HCFA is leaning strongly toward allowing nurse anesthetists to practice without direct supervision of a physician anesthesiologist, sources in Washington confirmed to MODERN HEALTHCARE last week.
The issue is one of a host of controversial moves contained within HHS' effort to update the Medicare conditions of participation. HHS proposed updating all the conditions of participation, which set the ground rules for Medicare certification, more than two years ago (June 29, 1998, p. 84). But, no final revisions have been published.
The last time the conditions of participation were updated was 1986. HCFA plans to separate the nurse-anesthetist issue from the rest of the conditions of participation regulations, and issue a final rule in June.
Whether nurse practitioners should be permitted to practice outside the supervision of a physician is a major point of friction between these two professions.
The nurse anesthetist supervision requirement was written into the conditions of participation at Medicare's inception. Nurse anesthetists tried to open the issue about six years ago, but HCFA declined to change the rule.
The American Association of Nurse Anesthetists (AANA) said the proposed rule change is "good news for the American public, because it ensures access to safe, high-quality anesthesia care, especially in rural areas and inner-city hospitals."
But the 35,000-member American Society of Anesthesiologists pronounced itself "shocked and frankly outraged" by a letter that HCFA Administrator Nancy-Ann Min DeParle sent to Sen. Arlen Specter (R-Pa.) on March 8.
In her letter, DeParle noted that HCFA proposed changing the rules to allow nurse anesthetists to practice on their own, where state law permits.
"The existing across-the-board supervision requirement did not seem to be supported by the existing scientific evidence," she wrote.
Ronald MacKenzie, D.O., president of the anesthesiologists society, wrote in a March 13 letter to DeParle that the scientific evidence strongly favors retaining physician supervision. An unpublished study at the University of Pennsylvania in 1998 reportedly found a 28% higher mortality rate when an anesthesiologist was not supervising the nurse anesthetist, he said.
HCFA should hold off issuing any rules, he argued, until that study can be published in a major medical journal.
Failing that, a bill pending in Congress would require HCFA to base its rule on the scientific evidence of a large patient outcomes study.
The AANA said 29 states do not require direct supervision of a nurse anesthetist by a physician.
Of the 60,000 comments HCFA has received on the proposed conditions of participation revisions, 20,000 address the nurse-anesthetist issue.
HCFA maintains that anesthesiology is so much safer than it was 20 years ago that physician supervision is no longer necessary. The anesthesiologists counter that the existing federal standard has contributed to the improvement in anesthesia safety.
HCFA must publish its decision in the Federal Register before making it public.