Anesthesia E-ssential, January 15, 2013

Anesthesia E-ssential

January 15, 2013


Vital Signs

Medicare Access to CRNA Pain Care Rule Takes Effect
The AANA-backed Medicare final rule authorizing direct reimbursement of all Medicare CRNA services within their state scope of practice took effect Tuesday Jan. 1, on schedule.
The development follows the publication of the Medicare access to CRNA pain care final rule last Nov. 1, and two months of work in which AANA members and allies contacted Congress and urged lawmakers to “protect my pain care” and oppose anti-CRNA “poison pill” provisions from being added to year-end budget legislation. Over 3,000 letters were sent to Congress from AANA members responding to appeals from AANA President Janice Izlar, CRNA, DNAP.
In the end, Congress cleared budget legislation for President Obama Jan. 1, and it did not include anti-CRNA poison pill provisions invalidating the Medicare agency’s final rule.
Meanwhile, the AANA is making available to state associations of nurse anesthetists a range of tools to help protect and advance CRNA practice in light of the Medicare rule. Medicare administrative contractors are implementing the rule for services beginning Jan. 1, 2013, and reviewing CRNA scope of practice in states. And some state legislatures beginning sessions in 2013 may have pain care on the docket. For further information, see the AANA’s statement and the rule.
For questions about Medicare reimbursement, contact the AANA Federal Government Affairs Division at For questions about state scope of practice, contact your state association leadership or the AANA State Government Affairs Division at


The Pulse

  • Register Today to Attend the Assembly of School Faculty
  • Available Volunteering Opportunities for CRNAs
  • AAPM Offers Discount in Honor of National Nurse Anesthetists Week
  • Request for Applications for the Safety Scientist Career Development Award (SSCDA)
  • Announcement from APSF: Request for Proposal
  • Wellness Resources Available Online
  • Upcoming Employment Webinar!
  • A Letter from Board of Trustees Chair Jack Hitchens
  • AcademyHealth Launches New Delivery System Science Fellowship
  • 2013 AANA Foundation Award Nominations Deadline Extended to March 1
  • AANA Foundation Student Scholarship Applications Available Online
  • Free Infection Control Webinar Coming in February
  • One Year’s Relief from Huge Medicare Cuts Included in “Fiscal Cliff” Bill
  • Medicare Releases 2013 Anesthesia Conversion Factor
  • Sequestration Threatens 2 Percent Cuts to Medicare, 7 percent - 9 Percent Cuts to Other Health Programs – but Not Medicaid or Veterans
  • MedPAC Again Recommends Congress Cut Anesthesia, Specialties 17 percent over Three Years; AANA Again Recommends Against It
  • New Congress Sworn In Jan. 3
  • AANA Addresses Noridian Medicare Denials for Cataract MAC Cases
  • AANA Submits Comments on Multistate Plans Proposed Rule
  • AANA Submits Comments Regarding Health Plan Quality in Exchanges
  • AANA Submits Comments on Essential Health Benefits Proposed Rule
  • No Partial Medicaid Expansions Under Affordable Care Act, HHS Says
  • 18 States and DC Establish Exchanges for Marketing Health Coverage
  • Still Seeking Nominations for the CRNA-PAC Committee
  • Name Your State Reimbursement Director

Healthcare Headlines

Healthcare Headlines is for informational purposes, and its content should not be interpreted as endorsements, standards of care, or position statements of the American Association of Nurse Anesthetists.

Inside the Association
Register Today to Attend the Assembly of School Faculty
February 21-23, at the JW Marriott Starr Pass Resort and Spa in Tucson, Ariz.
This year’s theme, “Information, Collaboration and Transformation in Education,” will include insights into integrity and ethics in academia, whether programs really need rural clinical sites, how to teach students the economics of nurse anesthesia practice, and the evolution of pain management education. You’ll also gain information on financial options for doctoral education, teaching health informatics, using electronic portfolios to document professional growth and more. In addition, the AANA Education Committee will be holding a hearing on the final first draft of the COA’s Practice Doctorate Standards for Nurse Anesthesia Programs. Don’t miss this exciting program and the chance to interact with your peers to exchange ideas on issues affecting nurse anesthesia education. Click here to register.
Available Volunteering Opportunities for CRNAs
One CRNA and two operating room nurses with pediatric experience are urgently needed for a medical mission trip to El Salvador organized by Healing the Children Southwest. This is an all-volunteer mission, therefore expenses are the responsibility of the volunteer. There may be an opportunity to apply for a small stipend. To learn more, email Bobbye at or call (505) 401-8576. To learn more about other volunteering opportunities, visit AANA’s Volunteerism webpage.

AAPM Offers Discount in Honor of National Nurse Anesthetists Week
In recognition of the efforts and work of nurse anesthetists, the American Academy of Pain Management (AAPM) is offering CRNAs $25 off of their first year of AAPM membership throughout National Nurse Anesthetists Week (Jan. 20-26). The AAPM is the largest pain management organization in the United States and the only organization to offer credentialing in pain management to CRNAs. To join, go to and use discount code AANA. Here are some of the benefits of belonging to AAPM:
  • Receive The Pain Practitioner, magazine quarterly.
  • Receive Currents, AAPM's e-newsletter monthly.
  • Credential with AAPM and become a Diplomate, Fellow, or Clinical Associate.
  • Gain exposure with a listing in the AAPM’s searchable clinician database.
  • Take advantage of networking opportunities with thousands of other clinicians.
  • Benefit from professional development through the Pain Management Learning Center (475 hours or online education).
  • Enjoy reduced registration rates for the AAPM's Annual Clinical Meeting.
  • Stay informed of updates on current regulations and legislation Advocacy Alerts. 

Request for Applications for the Safety Scientist Career Development Award (SSCDA)
Application deadline: Nov. 1, 2013
The Anesthesia Patient Safety Foundation (APSF) is soliciting applications for training grants to develop the next generation of patient safety scientists. In this initial proof of concept request for applications, APSF intends to fund one ($150,000 over two years) Safety Scientist Career Development Award to the sponsoring institution of a highly promising new safety scientist. The award will be scheduled for funding to begin July 01, 2014. Contact to request the SSCDA grant guidelines and application.

Announcement from APSF: Request for Proposal
The Anesthesia Patient Safety Foundation (APSF) announces a Request for Proposals (RFP) to study the implementation and performance of the APSF Pre-Anesthetic Induction Patient Safety Checklist (PIPS). The deadline for receipt of a proposal is Nov. 1, 2013 for a grant scheduled for funding to begin May 1, 2014.
  • APSF intends to provide up to $200,000 for a period not to exceed two years.
  • The proposed study should be a prospective observational clinical trial utilizing the  APSF PIPS checklist with a matched and/or parallel control group not cared for with the utilization of the checklist.
  • The proposals will be evaluated by a scientific review committee selected by APSF.
  • Proposals will be assessed for merit based primarily on their likelihood of meeting the contractual objectives outlined in the RPF as well as the proposed study’s scientific rigor, innovation, and cost-effectiveness.
  • The principal investigator must be an experienced scientist from a North American institution.
  • A contract mechanism will be used and funds will be awarded to a single institution.
  • Funding will be contingent upon acceptable modifications to the proposal based on feedback from the APSF review committee as well as appropriate IRB and institutional approvals.
Please contact to request grant guidelines and  an application
Wellness Resources Available Online
The AANA Health and Wellness’ online resources include postings of related recently published research and articles.  We’ve included a link to “My Story: How One Percocet Prescription Triggered My Addiction, ” a narrative with editorial commentary in the American Journal of Toxicology that portrays the perfect storm for rapid escalation that can emerge when an addiction vulnerable healthcare provider is prescribed routine narcotic pain medication.  

Upcoming Employment Webinar!
Upcoming Employment Webinar! The AANA State Government Affairs Division is hosting its latest webinar, “Most Prevalent Employment Issues Facing CRNAs” on Feb.6.The webinar, presented by AANA's General Counsel, Mark Silberman, JD, will discuss the most prevalent employment issues facing CRNAs. Silberman will help attendees understand various factors that may have an impact on their work environment and explain legal issues that should be taken into consideration when dealing with an employment situation.To register, go to

A Letter from Board of Trustees Chair Jack Hitchens
On behalf of everyone at the AANA Foundation, I would like to extend our warmest wishes for a happy, healthy and prosperous New Year. Last year was an eventful year for the Foundation.  With your help and support, in 2012 we were able to:
  • Award 62 students with $118,500 in scholarships, plus present one Post-Doctoral and 11 Doctoral Fellowships
  • Recognize and Honor:
    - Bruce Schoneboom, CRNA, PhD, FAAN – Researcher of the Year
    - Celeste Hinzmann, CRNA – Advocate of the Year
    - Goldie Brangman, CRNA – Rita LeBlanc Philanthropist of the Year Award:
    - Ronda L. Davis, CRNA, MSN – Janice Drake CRNA Humanitarian Award, and
    - Jamie Tessier, CRNA – Jack Neary Pain Management Award
  • Arrange for 100 poster presentations at the AANA Annual Meeting
  • Provide a Grant Writing Workshop and Workforce Study Workshop
I am deeply grateful for the continued dedication and commitment of the entire Foundation team, as well as friends, families, colleagues, and donors who continue to support the Foundation’s efforts. We are poised for another eventful year in 2013.
All the very best to you and your family and friends in the New Year.
John T. “Jack” Hitchens, CRNA, BA
AANA Foundation
AcademyHealth Launches New Delivery System Science Fellowship
In partnership with prestigious delivery systems across the country, and with support from the AcademyHealth President’s Fund, AcademyHealth is pleased to announce a new fellowship for students and researchers interested in delivery system science. The Delivery System Science Fellowship provides a paid post-doctoral learning experience to help researchers gain experience conducting research in delivery system settings. To learn about the fellowship, see AcademyHealth’s website. A brief statement of intent to apply for the Fellowship must be submitted by Jan. 31, 2013. For more information, email
2013 AANA Foundation Award Nominations Deadline Extended to March 1
Each year the AANA Foundation presents awards at the AANA Annual Meeting to individuals who have made a difference in the nurse anesthetist community. The deadline for award nominations has been extended to March 1, 2013. Please take the time today to recognize someone you know. It is truly an honor to be nominated.
Click here to access the nomination/application forms for:
  • Advocate of the Year: Presented to an advocate committed to supporting the AANA Foundation and  encouraging others to do the same.
  • John F. Garde Researcher of the Year: Presented to an individual who has made a significant contribution to the practice  of anesthesia through clinical research. 
  • Rita L. LeBlanc Philanthropist of the Year: Presented to an individual who has donated time, talent and direct financial support to the AANA Foundation and other deserving organizations.
  • Janice Drake CRNA Humanitarian Award: Presented to a CRNA who wishes to volunteer and provide anesthesia, education and training in needy areas.
  • Jack Neary Pain Management Award: Presented to a CRNA to further knowledge and skills in pain management.
Forward the completed form to the AANA Foundation – email to or mail to 222 S. Prospect Avenue, Park Ridge, IL 60068. Thank you in advance for recognizing a member of the nurse anesthesia community.  If you have any questions, please contact the AANA Foundation at (847) 655-1170 or
AANA Foundation Student Scholarship Applications Available Online
The AANA Foundation is pleased to announce it will once again be offering scholarships in 2013 to students attending accredited CRNA programs. Applications for scholarships will be available online by Jan. 16, 2013 and the application deadline is April 1, 2013. Scholarship awards range from $1,000 to $3,000 each. In order to apply for a scholarship, you must be enrolled in a program for at least six months prior to April 1, 2013. The scholarships will be awarded at the 2013 AANA Annual Meeting in Las Vegas, Nev. If you have any questions, please contact the Foundation at (847) 655-1170, or

Free Infection Control Webinar Coming in February
A free webinar titled “Does Your Infection Prevention Program Meet Survey Requirements?” will be held on Thursday, Feb. 21, 2013, 1:15 p.m. - 2:15 p.m. CST. Objectives include: How to build an infection prevention program that meets survey requirements; how to ensure your existing program is up-to-date with current standards; and rules and regulations you may have missed in your survey preparation process. Marcia Patrick, RN, MSN, CIC, member of the board of directors for the Association for Professionals in Infection Control and Epidemiology, and Marsha Wallander, RN, associate director of accreditation services at the Accreditation Association for Ambulatory Health Care, will present. Click here to register!

One Year’s Relief from Huge Medicare Cuts Included in “Fiscal Cliff” Bill
Medicare Part B cuts to CRNA and physician services beginning Jan. 1 totaling 27 percent were averted with the enactment of legislation reversing the cuts for one more year, as part of a year-end package extending tax and other provisions associated with the federal “fiscal cliff.” Had the cuts taken effect, CRNAs and physicians would have faced mammoth reductions in Medicare payment, with far-reaching effects on patient access to care.

The Senate had cleared the bill, H.R. 8, as amended very early Tuesday, Jan. 1, on a bipartisan 89-8 vote. The House approved the measure late Jan. 1 on a bipartisan 267-167 margin supported by about nine-tenths of House Democrats and a one-third minority of the chamber’s majority Republicans, splitting House majority leadership votes that are usually united. President Obama signed the bill into law Jan. 2. In addition to the Medicare fix to the “sustainable growth rate” (SGR) cuts, the bill also contained:
  • Sec. 601(b), which specifies that quality measures reported through a qualified clinical data registry satisfy requirements for reporting quality measures to CMS, for 2014 and subsequent years. The provision authorizes the Secretary of Health and Human Services to establish requirements for such registries within certain guidelines, and orders a GAO study on the subject;
  • Sec. 609, which extends CMS’ contract with a “consensus-based entity regarding performance measurement,” presumably the National Quality Forum (NQF), through 2013;
  • Sec. 638, which authorizes CMS to look back five years in recouping Medicare overpayments, not three years as was previously the case; and,
  • Sec. 643, which establishes a 15-member Commission on Long-term Care.
Enactment of the legislation sets up several future fiscal deadlines for the U.S. government that should continue drawing AANA and CRNA attention. In late February 2013, additional “sequestration” cuts of 2 percent on Medicare and 8 percent-9 percent on other health programs (exempting Medicaid and Veterans Affairs) will take effect, unless Congress acts to cut spending or forestall the cuts some other way. Also in late February, Congress will have to take up the issue of the debt ceiling. In late March 2013, the fiscal year 2013 “continuing resolution” funding much of the U.S. government expires, unless Congress acts to extend it. And on Jan. 1, 2014, Medicare SGR cuts of some 31% will hit Medicare Part B, unless Congress acts.
Read the bill here; see how your senators voted here; and see how your representative voted here.
Medicare Releases 2013 Anesthesia Conversion Factor
The Medicare Part B mean anesthesia conversion factor for services provided in 2013 is $21.9143 per unit, up 1.7 percent over 2012 levels, according to information posted by the Medicare agency last week. Medicare calculates fee-for-service anesthesia payment according to the formula (base units plus time units) times (dollar value conversion factor). Anesthesia conversion factors vary by locality following agency analysis of local healthcare costs, from a low of $20.31 per unit in Nebraska to a high of $29.76 per unit in Alaska. Growth from 2012-2013 also varied by locality, from plus 1.47 percent in Alaska to plus 2.4 percent in Santa Clara and Ventura, Calif. Read the Medicare 2013 anesthesia conversion factor list here.
Sequestration Threatens 2 Percent Cuts to Medicare, 7 percent - 9 Percent Cuts to Other Health Programs – but Not Medicaid or Veterans
Now that the 27 percent Medicare Part B cuts have been averted for one year by an act of Congress, CRNAs still have other cuts to avert thanks to a “budget sequestration” process originally slated to hit Jan. 1, but forestalled two months to March 1, 2013. The budget sequestration process is an artifact of attempts by Congress and the White House to reach a major budget agreement in 2011 to get America’s fiscal house in order by means of a “supercommittee.” The supercommittee’s failure triggered a package of automatic spending cuts, known now as a “budget sequestration” process.

According to that process, half of approximately $1.2 trillion in cuts over 10 years – about $110 billion in cuts per year -- must come from defense and national security budgets, and the rest from elsewhere in Uncle Sam’s budget, exempting Medicaid and Veterans Affairs programs. Of specific CRNA interest, a September 2012 White House report making estimates of the impact of sequestration outlines possible cuts as follows:
  • Medicare, 2 percent reduction or $11.1 billion;
  • Defense health programs, 9.4 percent or $3.2 billion;
  • Centers for Disease Control nondefense portions, 8.2 percent or $464 million, and defense portions, 10.0 percent or $6 million;
  • Medicare program management, 8.2 percent or $38 million from discretionary accounts;
  • Healthcare fraud and abuse control accounts, 8.2 percent or $25 million;
  • Food and Drug Administration salaries and expenses, 8.2 percent or $318 million;
  • Health Resources and Services including Title 8 programs, 8.2 percent or $509 million;
  • Indian Health Services, 8.2 percent or $317 million; and,
  • National Institutes of Health, 8.2 percent or $2.518 billion.
MedPAC Again Recommends Congress Cut Anesthesia, Specialties 17 percent over Three Years; AANA Again Recommends Against It
The Medicare Payment Advisory Commission (MedPAC) expressed interest at its December meeting in recommending Congress “fix” the Medicare sustainable growth rate formula problem in part by reducing Medicare Part B anesthesia and specialty services payments 17 percent over three years. And just as quickly, the AANA has responded to MedPAC, outlining why such cuts are a bad idea.
During the session on physician, other health professional services, and ASCs, MedPAC retained its recommendation from October 2011 to fix the Medicare sustainable growth rate (SGR) funding formula over the next 10 years by cutting specialty care by 17 percent over three years while holding primary care payments immune from cuts. AANA’s response Dec. 12 stated, “Recognizing that MedPAC is considering its proposal as part of long-overdue ‘sustainable growth rate’ funding reform, no evidence suggests anesthesia services drive healthcare cost growth. CRNAs and other anesthesia professionals are not subject to referrals and cannot control service volume as other specialties do. On the contrary, peer-reviewed literature demonstrates that services delivered by Certified Registered Nurse Anesthetists (CRNAs) represent a highly cost-effective value to the healthcare system. A 17 percent cut to Medicare anesthesia services, just five years after Medicare increased anesthesia payment by 25 percent citing persistent undervaluation identified by an independent government agency, would deeply impair patient access to care.”
MedPAC also proposed to update payment rates for ambulatory surgical centers by 0.5 percent for 2014 and to require ASCs to submit cost data to CMS. During the session on hospital inpatient and outpatient services, MedPAC proposed to increase the payment rates for the inpatient and outpatient prospective payment systems in 2014 by 1 percent and, for inpatient services, to use the difference between the current payment rate and the recommended 1 percent update to offset increases in pay rates to recover past overpayments due to documentation and coding changes. These proposals will be voted on at the MedPAC’s January meeting. MedPAC provides its recommendations to Congress. While MedPAC’s recommendations are influential, they are not binding.
For further information on this meeting, visit To read the AANA letter to MedPAC, click here.

New Congress Sworn In Jan. 3
The 112th Congress finished its work with the dramatic votes to alleviate effects of the “fiscal cliff” Jan. 1, and on Jan. 3 the new 113th Congress, elected this past November, is sworn into office. On that day, AANA’s Federal Government Affairs team combed the halls of Congress, met more than 50 new and veteran legislators and their staffs, and spread the message of the value and importance of CRNA care.
The new Congress includes 14 new members of the 100-member Senate (nine Democrats, four Republicans, and an Independent) and 67 new Representatives in the 435-member House (29 Republicans, 38 Democrats, two vacancies). Compared with the previous Congress, the Senate has a slightly larger Democratic majority (functionally 55-45), and the House has a slightly smaller Republican majority (233-200). AANA members will shortly be invited to contact members of Congress to welcome them aboard and to educate them about CRNA care in their home state and district.
Several health panels in Congress get new leadership. The Senate Health Education Labor and Pensions (HELP) Committee now has Sen. Lamar Alexander (R-TN) as its top Republican, succeeding Sen. Mike Enzi (R-WY) who was termed out of his chairmanship and remains in the Senate. The HELP Committee is still chaired by Sen. Tom Harkin (D-IA). Meanwhile, the Senate Special Committee on Aging now has Sen. Susan Collins (R-ME) as its top Republican, succeeding Sen. Bob Corker (R-TN) who took the helm of another committee. This panel will get a new chair shortly; its former chairman, Sen. Herb Kohl (D-WI), did not run for reelection. For the first time, the Senate Appropriations Committee chair and the House Appropriations Committee ranking Democrat are women, Sen. Barbara Mikulski (D-MD) and Rep. Nita Lowey (D-NY) respectively. And the House Labor-HHS-Education Appropriations subcommittee that funds Title 8 nurse workforce development gets a new chair, Rep. Jack Kingston (R-GA). 
Noridian Medicare Denials for Cataract MAC Cases Addressed by AANA
The Medicare administrative contractor serving 10 Western states has been denying Medicare reimbursement for certain monitored anesthesia care (MAC) services in cataract cases since mid-December. Following an inquiry from the AANA, the contractor, Noridian Medicare, said that it was aware of the issue, and attributed the problem to a faulty computer systems update. Noridian said that it would publish an update for providers shortly. The AANA will make this information available to its members as soon as it receives it. States served by Noridian include Alaska, Arizona, Colorado, Oregon, Idaho, Montana, North Dakota, South Dakota, Utah, and Washington.
AANA Submits Comments on Multistate Plans Proposed Rule
The AANA requested on Dec. 19 that the Office of Personnel Management (OPM) require anesthesia and pain management services to be included in the 10 categories of essential health benefits provided by multi-state plan program issuers and multi-state plans offered through exchanges. A proposed rule that the agency issued in early December outlines the process by which OPM will establish the Multi-State Plan Program (MSPP).
Section 1334 of the Affordable Care Act creates the MSPP to foster competition among plans competing in the individual and small group health insurance markets on the exchanges on the basis of price, quality, and benefit delivery. The Affordable Care Act directs OPM to contract with private health insurance issuers to offer at least two multi-state plans (MSPs) on each of the exchanges in the 50 states and the District of Columbia.
In a letter signed by AANA President Janice Izlar, CRNA, DNAP, the AANA also requested that OPM require MSPs participating in exchanges to include CRNAs and other nonphysician providers who bill for Medicare Part B, and that these plans should align their payment systems to comply with state and federal non-discrimination provisions. The letter also asks for CRNAs to be included in MSP provider networks and that the agency provide guidance and further clarification on the fraud detection systems the agency is requiring MSPP issuers to create and operate.
AANA Submits Comments Regarding Health Plan Quality in Exchanges
When asked what opportunities exist to further the goals of the National Quality Strategy through quality reporting requirements in the exchange marketplace, the AANA replied Dec. 19 that the Department of Health and Human Services (HHS) should require that CRNAs and other non-physician providers who bill for Medicare Part B be included in qualified health plans (QHPs) participating in Exchange marketplaces.
The agency issued a request for information in late November regarding existing quality measures and rating systems, strategies and requirements for quality improvement, purchasing strategies to promote care redesign and patient safety, as well as effective methodologies to measure health plan value. Last year, HHS adopted the National Strategy for Quality Improvement in Health Care (National Quality Strategy) to create national aims and priorities that would guide local, state, and national efforts to improve the quality of health care. Furthermore, the Affordable Care Act contains several provisions that support healthcare quality improvement across the insurance marketplace, and places quality-related requirements on health insurance issuers offering QHPs in the Exchange marketplace, including section 1311 which directs QHP issuers to implement quality improvement strategies, enhance patient safety through specific contracting requirements, and publicly report quality data.
In a letter signed by AANA President Janice Izlar, CRNA, DNAP, the AANA also recommended that the agency include pain management services administered by CRNAs as a priority area for the quality rating for QHPs participating in the exchange marketplace. To view the proposed rule, visit (Requires AANA member login and password).  
AANA Submits Comments on Essential Health Benefits Proposed Rule
The AANA requested that the Department of Health and Human Services (HHS) should require anesthesia and pain management services to be included in the 10 categories of benefits provided by essential health benefits (EHB) benchmark plans participating in exchanges. A proposed rule that the agency issued in late November outlines exchange and issuer standards related to coverage of EHBs. Section 1302 of the Affordable Care Act provides for the establishment of an EHB package that includes coverage of EHBs.
The law directs that EHBs be equal in scope to the benefits covered by a typical employer plan and cover at least the following 10 general categories: Ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. EHB-benchmark plans are the standardized set of EHB that must be met by a qualified health plan or other participating in an Exchange.
In a letter signed by AANA President Janice Izlar, CRNA, DNAP, the AANA also requested that HHS require EHBbenchmark plans participating in exchanges to include CRNAs and other nonphysician providers who bill for Medicare Part B, and that plans offering essential health benefits in exchanges should align their payment systems to comply with state and federal non-discrimination provisions.


No Partial Medicaid Expansions Under Affordable Care Act, HHS Says
States may choose to receive federal funding to expand their Medicaid programs as the Affordable Care Act provides, or they may choose to reject the funding and the expansion. However, they may not go halfway and partially expand Medicaid in exchange for additional partial funding under the Affordable Care Act, Health and Human Services Secretary Kathleen Sebelius said Dec. 10.
The issue is important for CRNAs, because Medicaid expansion is a substantial share of the expansion of health coverage under the Affordable Care Act, and may come to affect the case and payment mix in your anesthesia practice. And while Medicaid today chiefly covers indigent mothers and their children, and elderly persons in nursing home settings, the Medicaid expansion may offer coverage to an entirely new population: adults with low incomes who have difficulty getting coverage from other sources. In other words, a program for children, mothers, and the elderly infirm is being expanded to cover adults between those three age groups. Learn more at
18 States and DC Establish Exchanges for Marketing Health Coverage
Eighteen states and the District of Columbia have agreed to establish exchanges for marketing health coverage under the Affordable Care Act, meeting a Dec. 14 deadline to declare their intentions to the U.S. Department of Health and Human Services (HHS). But that leaves 32 states to decide by Feb. 15, 2013, to enter into a “federal/state partnership” arrangement, or to have the federal government run the exchange in the state.
This issue is important to CRNAs, because provisions of the Affordable Care Act project adding some 40 million people to the health coverage rolls in the U.S., primarily through exchanges for marketing health coverage, and the rules that exchanges have for plan participation may shape coverage for CRNA services in that state. The exchanges are slated to be established by October 2013 and running by January 2014. Leaders of state associations of nurse anesthetists will want to be aware of points of contact for the health plan exchange in your state, to have a basic understanding of its status and governance, and to seek to name at least one CRNA to any state advisory body for the exchange.
The Kaiser Family Foundation is tracking information relating to exchanges: See the fact sheet on state efforts to create exchanges and the news article summarizing the current situation.
Still Seeking Nominations for the CRNA-PAC Committee
Nominations due January 31
The AANA is seeking nominees to serve as a member of the CRNA-PAC Committee. From a slate of member nominees provided by the AANA Board of Directors in February, the CRNA-PAC Committee elects two CRNAs each year for three-year terms and one student nurse anesthetist for a one-year term. Committee member responsibilities include setting and overseeing CRNA-PAC expenditure and income policy, determining funding of open-seat and challenger candidates, fulfilling duties at CRNA-PAC events and AANA national meetings, participation in fundraising duties, and attendance at CRNA-PAC Committee meetings. Candidates should have a strong interest in furthering the profession through federal advocacy. If you are interested in serving on the CRNA-PAC Committee, see (AANA member login required).
Name Your State Reimbursement Director
Has your state association of nurse anesthetists named its State Reimbursement Director yet? Now’s the time, and the breadcrumb trail for what to do and why to do it is available to state association leaders right now.
In September, your AANA Board of Directors approved the development of a State Reimbursement Director (SRD) Program, with the goal of representation from all 50 state associations of nurse anesthetists for effective reimbursement advocacy in each state. With the AANA’s Federal Political Director (FPD) Program as a template, the SRD will be the point person for reimbursement knowledge and advocacy in each individual state.
To appoint that person in your state, State Presidents should email the name and contact information of their SRD to: with the words “State Reimbursement Director” in the SUBJECT line. To request more information about the SRD program, any AANA member may contact us at that same email address and SUBJECT line.
For further information, see the SRD official solicitation including a job description. 
You can also read more CRNA reimbursement essentials here (requires AANA member login and password).
Gifts to political action committees are not tax deductible. Contributions to CRNA-PAC are for political purposes. All contributions to CRNA-PAC are voluntary. You may refuse to contribute without reprisal. The guidelines are merely suggestions. You are free to contribute more or less than the guidelines suggest and the association will not favor or disadvantage you by reason of the amount contributed or the decision not to contribute. Federal law requires CRNA-PAC to use our best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year. I am a US Citizen.


Merck Says FDA Is Reviewing Re-Filed Drug for Reversing Anesthesia After Surgery
The Food and Drug Administration (FDA) has agreed to take a second look at sugammadex, an experimental drug designed to reverse the post-operative effects of anesthesia. If approved, it will become the first in a new class of U.S. medicines made for this purpose. In 2008, the FDA rejected the intravenous drug due to concerns about allergic reactions and bleeding in some clinical trial subjects. The manufacturer, Merck & Co., has since submitted additional information requested by the regulator and anticipates that the federal review will be finished during the first half of 2013.
From "Merck Says FDA Is Reviewing Re-Filed Drug for Reversing Anesthesia After Surgery"
Greenfield Daily Reporter (IN) (01/07/13) 

Canadian Study Reveals High Rate of Residual Paralysis
Canadian researchers say the rate of residual paralysis in their country, reported at 10 percent to 15 percent, is highly underestimated. The RECITE (REsidual Curarization and its Incidence at Tracheal Extubation) study, conducted at eight centers during the second half of 2011, looked at the occurrence of neuromuscular blockade during routine anesthesia care. Among 141 patients undergoing laparoscopic or open abdominal operations, 57 percent experienced paresis at tracheal extubation and 45 percent upon arrival at the post-anesthesia care unit. Lead researcher Andre Galarneau, PhD, said the findings may warrant better use of traditional reversal agents, improved timing of reversal, and better patient monitoring. The study has implications as well for the United States, where as many as 40,000 surgical patients each year suffer severe respiratory complications due to unresolved neuromuscular blockade.
From "Canadian Study Reveals High Rate of Residual Paralysis"
Anesthesiology News (01/01/13) Vol. 39, No. 1 Vlessides, Michael

Effect of Intravenous Paracetamol on Postoperative Morphine Requirements in Neonates and Infants Undergoing Major Noncardiac Surgery
For infants undergoing major surgery, the use of intermittent intravenous paracetamol after the procedure leads to a lower cumulative morphine dose over 48 hours than with continuous morphine. Researchers sought to determine whether intravenous paracetamol (acetaminophen) would reduce morphine requirements by more than 30 percent among neonates and infants who underwent major surgery. The study was conducted in a pediatric intensive-care unit in the Netherlands in 71 infants under one year of age who underwent major thoracic or abdominal surgery between March 2008 and July 2010. All of the babies received a loading dose of morphine 30 minutes before the end of surgery and then either continuous morphine or intermittent intravenous paracetamol up to 48 hours after the procedure. According to the results, the cumulative median morphine dose in the first 48 hours after surgery was 66 percent lower in the paracetamol group. Pain scores and adverse effects were similar in the two groups.
From "Effect of Intravenous Paracetamol on Postoperative Morphine Requirements in Neonates and Infants Undergoing Major Noncardiac Surgery"
Journal of the American Medical Association (01/09/13) Ceelie, Ilse; de Wildt, Saskia N.; van Dijk, Monique; et al.

Peds Group Outlines Global Anesthesia Needs
The Society for Pediatric Anesthesia welcomed more than 700 attendees from around the globe to its two-day discussion on what needs to be done to improve anesthesia safety for the world's children. A focus of the event was the dearth of training and resources in low- and middle-income countries, where anesthesia-related mortality has not come down along with rates in developed nations. The need to delve further into the impact of anesthetic drugs on the brains of very young children, including developmental or behavior disorders—as well as how to prevent or address these problems—also was discussed. Other sessions at the first International Assembly for Pediatric Anesthesia looked at new technologies and reviewed some of the recent scientific research that has been conducted. Additionally, Peter Pronovost, MD, PhD, of John Hopkins spoke to the crowd. Credited with developing and implementing a safety checklist that has practically eliminated central-line catheter infections in intensive care units at Johns Hopkins, he challenged the anesthesia professionals in attendance to adopt at least one measure—such as learning from a defect in their medical setting or brainstorming a list of potential dangers to patients.
From "Peds Group Outlines Global Anesthesia Needs"
Anesthesiology News (01/01/13) Vol. 39, No. 1 Blum, Karen 
Study Reveals Why Morphine Can Increase Pain in Some Patients
Researchers are close to pinpointing the biological causes of morphine-induced pain hypersensitivity. A team of scientists in Canada, Italy, and the United States has identified "a molecular pathway by which morphine can increase pain," said senior author Dr. Yves De Koninck. The research is published in the journal Nature Neuroscience. The researchers found that patients with morphine tolerance have very different cellular and signaling processes from patients who experience morphine-induced pain. Specialized cells in the spinal cord called microglia may be the cause of morphine-induced pain hypersensitivity. When morphine acts on certain receptors in these cells, it triggers a series of events that increase—rather than decrease—the activity of pain-transmitting nerve cells. The molecule responsible for the side effect is the protein KCC2, which regulates the transportation of chloride ions and oversees sensory signals sent to the brain. These findings eventually could benefit individuals with intractable pain who have stopped opiate medications because of pain hypersensitivity.
From "Study Reveals Why Morphine Can Increase Pain in Some Patients"
RedOrbit (01/07/13)
Study: Dantrolene May Control Malignant Hyperthermia for All Anesthetics
Anesthesia-Analgesia reports on a study that explored whether facilities using succinylcholine by itself instead of volatile anesthetics still need to stock dantrolene, which is used to treat malignant hyperthermia (MH). Researchers observed whether succinylcholine resulted in MH, finding that the risk of the condition developing was greater than 1 both when succinylcholine was used and when it was not. Until more epidemiological evidence is amassed, the team said, both facilities where succinylcholine is administered and those where volatile anesthetics are used should continue to keep dantrolene readily available in case of an MH emergency.
From "Study: Dantrolene May Control Malignant Hyperthermia for All Anesthetics"
Becker's Hospital Review (01/03/13) Linder, Heather 

Is Dexmedetomidine More Cost-Effective Than Propofol?
Dexmedetomidine is becoming an increasingly popular choice of anesthetic for sedating mechanically ventilated patients following cardiovascular surgery, but administrators complain about the drug's steep wholesale price. New research suggests that, despite its higher upfront expense, dexmedetomidine is cost-effective in this setting. The single-site retrospective study involved 352 adult patients who had coronary artery bypass graft surgery and/or valve surgery at The Methodist Hospital in Houston in the first six months of 2011. The researchers compared 319 patients who received propofol as the primary sedation agent against 33 who received dexmedetomidine, taking into consideration the acquisition cost of the drugs as well as for any secondary anesthetics, costs associated with mechanical ventilation, and costs associated with delirium. The costs associated with delirium were comparable, but dexmedetomidine reduced time on the ventilator and also curtailed the need for second sedative agent. As a result, the investigators found dexmedetomidine to be cost-effective, with an average cost of sedation per patient at $1,647 compared to $1,831 for propofol.
From "Is Dexmedetomidine More Cost-Effective Than Propofol?"
Pharmacy Practice News (12/12) Vol. 39 O'Rourke, Kate

Lower Dose of Dexamethasone Effective in Reducing Post-Operative Nausea
Researchers at Chicago's Northwestern Memorial Hospital set out to determine an optimal dose for dexamethasone, which calms anesthesia-induced nausea and vomiting following surgery. As reported in Anesthesia-Analgesia, the study involved 6,696 subjects who participated in 60 randomized clinical trials. The results revealed similar outcomes among those who received 4 mg to 5 mg of intravenous dexamethasone and those who received doses of 8 mg to 10 mg of the drug. The research favors administering the lower dosage, which achieves comparable antiemetic benefits while using less medicine.
From "Lower Dose of Dexamethasone Effective in Reducing Post-Operative Nausea"
Becker's ASC Review (12/12) Linder, Heather 
'Sensory' Block Promise for Postop Knee Pain

The use of an adductor canal block rather instead of femoral nerve block for analgesia after knee surgery may help minimize muscle weakness and the risk of falling, according to a study published in Anesthesiology. The study in 11 healthy volunteers showed that a femoral nerve block reduced quadriceps strength by 49 percent, but an adductor canal block reduced it by just 8 percent. An accompanying editorial pointed out that the study cannot compare the quality of postoperative analgesia provided by the two blocks. The double-blind study participants received femoral nerve block with ropivacaine in one limb and with placebo in the other. On another day, they received an adductor canal block under the same criteria. Researchers then assessed the subjects' maximum voluntary isometric contraction for quadriceps and adductor muscles. Adductor muscle strength was reduced by 5 percent after the adductor canal block, 10 percent after the femoral nerve block, and 1 percent after a placebo block. All volunteers could complete mobilization assessments after the adductor canal block, but up to six of them failed to complete these tests at hours one and six after a femoral nerve block.
From "'Sensory' Block Promise for Postop Knee Pain"
News-Medical.Net (12/19/12) McDermid, Eleanor 

Administration of N20 + ISO Appears to Have Negative Effect on Fetal Development
While the existing body of research indicates that inhaled anesthesia does not present a risk for pregnant patients, a new study contradicts the general consensus. Reporting in Systems Pharmacology in December, Drs. Fang Liu and Cheng Wang of the National Center for Toxicological Research in Arizona suggest that an anesthetic compound used routinely on expecting mothers actually may have an unfavorable effect on fetal development. Lab studies point to increased neuronal cell death, as well as a change in the gene expression of brain tissues, in post-natal rates administered a combination of nitrous oxide (NO2) and isoflurane (ISO). Although the brain tissue of post-natal rats appears to be more sensitive to NO2+ISO than adult brain tissue, the findings raise concerns that fetuses or newborns could suffer as a result of long-term exposure to this anesthetic regimen.
From "Administration of N20 + ISO Appears to Have Negative Effect on Fetal Development" (12/14/2012) 

Dirty Medical Needles Put Tens of Thousands at Risk in USA
Since 2001, more than 150,000 U.S. patients have been victims of unsafe injection practices, two-thirds of which were in the past four years, according to the U.S. Centers for Disease Control and Prevention. Unsafe injection practices have led to at least 49 disease outbreaks. One patient contracted hepatitis from an endoscopy center, which was found to have reused syringes to draw anesthetic from vials that were used for multiple patients. While the overwhelming majority of injections are administered safely and without incident, about 5 percent of clinicians do not follow accepted safety standards. Unsafe injections have been found to be more common in clinics, smaller outpatient facilities, and long-term care centers. The largest outbreaks have been linked to the reuse of syringes or the injection of multiple patients from single-use vials; many of these occur at stand-alone clinics, such as oncology and endoscopy facilities, or outpatient surgical settings. While the pharmaceutical industry could help the problem by manufacturing drugs in vial sizes better suited for doctors' requirements, a more urgent need is better education of clinicians on best injection practices.
From "Dirty Medical Needles Put Tens of Thousands at Risk in USA"
USA Today (12/28/12) Eisler, Peter

Rising Painkiller Addiction Shows Damage From Drugmakers' Role in Shaping Medical Opinion
Two earlier research studies said addiction problems related to OxyContin and other opioids were minimal, but the findings have been called into question in recent years as the destructive power of opiates has emerged. The nation is confronting an ongoing epidemic of addiction to prescription painkillers — more widespread than cocaine or heroin — that has left nearly 2 million in its grip, according to federal statistics. Doctors had only prescribed opioids for cancer or acute pain patients, but sources indicate drug manufacturers have been generating scientific research to show that the drugs are not addictive and should be used for other chronic conditions, like sore backs, knees, and arthritis. The studies report minimal risks of addiction and dependence, which were accepted by the U.S. Food and Drug Administration and medical journals, and medical boards in turn loosened their rules on prescriptions for opioids. However, a Washington Post investigation reveals that those claims were developed in studies supported by drug manufacturers. A review of 16 key clinical trials on the subject shows that five were funded by Purdue and an OxyContin distributor, two were co-authored by Purdue employees, and two were sponsored by other drug companies making different opioids. Meanwhile, subsequent research has shown that opioids are highly addictive, with Yale School of Medicine investigators saying diagnoses of addiction are "common" in patients given opioids for back pain.
From "Rising Painkiller Addiction Shows Damage From Drugmakers' Role in Shaping Medical Opinion"
Washington Post (12/30/12) Whoriskey, Peter
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