By Anne Federwisch, OTR
Illustration by Malcolm Garris/PhotoDisc
January 7, 1999

The ongoing tug of war between nurse anesthetists and anesthesiologists over CRNAs’ autonomy in the operating room shows no signs of relenting. The latest battle involves anesthesiologists’ payment for medically directing CRNA-delivered care and hospitals’ Medicare reimbursements. At the heart of both concerns is whether anesthesiology is solely the practice of medicine or also falls in the domain of nursing care.

Roots of conflict

Although many CRNAs and anesthesiologists work well together on an individual basis, many nurse anesthetists view their struggle with anesthesiologists as a microcosm of the conflict between advanced practice nurses and physicians in general. "I would characterize these particular issues as physicians’ attempts to control the practice of nurse anesthesia by telling the public wrongly that supervision is required in order for us, or any other advanced practice nurse, to work according to our lawful, legal scope of authority from the Board of Registered Nursing," said Scot Foster, PhD, CRNA, FAAN. Foster is a professor and director of nurse anesthesia at Samuel Merritt College in Oakland and the immediate past president of the American Association of Nurse Anesthetists (AANA).

The American Society of Anesthesiologists (ASA) sees things differently. "ASA believes that the practice of anesthesia care is the practice of medicine," said Michael Scott, ASA director of governmental and legal affairs. "Nurse anesthetists should not be independently giving anesthesia care. But under the supervision of a physician—preferably an anesthesiologist—they are very effective providers."

That opinion ignores the history of anesthesia care, said Ira P. Gunn, CRNA, FAAN, a nurse anesthesia consultant from El Paso, Texas. "Nurse anesthetists primarily were the early providers of anesthesia in this country dating back to about 1880," she said. It wasn’t until after World War II that physicians began to specialize in anesthesiology in large numbers.

Nursing practice acts

The ASA’s view of anesthesiology as the practice of medicine discounts judicial rulings as well, Foster said. "There have been judicial case after case decided at a national level for decades that anesthesiology is the practice of medicine when done by a physician," he said. "It is the practice of nursing when done by a nurse."

What nursing entails is defined by each state’s nursing practice act. According to the AANA, nursing statutes and regulations in 29 states—including California—allow CRNAs to practice independently. But current federal Medicare regulations supersede those state laws. For hospitals to get reimbursed for treating Medicare patients, they must require physician supervision of nurse anesthetists.

Supervision equation

The Health Care Financing Administration (HCFA) is considering a proposal to remove the federal requirement and allow deferral to state law on the issue of physician supervision. CRNAs do not require supervision or direction according to the California Nursing Practice Act.

But even if the revision goes through, the ASA’s contention that physicians would be cut out of patient care is erroneous, said Linda R. Williams, JD, CRNA, president of the AANA. "We don’t work in a vacuum," Williams said. Care always must be coordinated with the surgeon, she stressed. The comment period for the proposal ended in April, and HCFA is still analyzing the 45,000 responses received, a spokesperson said. The agency has no timetable for a final decision.

For their part, ASA officials contend that supervision of CRNAs is a patient safety issue. Scott referred to an American Board of Anesthesiology study that compared outcomes of surgical patients whose CRNAs were supervised by anesthesiologists with outcomes of patients whose CRNAs were supervised by nonanesthesiologist physicians. It showed CRNAs under anesthesiologists’ supervision achieved better outcomes. "We think it sends a major signal that you better think very hard before you eliminate physician supervision," Scott said.

The study sends no such message, Gunn said. The analysis investigated postoperative complications, the vast majority of which have nothing to do with anesthesia care, she said. The authors themselves wrote that "whether this is a caregiver or hospital effect remains to be determined." Gunn also questioned the study’s lack of statistics for patients treated by anesthesiologists practicing independently.

Money issue?

It isn’t a quality of care issue, it’s an economic one, said Billy Haggerty, CRNA, a partner with Midland Anesthesia Associates, in Midland, Texas. "[Anesthesiologists] prefer not to do the direct one-to-one patient care," he said. "They prefer to do the anesthesia care team approach, which allows them higher income."

Anesthesiologists can bill for medically directing CRNAs. To do so, they must fulfill seven steps outlined in the Tax Equity and Fiscal Responsibility Act (TEFRA), according to Williams.

Nurse anesthetists sought to revise those rules to better reflect current practice. "The proposed changes said that either the anesthesiologist does [the seven steps] or ensures that [they’re] done by a qualified provider," she said.

Foster does not see an end to the turf war even if the HCFA proposal wins approval, but he does foresee a more intelligent use of anesthesia services. "I think the supervisory role does not work anymore. Collegiality does," he said. "The ‘Me Tarzan, you Jane’ atmosphere is counterproductive."

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