Nurse anesthetists would need 'supervision' under bill moving through House
Posted March 12, 2013
Raleigh, N.C. — A battle involving big money, professional pride, health care costs and, oh yes, patient care played out as the House Health Committee gave near unanimous approval to a bill that requires physician supervision of nurse anesthetists.
The issue is a familiar one at the General Assembly, pitting doctors against other health professionals. At the heart of the anesthesiology battle is whether nurse anesthetists need to work "collaboratively" with or "under the supervision of" doctors.
"Anesthesia care requires the ability to diagnose human conditions and plan patient care," said Paul Rieker, president-elect of the North Carolina Society of Anesthesiologists. Those are things that only doctors are allowed to do under current law.
He and other doctors argued that court rulings, attorney general opinions and rulings by the North Carolina Medical Board already require nurse anesthetists to work under the supervision of doctors.
But nurses, who crowded the room wearing buttons illustrating their opposition to House Bill 181, said that they have worked in collaborative arrangements with doctors for decades and not ever run afoul of medical board guidelines.
"The current collaborative arrangement is working well," said Vaughna Galvin, a nurse anesthetist from New Bern. As the name suggests, she said, CRNAs are nurses who receive further training, including a master's degree, in order to manage anesthesiology care.
Professional pride on display
"I am responsible for my own decisions," Galvin said, describing different civilian and military workplace settings where she had worked with different teams of doctors.
Committee members repeatedly explored this issue of autonomy, trying to define how much latitude nurse anesthetists had to make decisions without a doctor present.
"What this is doing is settling the issue," said Rep. Nelson Dollar, R-Wake, the bill's sponsor.
He said the measure would merely codify existing appeals court rulings and other case law. Doctors, he said, are already required to supervise nurse anesthetists. That makes sense, he said, since nobody comes to a clinic or hospital just to be anesthetized but are seeking treatment from a doctor who will do something else while they are sedated.
But the nurses have been writing to lawmakers, saying the bill has the potential to curtail their practice, requiring a higher level of oversight than currently exists.
"It will change how things are currently done," said Johnny Loper, a lawyer for the nurses group.
Rep. Marilyn Avila, R-Wake, asked what the role of the nurse anesthetist would be in the event of an emergency involving anesthesia in an operating room where there was not an anesthesiologist present.
"The nurse anesthetist would be a support person for the team," said Bob Wilson, a anesthesiologist who had started as a nurse, drawing snickers from the crowd.
Rep. Jim Fulgham, a retired neurosurgeon, summarized the argument for fellow committee members by saying that, ultimately, it was the doctor who decided a patient's course of treatment and was responsible for anything that goes wrong.
"This is a captain-of-the-ship situation," Fulgham said.
The two sides were at loggerheads for the bulk of the 90-minute meeting, unable to agree even on factual points such as how many other states allow nurse anesthetists to practice without doctor's supervision or how costly the potential changes might be.
Doctors and their representative pointed to cases such as a 2010 California court ruling that removed nurse anesthetists from medical supervision as one reason to push forward with the bill. They also pointed to a measure filed in the state Senate that would codify a more liberal interpretation of state rules as a reason to move forward.
That Senate bill raises the possibility of a House-Senate conflict over the measure.
During Tuesday's committee hearing, the nurses group questioned why the state would change the law in a way that could cost the state money.
"There are financial implications," Sharon Pearce, vice president of the American Association of Nurse Anesthetists, told the committee, suggesting that patients could see their medical bills go up as a result of increased liability insurance.
Dana Simpson, a lawyer and lobbyist for the anesthesiologists, said that the state's largest liability insurer had already issued a letter saying rates would not go up because the supervision was already the law of the land.
The bigger monetary question may be one of cash flow and who controls it.
"Do I think my practice is going to change tomorrow? No," Pearce said. But she added that the bill would allow the medical board to define the rules for her profession later on, allowing the appointed body to limit her ability to practice at some future date.
"This is a slippery slope," she said.
National doctors groups, she said, have made clear that they want to bring all anesthesiology practice under "supervision," which could have consequences for who can bill for those services and how much nurses get paid for their work.
Wilson, the nurse turned doctor, brushed aside the question of money after the meeting, saying that most nurse anesthetists already happily practice in conjunction with doctors.
"Money or no money, our concern is what's best for patients," he said.
However, it's rare to see a committee room jammed with advocates, lawyers, lobbyists and others unless big money is at play. Those high stakes were on display during the 2012 campaign as well.
Campaign finance reports show the political action committee for the Association of Nurse Anesthetists gave $118,544.50 to candidates last election cycle. The North Carolina Medical Society, which supports the bill along with other causes, gave state candidates $191,804.34, along with thousands of dollars chipped in by other doctor's groups. That doesn't count individual donations doctors or nurses may have made.