Nurses ask Owens to opt out

Gary Kliewer, a certified registered nurse anesthetist, changes the settings on an anesthesia machine after a surgery in the East Morgan County Hospital. Governor Bill Owens may choose to opt out of a Medicare regulation, which requires a physician to sign the CRNA’s surgical anesthesia record.
Nurses can almost taste victory. Physicians are outraged. The governor has been sued by a medical association. And a controversial health issue will likely be decided before the fall, which may have a significant impact on the lives of many involved in surgical medicine in rural Colorado.

And the patients won’t feel a thing.

“This opt-out won’t allow me to do anything I don’t already do,” Gary Kliewer said. Kliewer is a certified registered nurse anesthetist who works as an independent contractor for hospitals and doctors in rural areas of Colorado, Nebraska, Kansas, Wyoming and Idaho.

During surgery, either a CRNA, an anesthesiologist – a doctor who specializes in pain relief and patient care – or a team of the two administer anesthesia to the patient to minimize pain and monitor vital signs.

The possibility Kliewer is talking about refers to a November 2001 rule published by the Centers for Medicare & Medicaid Services. The regulations require CRNAs to be supervised by a physician, usually the surgeon or anesthesiologist, during the procedure. Part of this supervisory role calls for the physician to sign the CRNA’s anesthesia record.

But the recent addition to the CMS rulebook allows a state’s governor to opt out of the policy if he or she consults with the state boards of medicine and nursing, and decides that exemption is in the best interests of the citizens and does not violate any state law.

Kliewer said the regulation is problematic for rural areas for two main reasons – lack of nurse and physician anesthetists in rural areas, and liability concerns. “The amount of surgeries performed in rural hospitals doesn’t draw in enough money to pay an anesthesiologist’s salary,” he said.

The Medical Group Management Association reports the average salary for a private practice anesthesiologist in the western United States is $229,524. Christopher Bettin, a spokesperson for the American Association of Nurse Anesthetists, estimated the average CRNA salary is $100,000. For this reason, most anesthesiologists work in larger cities, while CRNAs take jobs at rural hospitals.

For example, hospitals in Haxtun, Holyoke, Julesburg, Brush, Yuma, Wray and Fort Morgan all rely solely on CRNAs. “It’s really a distribution problem. They’re very much bunched,” Bettin said.

Surgeons often operate as independent contractors and some are reluctant to take on the supervisory title and responsibility because of limited training. Most surgeons complete a narrow anesthesia rotation during their residencies and don’t have the same knowledge as a CRNA or an anesthesiologist, so they may feel hesitant to sign their names to documentation they can’t validate.

According to Bettin, a CRNA and an anesthesiologist are equally qualified for the job. “One is a doctor and one is a nurse, so they both have different backgrounds from that perspective, but an anesthetist receives the same anesthesia education as an anesthesiologist,” he said.

Kliewer said he even helped train medical students at the Wichita Physicians’ School of Anesthesiology, where he earned his master’s degree.

“As juniors and seniors, we taught the new students the techniques we had learned. It was medical students and nurses together,” he said. “Not all schools are like that.”

Anesthesiologists opposed to the exemption list safety concerns as their primary reason. Some say they feel the anesthetists won’t have the same accountability for their actions.

Bettin disagrees. Surgery is “very much a team effort,” he said. “The anesthetists work very closely with the surgeon and other nurses.”

Additionally, a study published in the April issue of the American Association of Nurse Anesthetists Journal found no difference in surgical mortality rates based on the type of anesthesia provider.

The study, conducted by doctors Michael Pine, Kathleen D. Holt and You-Bei Loy, analyzed more than 400,000 patients undergoing one of eight surgeries and documented mortality rates in each procedure based on whether the anesthesia provider was an anesthesiologist, a CRNA or a team. The difference in results was deemed “scientifically insignificant.”

The Colorado Society of Anesthesiologists are so opposed to the opt-out they sued Governor Bill Owens in an attempt to keep him from signing the exemption. In addition to their safety concerns, they cited possible “decreased economic opportunities” if the supervisory language was removed.

They are worried that, because a CRNA’s salary is less than half that of an anesthesiologist, hospitals in larger cities might replace them with anesthetists.

If Owens does invoke the opt-out, anesthesiologists could petition their hospitals to adopt their own policies requiring physician supervision.

Kliewer pointed out that anesthesiologists were free to move into the rural areas to compete for the jobs if they wished.

The lawsuit also states there is a rule in the Colorado Board of Health books which requires supervision of anesthetists. Cheryl Blankmeier, a member of the Colorado Association of Nurse Anesthetists Board of Directors, said the rule dates back to the 1960s and has been overtaken by a more recent statute.

Nevertheless, she said the association will present its arguments to the Board of Health Wednesday to eliminate it completely.

Thirty-one states have the option to exempt their nurse anesthetists from supervisory signatures; the other 19 have state laws in effect which prohibit the opt-out.

If the governor approves, Colorado would be the eighth state to opt out since November 2001. The others, in the order they’ve filed, are Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico and Kansas. Kansas signed the order in April.

In response to the lawsuit, the Attorney General filed a motion to dismiss the case on the grounds that, because the governor has yet to opt out, the CSA failed to bring a lawsuit concerning an existing and current legal controversy. The motion also asserts the practice of anesthesia care by a CRNA is an independent nursing function under the Nurse Practice Act and asks the court to refer to the Board of Nursing rather than the Board of Medical Examiners for expertise.

The CSA filed their response to the motion May 9 and the governor’s office has one more chance to respond. The case is set to be reviewed in Denver District Court, Colorado District 2, on June 6.

Some argue the battle is solely about the egos of the health care providers.

“I have heard that argument from both sides,” Bitten said. “But anesthetists are wanting to practice as they’ve been educated to do, as they’ve been trained to do. It’s just not very realistic to expect the surgeon to be in the middle of a procedure and be able to advise or direct the anesthetist.”

(c) 2003 Journal-Advocate. All rights reserved. Reproduced with the permission of Media NewsGroup, Inc. by NewsBank, Inc.

Published in A1 “Today’s Headlines”