September 17, 2014
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Medicare rule could be painful for patients
Janice Izlar

Federal officials at the Centers for Medicare & Medicaid Services are currently considering whether to maintain patient access to crucial pain-relief treatments provided by Certified Registered Nurse Anesthetists (CRNAs) – or to eliminate these services and risk leaving millions of Americans with chronic pain conditions to suffer on their own. They'll make their final decision later this fall.

For well over a decade, CRNAs have administered routine, chronic pain-management services such as opiate and steroid injections, ultrasound medical imaging and refills for implantable anesthetic pumps. At issue is whether these qualified anesthesia professionals should be allowed to continue providing such services.

Medicare officials have proposed rules that would preserve patient access to CRNAs – and it's crucial that they ratify them. If they don't, millions of patients who rely on CRNAs for pain management will unnecessarily suffer. So who, then, wants to "fix what isn't broken?"

The issue came to Medicare's attention last year when two companies contracted by the program to process insurance claims began refusing to directly reimburse CRNAs for the treatment they delivered.

The companies' actions broke sharply with Medicare's history: Since the mid-1980s, the program has allowed nurse anesthetists to care for beneficiaries.

If the two contractors' dictates stand – and if other contractors follow their lead – many patients will lose convenient access to excellent pain-management care for no apparent reason.

There simply aren't enough health care providers to care for the millions of Americans suffering from chronic pain, according to a recent report from the Institute of Medicine. In rural and other medically underserved areas in particular, physician anesthesiologists are in short supply.

Qualified CRNAs fill the void. Many rural patients depend on them for therapy. Without CRNAs, many would have to drive hundreds of miles to a hospital to see a physician, move into an unfamiliar institution like a nursing home far from family and friends, or even forego treatment entirely.

Such unfortunate outcomes are already befalling some patients. One CRNA in Montana continued to provide pain care to local seniors even though he knew his claims would be denied. He did this because his beneficiaries had no other source of care. Another nurse anesthetist working in Kansas reported that the alternative for her patients was a three-hour round-trip to a major city.

Such examples of patient suffering are particularly galling because the contractors' stance on nurse anesthetists makes no sense, especially in light of two recent landmark studies that confirmed CRNA safety and cost-effectiveness.

One study, published in 2010 in Health Affairs, examined 500,000 individual cases of CRNA-only anesthesia care and concluded that the care delivered was as safe as CRNA care provided under physician supervision.

Also in 2010, a study in the Journal of Nursing Economic$ showed that not only are CRNAs safe, but CRNAs working alone are the most cost-effective anesthesia delivery model – in fact, 25 percent more cost-effective than any other model.

The importance of this cannot be overemphasized in these times of economic turmoil and an overburdened health care system. In the area of pain management alone, patient care exceeds $600 billion per year.

Additionally, by managing patients' chronic pain regularly, CRNAs cut down on the need for other far costlier services and interventions, including ambulance transport to distant health care facilities, surgical procedures, or even institutionalization in nursing homes or other post-acute care facilities.

There are more than 45,000 nurse anesthetists in the United States who collectively deliver some 32 million anesthetics every year. These providers complete a nationally accredited training program requiring rigorous graduate-level education. Many CRNAs also undertake formal and informal fellowships.

In order to become CRNAs, candidates must study anatomy, physiology, pathophysiology, pharmacology, and pain management, as well as obtain clinical experience with regional anesthetic techniques such as spinal and epidural anesthesia.

About a third of Americans suffer from chronic pain. They depend on Medicare to preserve their ability to access the crucial care delivered by CRNAs. For the sake of pain patients all across the country, CMS must affirm the ability of CRNAs to operate independently with direct reimbursement, as has been the case for more than a decade. The alternative would be too painful for patients to bear.

Janice Izlar is a Certified Registered Nurse Anesthetist and President of the American Association of Nurse Anesthetists.


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