Under Medicare rules Certified Registered Nurse Anesthetists (“CRNAs”) must be supervised by a physician, typically an anesthesiologists or perhaps by a surgeon in rural areas where anesthesiologists are not available. Medicare has a state “opt out” provision which permits CRNAs to practice without supervision of a physician. To date, 15 states have chosen to opt out and others like Colorado are considering doing the same. Anesthesiologists are compensated for supervising CRNAs and can supervise up to 3 at a time because they are not required to be in the same room.
Anesthesiologists of course tend to favor the supervision requirement because they have a financial interest in the same and can also claim the mantel of patient safety, because of their more substantial professional education and experience. If you ask an anesthesiologists what differentiates his or her service from that of a CRNA, the answer that you are likely to get is that “I am a physician.” That is of course empirically true. There are occasions when having a physician capable of making medical decisions available to assist the surgeon in an emergency is a net plus. The problem is that in the overwhelming number of cases having both a “belt and suspenders” is an expensive luxury.
The delivery of anesthesia is a technical service. Over time the technical expertise in delivering the service is about the same as between physicians and nurses and frankly in some cases nurses do it better, particularly in the delivery of epidurals during delivery.
It is also true that anesthesiologists, although they are physicians, tend to get a little rusty in the medical department because they are delivering a technical service and to some extent operate in a routine that does not call upon their medical expertise margin as physicians, thus reducing the benefit of that superior education as a practical matter.
Looking at the issue from a cost/benefit analysis, absent a showing of clear and substantial benefit to patient welfare, which is a difficult statistical case to make, more and more states are likely to join the opt out crowd as the use of so called “physician extenders” increases in the cost containment/healthcare access movement picks up steam. The irony is perhaps the prospect that the growing alternative use of CRNAs will not only eliminate the supervision requirement, but also cut a competitive slice of anesthesia delivery out of the anesthesiologist’s economic pie - a legitimate cause for anesthesiologists’ concern
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