[Congressional Record Volume 145, Number 56 (Thursday, April 22, 1999)]
[Senate]
[Pages S4117-S4118]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. CONRAD (for himself, Mr. Craig, and Mr. Dorgan):
  S. 866. A bill to direct the Secretary of Health and Human Services 
to revise existing regulations concerning the conditions of 
participation for hospitals and ambulatory surgical centers under the 
Medicare program relating to certified registered nurse anesthetists' 
services to make the regulations consistent with State supervision 
requirements; to the Committee on Finance.


                  Anesthesia Service Preservation Act

  Mr. CONRAD. Mr. President, I rise today to introduce legislation 
which would help clarify an issue that relates to Medicare coverage for 
anesthesia services and its impact on rural health care.
  As a senator representing a predominantly rural state, I know only 
too well the difficulties facing rural health care needs. Access to 
care in rural areas is slowly worsening as more and more rural 
hospitals close their doors in the face of overwhelming cost pressures. 
Clearly, one aspect of access to care is access to surgical procedures. 
And without anesthesia services, general surgery becomes impossible.
  Certified registered nurse anesthetists (CRNAs) tend to be the 
predominant anesthesia provider in rural and undeserved urban areas. In 
fact, CRNAs are the sole anesthesia provider in 65% of rural hospitals 
and in addition, provide at least 65% of the nation's anesthesia needs. 
The simple fact is that anesthesiologists have not been moving into 
rural areas in any significant numbers, and are not expected to do so 
in the foreseeable future. Given this trend, if rural hospitals are 
going to stay open, they desperately need CRNAs for their anesthesia 
and ultimately their surgical needs. That means we have to maintain a 
healthy supply of CRNAs to maintain access to care for rural Medicare 
beneficiaries.
  Unfortunately, current Medicare rules with respect to supervision 
provide a disincentive for hospitals to use nurse anesthetists. 
Medicare's regulations require physician supervision of CRNAs as a 
condition for hospitals or ambulatory surgical centers to receive 
Medicare reimbursement, despite many state laws that allow nurse 
anesthetists to practice without such supervision. Although HCFA has 
issued a proposed rule that would drop this requirement and defer to 
states on the issue of supervision, this rule has never been finalized.
  The federal supervision requirement creates several problems for 
CRNAs. First, some surgeons and hospitals have been dissuaded from 
working with

[[Page S4118]]

CRNAs, in the face of arguments that the physicians may be subjecting 
themselves to liability for engaging in supervision. But the truth is, 
the attending physician--or the hospital--is no more legally liable for 
the CRNAs actions than he or she is for the acts of an 
anesthesiologist. Second, the federal restriction is anti-competitive, 
acting as a disincentive for CRNAs to be used. Finally, the restriction 
creates an inaccurate perception among some surgeons that they have an 
obligation to direct or control the substantive course of the 
anesthetic process, even though there is no such obligation.
  The legislation I am introducing today would eliminate the Federal 
supervision requirement and instead direct Medicare to defer to state 
law requirements on supervision. By eliminating this prescriptive 
federal regulation, we can better maximize the use of nurse 
anesthetists and eliminate the confusion surrounding CRNA supervision. 
At a time when the Congress is seeking ways to reduce costs for the 
Medicare program without sacrificing quality or access to care, 
increasing the use of nurse anesthetists seems particularly 
appropriate.
  In terms of quality of care, there are no significant differences 
between anesthesia provided by CRNAs or that provided by 
anesthesiologists. Notwithstanding the claims of anesthesiologists, it 
is clear from a careful reading of the studies that there are no 
quantifiable differences in outcomes when CRNAs work with 
anesthesiologists, or when anesthesiologists provide anesthesia alone. 
CRNAs have been providing anesthesia services for more than a century. 
They have been the principal anesthesia providers in combat areas in 
every war the United States has been engaged in since World War I. 
CRNAs have received medals and accolades for their dedication, 
commitment and competence. And CRNAs perform the same anesthesia 
delivery function as anesthesiologists and work in every setting in 
which anesthesia is delivered: traditional hospital suites, obstetrical 
delivery rooms, dentist's offices, HMO's ambulatory surgical centers, 
Veterans Administration facilities and others.
  Mr. President, the Federal Government is deferring to state judgment 
on a whole host of issues, so it seems completely consistent to let 
states decide how best to use nurse anesthetists, particularly in light 
of CRNA's long track record of success. States, which have the primary 
responsibility for regulating nurse practice, have generally not seen 
any need for a physician supervision requirement in non-Medicare 
settings. Twenty-nine states do not require supervision of CRNAs in 
nurse practice acts or board of nursing rules. This clearly indicates 
that many states, as a matter of public policy, do not believe it is 
necessary to require physician supervision of CRNAs. It is easy to 
understand why. Anesthesia is provided only when necessary to permit 
some medical procedure or intervention. Thus, as a practical matter 
even when supervision is not required as a matter of law, a surgeon, 
podiatrist, or dentist will be in the room when anesthesia is provided, 
and would be capable of handling any emergency that might arise.
  Finally, I would note that when CRNAs were given direct Medicare 
reimbursement in 1986, there was no statutory requirement that CRNAs be 
supervised by physicians in order to receive reimbursement. This was 
not a requirement imposed by Congress then, nor has there been one 
since. Had Congress believed that such a requirement was appropriate, 
it would have been imposed as a condition of reimbursement at that 
time. Moreover, HCFA routinely defers to the states on scope of 
practice issues as its relates to other health care professionals.
  This proposed change is supported by the American Hospital 
Association and the National Rural Health Association. I urge my 
colleagues to support this legislation and let the states make their 
own decisions about how to regulate a health care professional's scope 
of practice. Rural and undeserved urban areas need CRNAs and it's time 
the federal government removed impediments in regulations so that 
consumers' access to anesthesia care, particularly in rural areas, will 
not be jeopardized.
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