By Todd Stein
February 17, 2000
Photo: Corbis

The decades-long debate of independent practice between anesthesiologists and nurse anesthetists is as heated as ever. The latest flurry of negative exchanges between the two camps concerns an apparent peace offering made by the Park Ridge, Ill.-based American Society of Anesthesiologists.

Last year, the ASA announced the formation of a committee to design an "educational affiliate" membership category for nurse anesthetists and anesthesia assistants. But because these new members must agree that anesthesiologists should direct them in the OR—the very sticking point of the controversy—the move has been met with suspicion from the nurses' group.

Questioning motive

"I question the underlying motive of the [ASA's] new membership," said Jan Stewart, CRNA, president of the 25,000-member, Park Ridge, Ill.-based American Association of Nurse Anesthetists. "They're couching it as an educational opportunity, when in fact they may be trying to get nurse anesthetists to join the ASA instead of the AANA as a mechanism to control the political views of nurses. I think it's just a political ploy to divide and conquer."

Concern for patient safety, not politics, is the real reason for the new membership, countered Ronald MacKenzie, doctor of osteopathy, president of the 35,000-member ASA. "The ASA is not against nurse anesthetists," MacKenzie said. "We're against unsupervised, independent nurse anesthesia. We don't think it's safe."

Such concern about patient safety underlies the ASA's effort to block a proposed change in Medicare regulations that would allow nurse anesthetists to work without physician supervision in states that allow it. Nursing statutes in 29 states, including California, allow CRNAs to practice without physician supervision. But under Medicare reimbursement rules, hospitals that use CRNAs cannot be paid for the anesthesia portion of the surgery unless a physician supervises the nurses.

Ironically, separate Medicare rules allow CRNAs who act as independent providers—such as those who service rural hospitals with no anesthesiologist on staff—to bill the government for their services at the same rate as anesthesiologists.

"If that sounds like a contradiction, it is," said AANA spokesperson Christopher Bettin. "It's just one of the big mysteries of Medicare." The inconsistency of the Medicare rules does little more than create a paperwork hassle for hospitals, since the supervision requirement is met automatically by the presence of a surgeon, and CRNAs only work during surgery.

Still, confusion over the rules led the Health Care Financing Administration (HCFA), the government body that oversees Medicare, to propose deferring to state laws on the issue of supervision in 1997.

Sen. Arlen Specter, R-Pa., chairman of the Senate Labor, Health and Human Services Appropriations subcommittee and one of the HCFA proposal's chief supporters, said, "There is a wealth of information already in existence that supports the view that the issue of supervision should be left to the states, just as HCFA has proposed." Yet the proposed rule change has languished in Congress, slowed by strong opposition from physicians' groups. Peter Ashkenez, HCFA spokesperson, said, "No decision has been made and there's no timeline for a decision" on the rule change.

Convoluted issue

The AANA's Stewart challenges the anesthesiologists' claim that their opposition to the Medicare rule change is based on concern for patient safety. She noted that the 1998 study cited by the ASA to bolster its safety argument has not been published in a peer-reviewed journal and is "inconclusive." The study, directed by University of Pennsylvania researcher Jeffrey H. Silber, MD, and funded by the American Board of Anesthesiology, found that surgical death rates and complications were lower when an anesthesiologist supervised the anesthesia team. But the study's authors noted that they did not correct for differences in the quality of care provided at different hospitals, or for differences in the kinds of patients involved.

Stewart said this oversight is critical because anesthesiologists are heavily concentrated in well-funded hospitals and surgical centers in urban and suburban areas while a majority of CRNAs work for rural and inner-city hospitals where funding and staffing levels are often critically low. More than 65 percent of rural hospitals in the United States use CRNAs instead of anesthesiologists, according to the AANA.

The real reason for the ASA's opposition to the Medicare change, Stewart contends, is economics. "Whoever controls the practice controls the money," she said. "The whole supervision issue comes from Medicare, which regulates payment, not safety."

The median income for anesthesiologists is $244,000 a year, according to the ASA, compared to $88,000 for CRNAs. Anesthesiologists' higher incomes stem not from performing different services for patients—CRNAs are legally allowed to perform all the anesthesia-related duties of an anesthesiologist—but from their role as director of the "anesthesia care team." Eighty percent of CRNAs are members of such teams, working under the direction of anesthesiologists. Essentially, anesthesiologists' pay rates are higher because they can bill for medically directing CRNAs. "If they lose their supervisorial role, they stand to lose a lot of money," Stewart said.

Peaceful prospects?

Despite their differences, both anesthesiologists and CRNAs say they hope to find a way to continue working together in harmony. "There's plenty of work for all of us," Stewart said. "There's no need to be fighting turf wars."

Even the new ASA membership category is an effort to heal the wounds, MacKenzie added. "It's unfortunate that there has been this kind of blowup," he said. "This is an altruistic, honest-to-goodness attempt to help our nurse anesthesia colleagues with education. All we can do is reach out. They don't have to take our hand if they don't want to."