[Congressional Record Volume 140, Number 46 (Monday, April 25, 1994)]
[Extensions of Remarks]
[Page E]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: April 25, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                 FAIR TREATMENT FOR NURSE ANESTHETISTS

                                 ______


                           HON. MIKE KREIDLER

                             of washington

                    in the house of representatives

                         Monday, April 25, 1994

  Mr. KREIDLER. Mr. Speaker, high quality health care for older 
Americans is the goal of the Medicare Program. Medicare is designed to 
pay for needed and appropriate care, by professionals qualified to 
provide that care. Among those qualified professionals are the 
certified registered nurse anesthetists who administer anesthesia 
during surgery and other procedures.
  All States license these highly trained professionals, and in many 
areas they are the only professionals who perform anesthesia services. 
Whether practicing independently or employed in hospitals and other 
facilities, nurse anesthetists administer two-thirds of the 26 million 
anesthetics given to patients each year in this country. They are the 
sole anesthesia providers in 85 percent of rural hospitals.
  Licensed as nurses, CRNA's perform the same functions as physicians 
who administer anesthesia, while working in collaboration with a wide 
range of other health professionals. Their education includes college, 
at least a year's experience in acute care nursing, a 2-year 
postgraduate nurse anesthesia program, including extensive didactive 
and clinical training, passing a national certification examination, 
and a continuing education program with mandatory recertification every 
2 years.
  Despite these qualifications and State laws enabling them to 
practice, nurse anesthetists face barriers to practice because of 
Medicare regulations that were intended to serve other purposes. I have 
introduced H.R. 4291, to revise those Medicare rules so that CRNA's can 
practice their profession to the full extent of their skills and 
training.
  The bill would resolve three major problems facing nurse anesthetists 
who serve Medicare patients:
  First, conditions of payment.
  Before 1982, some anesthesiologists billed Medicare for services that 
were performed mainly by nurse anesthetists, with little or no actual 
involvement by the anesthesiologist. In 1982, Congress required the 
Health Care Financing Administration to define more precisely how 
physicians are to be involved in directing the work of nurse 
anesthetists, in order to receive payment from Medicare.
  HCFA's regulations require that the physician participate in certain 
components of the anesthetic process, many of which could be 
appropriately handled by the nurse anesthetist without the physician's 
presence. Unfortunately, many hospitals have treated these regulations 
as quality of care standards, instead of conditions for paying 
physicians. The results have been to restrict unnecessarily the scope 
of many nurse anesthetists' practice to less than State laws allow, and 
to cause duplication of effort and periodic delays in treatment.

  H.R. 4291 would require HCFA to revise its regulations so as not to 
restrict nurses from performing all State-authorized services, while 
maintaining the original objective of preventing fraud and abuse. 
Additionally, the bill would eliminate these medical direction 
conditions of payment in 1998, when Medicare will pay the same for 
medically directed and nonmedically directed anesthesia services.
  Second, physician supervision of nurse anesthetists.
  Medicare regulations now require physician supervision of nurse 
anesthetists, as a condition for hospitals or ambulatory surgical 
centers to receive Medicare payment, despite State laws allowing nurse 
anesthetists to practice without such supervision. H.R. 4291 would 
prohibit HCFA from requiring physician supervision of anesthetists 
unless such supervision is required by State law.
  The bill would also eliminate current limits on the ratio of 
anesthesiologists to nurse anesthetists in a medically directed 
setting, when Medicare payments for medically directed and solo 
anesthesia services reach the same level in 1998. Removing these limits 
will allow health professionals in different localities to determine 
appropriate anesthesia delivery patterns, rather than having them 
determined indirectly by Medicare.
  Third, parity of payment when two professionals provide a service.
  Often an anesthesiologists and a nurse anesthetist work together on a 
procedure. Unless the Medicare carrier determines that the services of 
both professionals were medically necessary, Medicare typically pays 
the physician the whole fee and the anesthetist nothing. When the 
anesthetist is a hospital employee, the hospital takes the loss.
  H.R. 4291 would provide, in cases where two professionals performed a 
service jointly, that the fee otherwise payable to the physician be 
divided equally between the physician and the nurse anesthetist--or his 
or her employer. While Medicare should not have to pay for more service 
than was needed, there is no good reason to penalize the nurse 
anesthetist alone.
  Mr. Speaker, this legislation would add no cost to the Medicare 
Program, and could reduce costs by encouraging more use of cost-
effective nurse anesthetist services. I urge my colleagues to support 
it.
  The Text of H.R. 4291 follows:

                               H.R. 4291

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. REVISION OF CONDITIONS OF PAYMENT RELATING TO 
                   ANESTHESIA SERVICES FURNISHED BY CERTIFIED 
                   REGISTERED NURSE ANESTHETISTS.

       (a) Promulgation of Revised Regulations.--The Secretary of 
     Health and Human Services shall revise any regulations 
     describing the conditions under which payment may be made for 
     anesthesia services under the medicare program so that--
       (1) payment may be made for anesthesia services furnished 
     in a hospital or an ambulatory surgical center by a certified 
     registered nurse anesthetist who is permitted to administer 
     anesthesia under the law of the State in which the service is 
     furnished; and
       (2) the conditions under which payment may be made for a 
     physician service consisting of the medical direction or 
     medical supervision of a certified registered nurse 
     anesthetist meet the requirements of subsection (b)(1).
       (b) Requirements for Medical Direction Described.--
       (1) In general.--The requirements of this subsection are 
     that the conditions under which payment may be made for the 
     medical direction or medical supervision of a certified 
     registered nurse anesthetist--
       (A) shall not restrict such nurse anesthetists working with 
     anesthesiologists from performing all the components of the 
     anesthesia service that such nurse anesthetists are legally 
     authorized to perform in the State in which the service is 
     furnished; and
       (B) shall prevent fraud and abuse in payment for anesthesia 
     services by requiring that the physician providing medical 
     direction or medical supervision must be physically present 
     in the facility where the certified registered nurse 
     anesthestist's services are performed and be available in a 
     timely manner for consultation or assistance if indicated.
       (2) Consultation required.--The Secretary shall revise the 
     regulations referred to in subsection (a)(2) after 
     consultation with representatives from professional 
     associations of certified registered nurse anesthetists and 
     anesthesiologists.
       (c) Effective Date.--The revisions to the regulations 
     referred to in subsection (a) shall apply to anesthesia 
     services furnished on or after January 1, 1995.
       (d) Termination of Regulations on Medical Direction or 
     Supervision.--The regulations referred to in subsection 
     (a)(2) shall be repealed effective January 1, 1998.

     SEC. 2. ENSURING PAYMENT FOR PHYSICIAN AND NURSE FOR JOINTLY 
                   FURNISHED ANESTHESIA SERVICES.

       (a) Payment for Jointly Furnished Single Case.--
       (1) Payment to physician.--Section 1848(a)(4) of the Social 
     Security Act (42 U.S.C. 1395w-4(a)(4)), as added by section 
     13516(a) of the Omnibus Budget Reconciliation Act of 1993 
     (hereafter referred to as ``OBRA-1993''), is amended by 
     adding at the end the following new subparagraph:
       ``(C) Payment for single case.--Notwithstanding section 
     1862(a)(1)A), with respect to physicians' services consisting 
     of the furnishing of anesthesia services for a single case 
     that are furnished jointly with a certified registered nurse 
     anesthetist, if the carrier determines that the use of both 
     the physician and the nurse anesthetist to furnish the 
     anesthesia service was not medically necessary, the fee 
     schedule amount to be applied shall be equal to 50 percent of 
     the fee schedule amount otherwise applicable under this 
     section if the anesthesia service were personally performed 
     by the physician alone.''
       (2) Payment to crna.--Section 1833(l)(4)(B) of such Act (42 
     U.S.C. 13951(l)(4)(B)), as added by section 13516(b) of OBRA-
     1993, is amended by adding at the end the following new 
     clause:
       ``(iv) Notwithstanding section 1862(a)(1)(A), in the case 
     of services of a certified registered nurse anesthetist 
     consisting of the furnishing of anesthesia services for a 
     single case that are furnished jointly with a physician, if 
     the carrier determines that the use of both the physician and 
     the nurse anesthetist to furnish the anesthesia service was 
     not medically necessary, the fee schedule amount shall be 
     equal to 50 percent of the fee schedule amount otherwise 
     applicable under this section if the anesthesia service were 
     personally performed by the physician alone.''.
       (b) Uniform Treatment of All Multiple Concurrent Cases.--
     Section 1848(a)(4) of such Act (42 U.S.C. 1395w-4(a)(4)) and 
     section 1842(b)(13) of such Act (42 U.S.C. 1395u(b)(13)), as 
     amended by section 13516(a) of OBRA-1993, are each amended--
       (1) by striking ``two, three, or four'' each place it 
     appears and inserting ``two or more''; and
       (2) by inserting ``or medical supervision'' after ``medical 
     direction'' each place it appears.
       (c) Effective Date.--The amendments made by subsection (a) 
     and (b) shall apply to services furnished on or after January 
     1, 1995.

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