More states are taking advantage of a Medicare opt-out provision that enables certified registered nurse anesthetists (CRNA) to administer anesthesia at Medicare-participating hospitals without the supervision of a physician.

The anesthesia care rule, first published by the Centers for Medicare & Medicaid in November 2001 allows state governors to notify CMS in writing of the state’s desire to opt out of the Federal supervision requirement after meeting the following criteria:

  •             Consulting with the state’s boards of medicine and nursing.
  •             Determines that opting out is consistent with state law.
  •             Decides that opting out is in the best interest of the state’s citizens.

Within the last nine years 16 states have applied for the exemption in an effort to provide anesthesia services in poor and rural communities that have trouble attracting physicians and cannot afford an anesthesiologist.

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Colorado, the most recent state to opt out in September 2010, pursued the exemption shortly after the publication of two studies confirming the safety and cost-effectiveness of nurse anesthetists.

Data from a study conducted by Jerry Cromwell, PhD, senior fellow in health economics at the independent research firm RTI International and colleagues found that patient outcomes were the same among opt-out states and those where physician supervision is required.  The study, which examined about 500,000 cases in 14 states, was published in the August 2010 issue of Health Affairs.

“We find no evidence that opting out of the oversight requirement harms patients in any way,” Cromwell said in a press release. “Based on these findings we recommend that CMS repeal the supervision rule.”

Findings from a separate study indicated that having a CRNA as the sole anesthesia provider was more cost effective than a physician anesthesiologist acting solo or supervising a group of one to six CRNAs. These data were first published in the May/June issue of The Journal of Nursing Economics.

Despite favorable evidence, some physician organizations have challenged state opt outs.  The Colorado Medical Society and the Colorado Society of Anesthesiologists filed a lawsuit against Colorado Gov. Bill Ritter Jr. on Sept. 28. The case is still pending.

But on Oct. 8, a California Superior Court judge ruled in favor of independent nurse anesthesiologists on the grounds that there is no state statute that requires physician supervision, after the California Medical Association and the California Society of Anesthesiologists sued Gov. Arnold Schwarzenegger.

The ruling came following a landmark report from the Institute of Medicine (IOM) that urged policymakers to remove barriers that may hinder nurses from practicing to the full extent of their education and training in the wake of health care reform.

“Transforming the nursing profession is a crucial element to achieving the nation’s vision of an effective, affordable health care system that is accessible and responsive to all,” Linda Burnes Bolten, PhD, RN, vice chair of the IOM’s committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, said in a statement.

Paul Santoro, CRNA, president of the American Association of Nurse Anesthetists said the three reports were further evidence of the important role that nurses play in the U.S. health system, adding, “it is long overdue that these highly qualified professionals be allowed to practice to the full extent of their capabilities, ensuring all Americans access to safe, affordable healthcare.”