PHYSICIAN SUPERVISION OF CERTIFIED REGISTERED NURSE ANESTHETISTS
Background: The Health Care Financing Administration today issued a final rule that defers to state professional practice laws and hospital by-laws to determine which licensed professionals can administer anesthesia. The rule, to be published in the Federal Register tomorrow, removes a federal requirement for physician supervision of anesthesia administration in hospitals, critical access hospitals and ambulatory surgical centers. The old rule required supervision by physicians, whether or not they had any expertise in the delivery of anesthesia. The new rule increases overall flexibility by letting states and hospitals, who are closer to patient care delivery, make decisions about the best way to deliver care. The new rule allows certified registered nurse anesthetists (CRNAs) to practice without physician supervision where state laws permit. However, it requires that CRNAs be supervised by a physician when required by state law. This decision is consistent with HCFA's commitment to decrease regulatory burden by deferring to state licensing laws regulating professional health care practice. This final rule was proposed in 1997 in an effort to restructure and refocus Medicare's conditions of participation for hospitals so they focus on outcomes rather than regulating processes.
Major Provisions of the Regulation
The new Medicare rule changes the physician supervision requirement for CRNAs furnishing anesthesia services in hospitals. The rule removes a federal requirement that a physician supervise every case of anesthesia administration by a nurse anesthetist and allows states to determine whether such supervision is needed. The rule would allow CRNAs to practice in hospitals without physician supervision where state law and hospital policy permits. Similarly, the rule would require that CRNAs be supervised by physicians where such oversight is required by state law and hospital policy. And any hospital can establish stricter standards than required by state law.
The final rule recognizes the states' traditional domain in establishing professional licensure and scope-of-practice laws. It does not prohibit, limit, or restrict in any way the practice of medicine or prevent anesthesiologists from administering anesthesia or supervising another professional.
Medicare has a consistent policy of respecting state control and oversight of health professionals by deferring to state licensing law to regulate health professional practice. Congress left this licensure function to states, and Medicare recognizes the scope of practice for which health professionals are licensed by states. Medicare's hospital conditions of participation do not have federal requirements for physicians to oversee the practice of other state-licensed independent practitioners, with the sole exception of the federal requirement for physician supervision of CRNAs that this final rule eliminates.
Patients Come First
The new rule allows an appropriate level of regulatory flexibility without compromising patient health or safety. Research has demonstrated that a variety of factors contribute to the unprecedented safety record for anesthesia administration that now exists in this country. Advances in medical knowledge, implementation of practice guidelines, better drugs and safer equipment, all have contributed to better quality care. For example, according to the 1999 Institute of Medicine Report on medical errors, "To Err Is Human," the number of deaths from errors in administering anesthesia has dropped from two deaths per 10,000 patients receiving anesthesia in the 1980s to about one death per 200,000-300,000 such patients today, a 40-to-60-fold improvement.
There is no evidence that CRNA independent practice would cause adverse outcomes. There also is no evidence that states are any less concerned with ensuring the quality of care and safety of their citizens than is the federal government -- or that states have been unsuccessful in overseeing other health care professional practice. Critics of the proposed rule have cited findings of researchers at the University of Pennsylvania that anesthesia outcomes are better when anesthesiologists are involved in furnishing anesthesia care. However, this study is not relevant to the issue involved in this rule. It did not compare CRNA practice with non-anesthesiologist physician supervision to CRNA practice without physician supervision. It does not provide sound and compelling evidence to support maintaining federal preemption of state law.
This change was first proposed in 1997, when HCFA proposed changes to its hospital conditions of participation and stated its desire to move toward standards that are patient-centered, evidence-based, and outcome-oriented. HCFA proposed eliminating many outdated federal requirements and deferring to states unless there was compelling and sound evidence to support an across-the-board federal requirement for the supervision of one state-licensed health professional by another. After three years of deliberation and comment from the public and the health care community, HCFA believes its new rule allows the appropriate level of regulatory flexibility without compromising patient health or safety.