Controversy in California: Should CRNAs Be Supervised?

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  • March 1, 2010
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Californian hospitals and nurse anesthetists generally agree with Gov. Arnold Schwarzenegger’s decision last summer to opt out of a Medicare provision requiring physician supervision of certified registered nurse anesthetists (CRNAs) in hospitals, but a couple of state physician organizations do not. Whereas the former group says opting out will ensure patient access to anesthesia services, the latter group says lack of physician oversight puts patients at risk.
The California Society of Anesthesiologists (CSA) and the California Medical Association (CMA) feel so strongly about this that, on Feb. 2, they took the matter before the San Francisco County Superior Court. The two physician organizations maintain in the petition that Gov. Schwarzenegger did not follow protocol for opting out of the Medicare provision.

The Centers for Medicare & Medicaid Services (CMS) permits state governors to invoke the federal opt-out final rule (Nov. 13, 2001 Federal Register) by simply writing a letter certifying that:

  • State boards of medicine and nursing were consulted;
  • It is in the state citizen’s best interest; and
  • It is consistent with state law.

CSA and CMA contend in the CSA/CMA vs. Schwarzenegger case that the governor did none of the above. “Based on the information we have received to date, it appears the Governor has violated every aspect of this regulation,” CMA states in Resolution OMSS 02-09, which was published prior to litigation.
CMA contends that CRNA supervision “has been a long-standing public safety requirement deemed appropriate by California law” (HOD 602a-08); and that opting out of the physician supervision requirement will not increase access, improve patient outcomes, or produce cost savings.
“Maintaining physician supervision of anesthesia is important for the safety of care delivered to all patients,” said CSA President Dr. Linda Hertzberg in a press release issued the same day as the petition.
Since the Nov. 13, 2001 CMS rule, 14 other states have opted out from the federal supervision requirement. California is the 15th and most recent state to exercise this right.
CMA says that, “in the event that we are not successful [in litigation], another avenue would be to request that the federal government rescind the opt out option.”
Sources: American Medical News, American Association of Nurse Anesthetists, California Medical Association, California Society of Anesthesiologists


No Responses to “Controversy in California: Should CRNAs Be Supervised?”

  1. Connie Franklin says:

    It would definitely diminish my comfort level knowing that the CRNA has no supervision during my procedure. What happens to hospital liability???. Makes more sense to be protected under hospital/physician umberella. Should something go wrong, who will stand with the CRNA in a court of law?.

  2. Helen R. says:

    This is certainly cause for concern as a patient. However, I would like to keep the federal government out of these types of issues. I believe we can handle this within each state. The people in each state involved should be voicing their concerns to the appropriate people and holding them accoutable. I know I will be checking on whether or not Ga has opted out.

  3. Peggy Sloss says:

    It would depend on what type of physician is doing the supervising. I have worked at places that the surgeon is “supervising”, with much less knowledge of anesthesia and is concentrating on the surgery, not vital signs etc. I agree that anesthesiologist should be in a supervisory role within the surgical department.

  4. R. Douglas Wise, CPC says:

    CRNAs are trained professionals. Why must there be 2 doctors in the room in all cases?

  5. Noelia Wilson says:

    At the community college i attended i was taught the reason for an assistant surgeon was not only to assist but to take over the case if anything happened to the primary surgeon. i have seen a few surgical cases where no assistant was used and wondered if the patient’s well being were not being jeopardized. i agree that an anesthesiologist should be in a supervisory role within the surgical department.

  6. Bob bolton says:

    I much prefer a CRNA to administer my anesthesia than an anesthesiologist. Why should the anesthesiologist be bothered doing a mundane case when he has more important things to do such as talk on his cell phone, surf the net and complain that CRNAs need supervision while he sits in the Doctors lounge drinking his coffee.

  7. Jimmy says:

    The anesthesia is the most dangerous part of the surgery. And it can be very complicated, especially if the patient has multiple medical issues than can complicate the anesthesia. If it was my life or a loved one’s, I would only want the most highly trained person (a full fledge anesthesiologist who is a medical doctor) taking care of me. When it comes to my life, saving money should be the last thing on the list. If you end up dying, what’s the point?
    (Besides being more highly trained, I think you are more likely to get an “inherently” smarter person with an Anesthesiologist than a CRNA since the Anesthesiologist had to at least make it through the “filters” and extraordinarily selective process of medical school and anesthesiology residency. Nursing school?….not even close….)

  8. Daniel says:

    You obviously don’t realize that there are as many dumb doctors as there are nurses. So maybe you made it through medical school? Does that mean I’ll let you stick a needle in my back? My point is that going from theory to practice goes a long way.

  9. Christina says:

    A physician may not be adept at placing an IV (which is technical skill) but that does not make one dumb. Moreover to pass the following exams is tremendous act in the implementation of knowledge and atrition:
    -Step 1 – 8 hours exam
    -Step 2CK – 8 hour exam
    -Step 2 CS – 8 hour exam
    -Step 3 – 2 day exam
    -Board certification in the specialty of choice, written and oral.
    Not to mention organic chemistry, physics and gen chem in undergrad.
    To get your RN:
    minimum number of 75 questions correct .
    “So maybe you made it through medical school” sounds like you are completely underestimating and undermining the process of earning an M.D.

  10. Brad says:

    It is a knee-jerk reaction to want a physician doing the anesthesia. But lets be honest, most people don’t know a thing about anesthesia and much less have a clue what training and experience the person doing the anesthesia has and how that impacts the safety of anesthesia practice. Look at the evidence. There are millions of anesthetics to evaluate. I think that data is more accurate than ones gut feeling. I wont even post the results of the data. If you’re not willing to look it up, too bad.

  11. Nikki says:

    Wow! So many opinions on here. Well, coming from a trained CRNA with 4 years of undergraduate study, required critical care experience, and 2 1/2 years in a masters program of anesthesiology logging an average of 9,369 hours during training. That’s a full time work load. You have to quit your job and dedicate your life….eat, breathe, sleep anesthesia for 2.5 years. Everything an anesthesiologist can do, a CRNA is trained and require to demonstrate they can perform before they can even graduate. We are trained to be autonomous because there are already states that are opt out states that don’t require MDA supervision and have been doing so for years. It’s not a new concept by any means.
    In addition, there are studies that demonstrate that care by a CRNA is just as safe, if not safer, than an anesthesiologist.
    We are cost effective and value based. We provide the same care at a fraction of the cost when providing care independently….and a tid bit of info from an inside perspective. Majority of anesthetics are done by CRNA’s with little hands on help from an MD when being supervised. We do your entire case by ourselves most of the time. Very few anesthesiologists step in and help us in the OR. We are trained in advanced cardiac life support and pediatric advanced life support and can run a code on our own should the patient’s condition deteriorate in the middle of a procedure.
    The lack of credit being given to the workhorses of the anesthesia care team in response to this article is very disheartening and frankly shameful. It’s highly likely that your next anesthetic will be done by a CRNA who will do that entire case by themselves and I hope when you wake up, you give credit where it’s due.