With strong support from the state Board of Medicine and Surgery (BOMS), Nebraska became the second state to opt out of Medicare’s physician supervision requirement for nurse anesthetists.
Just three months after the Centers for Medicare & Medicaid Services (CMS) published its anesthesia care rule granting state governors the ability to opt out of the supervision requirement, Nebraska Governor Mike Johanns sent a letter to CMS informing CMS that "it is in the best interest of the State’s citizens to exercise this exemption." The opt-out is effective immediately.
The CMS rule, published in the Federal Register [66 FR 56762-56769] on November 13, 2001, allows a governor to notify CMS in writing of the state’s desire to be exempt from (opt out) the supervision requirement for Certified Registered Nurse Anesthetists (CRNAs) after the governor meets the following prerequisites: consults with the state’s boards of medicine and nursing, determines that opting out of the requirement is consistent with state law, and decides that it is in the best interests of the state’s citizens.
In a ringing endorsement, the Nebraska BOMS told Johanns in a strongly worded letter that it "believes that such a [federal supervision] requirement would negatively impact health accessibility for Nebraska residents and recommends that you exercise the option of exemption from the requirement of physician supervision of CRNAs in the state of Nebraska."
According to a news release disseminated to Nebraska media by the governor’s office, approximately 69 of the state’s 85 acute care hospitals rely solely on nurse anesthetists to provide safe anesthesia care to patients.
The Nebraska Board of Nursing (BON) echoed the sentiments of the BOMS. In a letter to Johanns, the BON emphasized "the benefit this opt-out will have for physicians, facilities, and the citizens of the State of Nebraska," and stated that it "strongly encourages" the governor to apply for the opt-out.
Johanns informed CMS that he made his decision after "consultation with the State’s Boards of Medicine and Nursing on issues related to access to and the quality of anesthesia services," and after ensuring consistency with state law.
In citing his reasons for seeking the opt-out, Johanns said in the news release that "patients’ health is protected because CRNAs have the education and training that enable them to provide quality services." CRNAs are critical care nurses with a graduate degree in anesthesia. They must pass a national certification examination to become a CRNA, and must complete 40 hours of continuing education every two years to continue practicing as a CRNA.
"States are in the best position to assess their needs," said Dr. Richard Raymond, chief medical officer of the Nebraska Health and Human Services System, in the news release. "Opting out will allow hospitals to utilize CRNAs in ways that fit their own unique circumstances. CRNAs working closely with physicians will ensure that patients receive the best care possible."
"This decision will NOT change the delivery of health care in Nebraska," Johanns added. "In fact, it will help ensure the affordability and accessibility of anesthesia services in rural areas."
As always, Nebraska’s CRNAs will work closely with surgeons, obstetricians, and other doctors in the delivery of safe, high-quality patient care. In 1999, the Institute of Medicine published a report stating that anesthesia care today is nearly 50 times safer than it was 20 years ago. CMS echoed that statement in the Federal Register last January. CRNAs provide 65 percent of all anesthesia care delivered each year in the United States.
"Opting out of the supervision requirement is great news for the citizens of Nebraska," said Deborah A. Chambers, CRNA, president of the 28,000-member American Association of Nurse Anesthetists. "AANA applauds the Board of Medicine, Board of Nursing, and Governor Johanns for making this decision and for recognizing that Nebraska’s CRNAs have long provided safe anesthesia care to patients of all ages, for all types of procedures, and in every setting in which anesthesia care is delivered."
Emphasizing that CRNAs are the predominant anesthesia providers in rural and other medically underserved areas, Chambers pointed out that without these advanced practice nurses many of the facilities serving these areas would be unable to maintain surgical, obstetric and trauma stabilization services. Further, rural areas have an uncommonly high population of Medicare beneficiaries.
Lending credence to Chambers’ comments about the importance of CRNAs to rural America is an article in the December 2001 newsletter of the American Society of Anesthesiologists (ASA) written by Michael Scott, JD, the society’s director of governmental and legal affairs. Scott wrote: "ASA is aware of considerable anecdotal evidence that increasing numbers of anesthesiologists are electing to move from, or not to enter, geographic areas with heavy Medicare populations." He went on to cite reimbursement levels as the main reason, stating that "Medicare anesthesia fees represent about 39 percent of private payment levels."
Despite this, ASA has opposed removal of the supervision requirement at both the federal and state levels, even though removal ensures access to care for patients in rural areas and allows facilities to staff their anesthesia departments to best serve their patients.
The first state to opt out of the supervision requirement was Iowa, which made the move in December 2001. In that state, 91 of 118 hospitals rely solely on nurse anesthetists to provide anesthesia care.