Nurse anesthetists would need 'supervision' under bill moving through House

Posted March 12, 2013

— 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.

Money involved

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.


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  • dwpcrna Mar 17, 2013

    I am a nurse anesthetists and manage an anesthesia group that takes care of thousands of North Carolinians every year. We have no anesthesiologists and provide safe and affordable anesthesia to every patient we care for. Our anesthetists insist on safe care and the highest standards each day in our facilities. I am committed to making sure this access to quality anesthesia care continues. My worry is this bill (and further regulations) will intimidate operating physicians from choosing to work with nurse anesthetists. The anesthesiologists will make life difficult for the operating physicians I work with even though we have an excellent safety record.

  • larrrywilson Mar 16, 2013

    The original delivery of anesthesia was done by RNs, not MDs. It wasn't until later that MDs coopted the practice as a specialty. The reality is that anesthesia is delivered skillfully by both providers, but at a much higher cost with essentially limited-to-no added benefit by the more expensive MD. MDA salaries are generally more than double what a nurse anesthetist makes, but patients do not enjoy more than double the skill or service.

    This is purely a money game as jnitz pointed out. The point is that anesthesia is not a "doctor's game" exclusively. Demanding an MD when a CRNA will do it just as well is as silly as demanding that Doug Shulman review your tax return.

    Research has shown that complications from anesthesia are not diminished by MD delivery.

    I personally don't oppose the democratic ideal that MD's be the "Captain" when it comes to anesthesia, but then people need to brace themselves for far more expensive medical bills, & delays related to MD shortages.

  • jnitz Mar 14, 2013

    CRNAs deliver high quality safe anesthesia care everyday throughout the US. Scientific outcome data confirms this fact. A vast majority of anesthesia care is delivered via a collaborative (CRNA and MD) "INTERdependent" approach. Not the MD dictating the anesthetic. MDs are pushing HB181 for one reason, $$$$. Rep. Jim Fulgham 'captain of the ship' argument is legally outdated and not applicable. The healthcare 'horses' have left the barn and are not coming back and the anesthesiologists are panicking. Healthcare delivery must change and studies conclude CRNAs are excellent anesthesia providers. Until the anesthesiologists can present evidence to the contrary, NC citizens should demand collaboration between these providers. If HB181 passes, costs will increase and access will decrease! JimN

  • tarheels21 Mar 13, 2013

    Please ask your anesthesiologist the next time you go to have surgery if they will be providing you the anesthetic the whole entire time. The entire time includes taking you from the pre-operative holding area into the operating room and personally taking you to the recovery room. I heard that the anesthesiologist doesn't stay with you the entire time in the room. So then I wonder who is actually in charge of my anesthetic? The anesthesiologist or the CRNA?

  • tarheels21 Mar 13, 2013

    @headsup! If you want your anesthesiologist to be in charge of your anesthesia...please request that he or she to not leave you during your entire surgical procedure. I want you to request for them not to leave the operating room and for them to promise you that they will be "right there with you" for the entire surgical procedure. The reality is they will snicker and say they work has a team with the nurse anesthetist and that he or she will be in the room with you. So I ask you, headsup, who is really in charge of providing your anesthetic?

  • JennyB Mar 12, 2013

    So..."CRNAs are nurses who receive further training, including a master's degree, in order to manage anesthesiology care."

    Why not just become an anesthesiologist then? I've had enough problems with anesthesia in my life. To include a deceased family member from too much anesthesia, and my own back pain caused by poor placement of a spinal. I don't think they have it perfected enough to now allow nurses, with less experience, handle it.

  • HeadsUp Mar 12, 2013

    It's no slight against nurses to say that I want my doctor in charge of my anesthesia, period. Supervision is and should be required by law.

    Nurses who want to be doctors should go to med school, which I'd encourage.