Writer All Wrong About Anesthesia Administration Issue

As a certified registered nurse anesthetist, or CRNA, practicing for the past 16 years here in Spokane, I was alarmed by the July 11 Opinion page commentary by Betsy McCaughey, “Standard of Safety Going Down.” It contains many errors and does a disservice to both CRNAs and the anesthesiologists with whom we often work. This type of muck-raking to stimulate controversy is irresponsible.

The issue, which concerns an upcoming Health Care Financing Administration rule change, is difficult enough to explain to the layperson without a politician such as McCaughey injecting falsehoods. CRNAs and anesthesiologists are at odds about this. But our patients need to know that, because of the overlap of our professions, in our long histories this has often been the case. We are used to it. However, we all bring special skills to the health care arena and can all be supremely proud of our records in providing safe, quality anesthesia care.

It’s distressing that this most recent battle has caused the gloves to come off and non-anesthetists such as McCaughey to weigh in with remarkable misstatements of the facts. Let me set the record straight by responding to statements from McCaughey’s commentary:

* McCaughey writes, “Until now, the federal government … set a standard that every surgery patient must have an anesthesia care team with a nurse anesthetist supervised by a physician trained in anesthesiology.” The truth: There is no such standard set by Medicare or HCFA and there has never been such a standard. (See the Medicare Handbook for Hospitals, available through http://www.hcfa.gov/pubforms/p2192ch2.htm)

* “Now, the nurse and the doctor share the fee paid by Medicare. Once the physician safeguard is dropped, the fee stays the same and the nurse anesthetist pockets the whole fee.” The truth (and the crux of the issue): Currently, if a physician “medically directs” a CRNA, the physician and CRNA share the fee. A physician who “supervises” a nurse anesthetist is not reimbursed and the CRNA is reimbursed the whole anesthesia charge. When HCFA’s regulation change takes effect there will no longer be a requirement by Part A Medicare that a physician “supervise” the CRNA - a service for which physicians were not directly reimbursed and which was never clearly defined by Medicare.

(Note that “medical direction” and “supervision” are distinct, noninterchangeable terms in this context.)

* “A study of postoperative deaths related to anesthesia, published in the North Carolina Medical Journal, showed that patients treated by a nurse anesthetist alone had a significantly higher mortality rate than patients treated by an anesthesia care team with a supervising physician trained in anesthesiology.” The truth: McCaughey refers to -Bechtoldt, A. (1981). “Committee On Anesthesia Study. Anesthetic-Related Deaths: 1969-1976.” North Carolina Medical Journal 42: 253-259. The authors of that article actually concluded that: “the incidence (of death) among the three major groups (the CRNA, the anesthesiologist, and the combination of CRNA and anesthesiologist) to be (sic) rather similar” (pp. 257-258).

* McCaughey writes, “The Stanford Center for Health Care Research analyzed patients undergoing 15 types of surgery and found that those who received their care from a nurse anesthetist alone had an 11 percent higher-than-expected rate of death or severe illness after surgery.” The truth: McCaughey cites a study referred to in - Forrest, W. (1980). Outcome - The Effect of the Provider. Health Care Delivery in Anesthesia. R. Hirsh, W. Forrest, et al. Philadelphia, George F. Stickley Company: 137-142.-. Again, what the authors - actually - concluded was that: “using conservative statistical methods, … there were no significant differences in outcomes between the two groups of hospitals defined by type of anesthesia provider.” (p 141).

* McAughey writes, “… they first announced the Medicare requirement that nurse anesthetists be supervised by an anesthesiologist.” The truth: Again, as pointed out in above, Medicare does not and has not had such a requirement.

As to Dr. John Neeld Jr.’s comment, which McCaughey quoted, I suggest that if a patient is being prepared for surgery and their anesthetist announces, “Good morning, Mr. Jones, I am about to dangle you by a thin thread over the abyss for your knee operation,” they should ask for another anesthetist.