The debate over whether nurse anesthetists can treat Medicare and Medicaid patients without physician supervision has moved from the federal to the state level.
Under a rule published Nov. 13 in the Federal Register, physicians must supervise nurse anesthetists when they treat Medicare and Medicaid patients unless a state provides an exemption.
The ruling from the Centers for Medicare and Medicaid Services reverses an earlier rule issued in the waning days of the Clinton administration that allowed nurse anesthetists to practice independently.
The new rule, which went into effect immediately, allows nurses to practice independently if states have laws permitting it. Twenty-nine states allow nurse anesthetists to work on their own.
"This rule allows states to make the most effective use of nurse anesthetists while ensuring Medicare beneficiaries continue to receive safe, high-quality anesthesia services," CMS Administrator Thomas Scully says.
One of Clinton's final acts was to approve a rule change that eliminated the requirement that an anesthesiologist be present or supervise nurse anesthetists when beneficiaries receive such care.
Under Clinton's rule, healthcare institutions would have received reimbursement for anesthesia services provided to Medicare and Medicaid patients regardless of whether a physician supervised the nurse anesthetist.
Previously, the institutions were only reimbursed if physicians supervised nurse anesthetists.
Nurse anesthetists hailed the rule, saying they have an excellent safety record.
Physicians decried the decision, arguing that the safety of anesthesia is the result of cooperative efforts with physician supervision.
The Bush administration rule calls for reimbursement to institutions if states allow nurse anesthetists to practice independently.
Officials with the American Association of Nurse Anesthetists say they're not thrilled with the new rule but they'll live with it.
Government officials "got (the rule) right the first time," says Deborah Chambers, a nurse anesthetist and president of the AANA. "But that's obviously not what we're going to have here. The AANA and the registered CRNAs (certified registered nurse anesthetists) across the country will work with the language that we have."
Chambers says more than two-thirds of all anesthesia across the country is provided by nurse anesthetists. The rule change was not about patient safety, and nurse anesthetists provide high-quality, safe care for patients, she says. The rule change was about reimbursement for healthcare institutions.
Chambers says AANA officials plan to encourage governors, especially those in rural states, to carefully look at the rule and the effect it will have on their residents. Many states with large rural areas have a difficult time finding anesthesiologists to cover rural hospitals.
Officials with the American Society of Anesthesiologists didn't return phone calls seeking comment. However, a statement from ASA officials says they are "cautiously optimistic" about the rule.
"While the new rule preserves the much-needed physician-supervision requirement, there are some portions that could be exploited and abused by those opposed to having a physician involved in every anesthetic," the ASA says. ASA officials say they are "wary" of the provision allowing the states to allow nurse anesthetists to practice alone.