In: Anesthesia

20 Nov 2009


In November 2001, the Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration, reversed a rule passed in the last few hours of the Clinton administration that would have allowed certified registered nurse anesthetists (CRNAs) to administer anesthesia without physician supervision. Inherent in this new CRNA independent practice privilege would have been the ability for CRNAs to bill independently for their services, thus directly competing with physician anesthesiologists. Approximately 36,000 members of the American Society of Anesthesiologists (ASA) were pitted against approximately 28,000 members of the American Association of Nurse Anesthetists (AANA). A huge amount of time, energy, and РАС money was spent by each side in this gigantic political struggle in Washington. The AANA accumulated more РАС funds than any other health care organization in America, which placed them among the elite of all РАС entities. The outcome appears to have favored the ASA, but the AANA also claimed victory at the state level. In a related matter, a state association of nurse anesthetists has filed a $1 billion Medicare fraud lawsuit related to improper supervision by anesthesiologists.

The CRNAs claimed that they provide 65% of all anesthetics in the United States, but did not mention that many of those are undoubtedly under the supervision of medical anesthesiologists as part of the anesthesia care team. The CRNAs also claimed that in more than half of all rural hospitals, CRNAs are the only anesthesia care providers available. Solo physician anesthesiologists practice in only about 10% of rural hospitals, since few of these communities can attract an anesthesiologist, especially during the current overwhelming national shortage of anesthesiologists. The CRNAs point out that in the small hospitals where there are no anesthesiologists, the Medicare requirement of supervision of the nurse anesthetist by a physician, any physician, is merely a technicality, since many surgeons may have only superficial knowledge of modern anesthesia care and appropriate resuscitation procedures during anesthesia emergencies. Thus, the nurse anesthetists in this situation typically bear the entire responsibility for the anesthetic and believe they should be compensated appropriately. Additionally, because CRNAs can obtain a limited Drug Enforcement Agency permit to order and administer controlled substances, dependence on physicians is no longer required for that activity. They also claim that their morbidity and mortality statistics are equal to those of physician anesthesiologists, so safety is not an issue in their minds. The CRNAs believe that the Clinton legislation would have provided optimal care, especially for rural and underserved populations, and that what was originally aimed as merely a reimbursement issue for hospitals became a turf battle with anesthesiologists.
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The anesthesiologists countered with the American Medical Association’s recently passed resolution that agreed with the official policy statement of the ASA that “anesthesia is the practice of medicine.” Therefore, nurses providing anesthesia without physician supervision could be viewed as practicing medicine with neither medical training nor a medical license. They even surveyed groups of surgeons and Medicare-insured senior citizens to see if they would be comfortable having a nurse anesthetist, who may be without a college degree and who may have had only a couple of years of nurse anesthesia schooling, to be entirely responsible for the anesthetic or whether they preferred a physician who had graduated from 4 years of college, 4 years of medical school, and 4 years of rigorous internship and residency in anesthesia. It is no surprise that the results from the seniors indicated a preference for the anesthesiologists, whereas the surgeons preferred anesthesiologists for all but ASA I patients. The anesthesiologists also lobbied for a national survey to be conducted to determine whether anesthetics given solely by CRNAs were as safe as those given by anesthesiologists.

In the end, both sides can claim victory. The physician anesthesiologists won their federal standard of required physician supervision of CRNAs for CMS reimbursement, and it is anticipated that the private sector will eventually follow these federal requirements. However, the CRNAs won their right in each state for the governor to consult with the state’s medical and nursing boards to determine if there are shortages that deny access to the public of quality anesthetic care. If the governor determines that such shortages exist and there is no conflicting state law, a letter can be written to the CMS by the governor indicating that the state has “opted out” of the federal supervision requirement, and the CRNAs can then practice independently in that state.
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The AANA claims that 30 states do not have a “physician supervision requirement” in nursing or medical board regulations or in the state’s laws. The “opt out” option could therefore be activated by the governors of those 30 states and any others if their state laws were changed. Thus, the controversy moves from Washington to the state level. Both sides will surely push for legislation either to ban independent practice of CRNAs or to accept it as being in the best interests of the public. In the short term, governors will undoubtedly be lobbied for or against the “opt out” provision.

Medicare rules currently require supervising anesthesiologists to document their presence at induction, emergence, and critical portions during anesthetic administration. If this is not documented in the record or if this supervision did not occur, it would be fraudulent for the anesthesiologist to bill for the anesthetic. In January 2002, the US Eighth Circuit Court of Appeals reversed a lower court ruling that now will permit the Minnesota Association of Nurse Anesthetists to proceed with their $1 billion Medicare fraud lawsuit against Minnesota’s largest health maintenance organization; they allege that their anesthesiologists were not always present in the operating rooms as required for billing Medicare.

What are the implications for the dental profession as these battles unfold at the state level? First, if one counted every dentist who gives sedation or general anesthesia who might be affected by a change in state anesthesia rules or laws that this struggle might produce, their numbers would be small in comparison to the “big 2.” The 6000 oral surgeons, the handful of dentist anesthesiologists, and the few periodontists and general dentists who give intravenous conscious sedation, deep sedation, and/or general anesthesia pale in comparison to the tens of thousands of anesthesiologists and CRNAs who have flexed their massive political muscle power and tenacious resolve to control who can be responsible for administering anesthesia.
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Second, with physicians claiming that their specialty of anesthesia is the practice of medicine and CRNAs claiming that their anesthesia specialty is also the practice of nursing, dentists, including oral surgeons, dentist anesthesiologists, and others who have some advanced training in anesthesia but no recognized anesthesia specialty, must pay particular attention to new legislative efforts in individual states lest we be lost in the turmoil. Because the combined 64,000 anesthesiologists and nurses all practice as anesthesia specialists and are not involved in any aspect of simultaneously performing surgery, it would not be surprising that the concept of the operator-anesthetist supervising a team of self-trained, nonprofessional auxiliaries in any type of private medical or dental office would be viewed unfavorably by both sides and by the legislators whom they will both lobby for their individual causes. In fact, Medicare rules and virtually all medical insurance policies already prohibit separate billing for sedation services provided simultaneously by the operating surgeon. Instead, operator-se-dationist medical surgeons must include their sedation in their overall surgical fee. In light of the current trends nationally, whether dentistry can hold the line in its current method of anesthesia practice is questionable.

The American Dental Association’s (ADA’s) Guidelines for the Use of Conscious Sedation, Deep Sedation, and General Anesthesia for Dentists advises that a CRNA should only work under the supervision of a dentist who also has been trained in the sedation and anesthesia procedures that the CRNA will be administering. Thus, the ADA would recommend, for instance, that an oral surgeon could supervise a CRNA in administering a deep sedation or general anesthetic, but a conscious sedation-trained dentist could only supervise a CRNA for conscious sedation. A dentist without sedation training could not use the services of a CRNA, since dentists cannot supervise someone doing a procedure that they cannot legally perform themselves. However, particularly in states where the “opt out” provision will be hotly debated, CRNAs may prevail and open all health care facilities, including all dental offices in the state, to their services if supervision by the dentist or physician, whether trained or untrained in sedation and anesthesia, is no longer an issue. Although initially only pertaining to Medicare cases, the “opt out” rule will undoubtedly lead to independent practice in other cases as has occurred in other similar venues.
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When the current CMS rule, which requires CRNA supervision, is followed, the ASA states that the supervising physician should ideally be an anesthesiologist but at least must be a physician. In every state, any licensed physician can legally perform essentially any aspect of medicine, including anesthesia, even if he or she practices a different specialty and has no specific training in anesthesia beyond medical school. Physicians must decide what is the best treatment for their patients and whether or not they feel qualified to render that care. Essentially, any physician can legally give anesthesia and can therefore supervise a nurse anesthetist administering anesthesia.

Dental laws are different. Sedation and anesthesia are tightly regulated procedures. Considering the good safety record of sedation and anesthesia in dentistry, the ADA believes it would be unwise for dentists without training to begin working with independently practicing CRNAs because neither anesthesiologists nor nurse anesthetists train in the dental office setting. They are accustomed to hospitals and surgical centers, where, for example, there is backup from other qualified practitioners in case of an emergency and where the availability of essential emergency drugs, equipment, and backup power sources are taken for granted. The dentist not trained in anesthesia administration may not understand what is needed, and the anesthesia provider may incorrectly assume that the office is already set to provide emergency aid. The dentist who has not been trained in sedation and anesthesia administration would also not be expected to medically evaluate the patient for suitability of the technique or recognize poor anesthesia care provided by a substandard anesthesia provider who has not been trained and evaluated to provide anesthesia in the dental office setting. The nondentist anesthesia provider and the dentist not trained in anesthesia administration may have no understanding of the usual safeguards, such as the usefulness of a gauze throat screen that we use to protect the airway in non-intubated cases. Thus, even the well-trained nondentist anesthesia practitioner may increase the morbidity and mortality rates when practicing in the unfamiliar territory of the dental office.

For all these reasons, the potential for some dentists or the entire dental profession to lose sedation and anesthesia privileges looms constantly overhead. All dentists must therefore work together and be proactive. We must follow the lead of states such as Ohio, which passed state board rules that are fair to all dentists who give sedation and anesthesia, not just to oral surgeons, but also fair for conscious sedationists and dentist an esthesiologists. Rather than trying to reinvent the wheel with reams of complicated and often ridiculous and unfair rules, Ohio simply accepts the ADA guidelines, as well as several other related guidelines, as the state’s standard. When the guidelines are changed, the changes are automatically incorporated without opening up the dental codes every time another change needs to be made. Additionally, with the prestige of the ADA behind them, the Ohio rules, including the supervision of CRNAs by qualified dentists, appear to be reasonable and not arbitrary and capricious. All groups of Ohio’s sedation- and anesthesia-trained dentists have worked together for the common good of preserving our individual privileges of providing anesthesia care, whether we use the operator-anesthetist team concept in a single office or practice as a mobile dentist anesthesiologist who can transform any dental office into a safe operating room-like environment.
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If the “opt out” option is permitted for Medicare cases in your state, unsupervised anesthesia in all dental offices may follow for all cases. It is therefore in the interest of the safety of our patients that states maintain the federal supervision requirement for CRNAs.

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Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.