Colorado seeks to end doctor oversight of nurse anesthetists

Proponents say rural access to health care will improve. But opponents say patient safety is at risk.

By Myrle Croasdale, amednews staff. Oct. 13, 2003.

Colorado is on the verge of becoming the eighth state to take advantage of a federal offer to opt out of a Medicare rule that requires physician supervision of certified registered nurse anesthetists.

The Colorado Society of Anesthesiologists, which opposes the move, has filed a lawsuit in Denver District Court against Gov. Bill Owens alleging that an opt-out would violate the state's laws. The governor has asked the court to dismiss the case and has succeeded in removing what many consider to be the other big barrier to opting out by convincing the state health department to lift its requirement for physician supervision of CRNAs. The governor has yet to formalize the opt-out on the federal level.

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Region: West

The two sides in this struggle agree that Colorado's rural population needs better access to medical care. They disagree, however, on how to deliver it. Opponents say physician supervision of CRNAs is the safest approach to anesthesia and that lifting this requirement would compromise patient care. Proponents argue that CRNAs have an excellent safety record and that ending the oversight requirement would improve health care for Colorado's rural residents, because more physicians would be willing to do surgery in rural areas if they weren't required to sign off on the work of CRNAs.

Issue important to rural FPs

While most state and national physician organizations, including the AMA, oppose relinquishing physician oversight of CRNAs, the Colorado Academy of Family Physicians board of directors is supporting the governor's proposal.

Ned Calonge, MD, chair of the academy's board and chief medical officer for the state's department of public health and environment, said the academy's rural constituency made it clear this was an important issue to them.

They say the oversight requirement is an ongoing hindrance to recruiting new physicians to rural communities. Physicians considering rural areas don't want the added liability of being responsible for CRNAs, Dr. Calonge said. Their concerns are mirrored by specialists who are asked to go to rural areas for one-day clinics.

"Several board of director members said the same thing," Dr. Calonge said. "They couldn't get metro-area surgeons to come and provide surgical services because of this requirement."

Sharon Hammond, MD, past president of the American College of Surgeons Colorado chapter, acknowledged that some in the group favor having the state opt out of the Medicare requirement, but the organization is against relinquishing physician oversight.

"There are mixed feelings on both sides," she said. "The ACS national policy is not in favor of opting out, and that's our chapter's stance."

Those in favor of maintaining physician supervision say the loss of physician oversight would be detrimental to patient care.

According to the American Society of Anesthesiologists, estimates for the number of deaths attributed to anesthesia have dropped from 1 in 10,000 anesthetics to 1 in 250,000 in the past 10 years. This improvement is due in part to new technologies and new pharmaceuticals, but anesthesiologists say their leadership of the anesthesia team has been critical to these safety gains.

Statistics on CRNA safety performance in states that have opted out of the Medicare requirement are not yet available. Anecdotally, the health department in Iowa, the first state to adopt the opt-out, said no negative incidents involving a CRNA had been reported since anesthetists were allowed to work without physician oversight in December 2001.

Randall Clark, MD, past president of the Colorado Society of Anesthesiologists, said studies demonstrate that the safest scenario is to have an anesthesiologist oversee anesthesia.

The next best situation is to have the physician doing the procedure take responsibility. Removing the physician entirely is not good medicine, he said.

"There is no evidence to show that this change is safe," he added.

Access debate

Diane Turpin, associate director of governmental and legal affairs for the American Society of Anesthesiologists, said taking away the supervision requirement means an anesthesia problem could arise that the nurse doesn't have the skills to handle.

"The doctor could say, 'That's not my job; let the nurse deal with it,' " she said. "There needs to be a physician medically managing the patient. The nurse may not know enough about a medical condition to correct for whatever is going on."

But Dr. Calonge said physicians don't need to be legally responsible to respond to problems in surgery. "The doctor is still in the operating room and will still respond if something happens to the patient," Dr. Calonge said. "Care would continue exactly as it does now, but the doctor wouldn't have to sign the CRNA chart."

Dr. Clark said it was unethical for a doctor to avoid overseeing a CRNA. "We think patients expect physicians to take that responsibility," he said.

For family physician John Fox, MD, chief of medical staff at Lincoln Community Hospital in Hugo, Colo., the opt-out could mean he is able to offer more services to his patients, some of whom drive 70 miles to get to his office and have to go another 100 miles to Denver to get to the nearest tertiary medical center.

Dr. Fox has organized day-long clinics during which surgeons from the Denver area come to see patients and perform procedures, but some surgeons have refused to participate in these clinics.

"I've heard repeatedly from specialists they'll be more than happy to do the surgery when they don't have to sign on the dotted line," he said, adding that they don't want to be held legally responsible. "The bottom line for me is that I have patients who need taking care of."

The anesthesiologists are sympathetic to the need for better access to care in rural areas. But Turpin said that while the exemption gives hospitals more flexibility in what anesthesia services they offer, it won't broaden access to care.

"I think that governors have been misled," Turpin said. "They've been persuaded that somehow hospitals will close their doors if they don't do this. Opting out doesn't improve access in any way we can see."

States began seeking to end physician oversight of CRNAs after November 2001 when the Bush Administration granted state governors the right to opt out of this Medicare rule if doing so would be in the public's best interest.