1. Lyttle, Bethany


Physicians challenge the 'opt-out' rule.


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Certified registered nurse anesthetists (CRNAs) are the focus of a lawsuit that would prevent them from administering anesthesia to Medicare patients in hospitals or ambulatory surgical centers without physician supervision. The suit, filed in February jointly by the California Society of Anesthesiologists (CSA) and the California Medical Association (CMA), alleges that Governor Arnold Schwarzenegger violated state law and failed to follow proper procedure when he opted out of federal Medicare requirements regarding physician supervision last summer. In addition, the suit suggests that the governor's action threatens patients' safety and compromises the quality of anesthesia care.

Figure. A CRNA adjus... - Click to enlarge in new windowFigure. A CRNA adjusts the flow of IV fluids during surgery. Photo by

"[Yet] the evidence is overwhelming that nurse anesthetists provide expert, high-quality, safe anesthesia care regardless of whether a physician is supervising," said Mitchell H. Tobin, senior director of State Government Affairs at the American Association of Nurse Anesthetists. "Tellingly, there hasn't been a single published report of adverse patient care related to opting out of the requirements in any of the 15 states [including California] that have done so" since November 2001, when the rule allowing state governors to opt out went into effect.


Access to care and facilities' flexibility are other concerns of those who don't support the CMA-CSA lawsuit. Approximately two-thirds of rural and small hospitals in California rely on CRNAs. Not only do they provide expert care, their lower salaries offset the limited budgets and shortage of anesthesiologists in these hospitals. In addition, facilities and the surgeons who practice in them have concerns about how to comply with the supervision requirement and about liability with respect to CRNA actions. However, case law demonstrates that surgeons are typically no more liable for a CRNA's actions than they are for those of an anesthesiologist, regardless of whether supervision is required. Opting out alleviates the concerns facilities and surgeons might have.


Mr. Tobin noted that not all physicians oppose states' opting out, saying that many surgeons recognize that anesthesia care isn't their area of expertise and view deference to CRNAs as both reasonable and safe.


And, with an aging U.S. population, increasing demand for surgical procedures is inevitable. For the hundreds of nurse anesthetists in California who safely and independently administer medication to prevent pain, induce sedation, and manage anesthesia during surgery every day, the implication is obvious: CRNAs are going to be needed more than ever. Without the ability to allow CRNAs to work without physician supervision, California's aging population will wait longer for care, and its hospitals, both small and large, will incur unnecessary costs: anesthesiologists' salaries are roughly twice those of their nurse counterparts.


Bethany Lyttle