.
Horowitz, CRNA, ARNP, practices in Florida.