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The American Society of Anesthesiologists is an educational, research and scientific association of physicians organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient.


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N. Martin Giesecke, M.D., Chair



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March 1, 2013 Volume 77, Number 3
Practice Management: Not in My Backyard: Protect Competency-based Pain Care in Your State Lisa Pearlstein, J.D.

In spite of an ASA nationwide campaign, the Centers for Medicare & Medicaid Services (CMS) adopted a new national policy that will allow Medicare funds to be used to pay nurse anesthetists (NAs) to diagnose and treat chronic pain as long as NAs are permitted to perform these services under state law. CMS started paying NAs for chronic pain management services January 1, 2013.

Upon learning of the CMS proposal, ASA generated strong opposition to CMS’ proposal to pay NAs for chronic pain management. ASA’s grassroots network sprang into action, and nearly 2,000 anesthesiologists filed comments urging CMS to withdraw the proposal. ASA joined with the physician community to demonstrate the multidisciplinary nature of pain care and widespread concern about unqualified practitioners being paid to provide chronic pain management services through comment letters from the American Medical Association, American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, North American Spine Society, American Society of Interventional Pain Physicians, and the American Association of Neurological Surgeons.

In addition to other physician groups, ASA worked with major stakeholders to stress that NAs have no education or training in chronic pain management. In fact, the American Association of Nurse Anesthetists’ own “Standards for Accreditation of Nurse Anesthesia Education Programs” specifically cite that no clinical experience with “Pain management (acute/chronic)” is required as part of nurse anesthesia training. Patients, including the National Fibromyalgia & Chronic Pain Association, recognized the danger of paying untrained providers for chronic pain management services and joined with ASA to urge CMS to withdraw the proposal. ASA also worked in support of a GOP Congressional Doctors Caucus letter to CMS expressing concern over the proposal. The author of the letter, Congressman Phil Gingrey, M.D. (GA-11), noted that the new policy would mandate “Medicare coverage of providers with no education or training in the medical specialty of pain management.” Rep. Gingrey’s Doctors Caucus letter was followed by another letter from 13 members of Congress, led by Rep. Paul Broun, M.D. (GA-10), who urged “CMS to prioritize competency-based care when considering whether to finalize this proposal” due to the “complex nature of diagnosing and treating patients who suffer from chronic pain.”

ASA and other stakeholders also stressed that the proposal may exacerbate the prescription drug abuse epidemic. There is widespread agreement across federal agencies that health care professionals need additional education on proper opioid prescribing. The White House Office of National Drug Control Policy (ONDCP) believes that practitioners who prescribe controlled substances should have additional training on responsible opioid prescribing practices. The Food and Drug Administration, in concert with ONDCP, created a Risk Evaluation and Mitigation Strategy (REMS) for long-acting and extended-release opioids, the centerpiece of which is a voluntary prescriber education program on opioids.

ASA, as the medical specialty representing the largest number of practicing pain medicine physicians and the recognized leader in patient safety, joined the fight against prescription drug misuse, abuse and diversion. Major projects at ASA include applying for a grant to be a CME provider for the REMS program and working with the Partnership at on the Medicine Abuse Project to raise awareness about the dangers of abusing prescription and over-the-counter medicines. Despite calls for additional education on opioids and efforts to raise awareness about prescription drug abuse, CMS adopted a national policy that will open the door to NAs prescribing opioids even though they are not required to have any clinical experience with chronic pain management as part of their training.

CMS’ policy also preempts work by its sister agencies to create a strategy to improve pain care, including changes to payment for chronic pain management services. The Institute of Medicine report, Relieving Pain in America, called for a comprehensive population-level strategy to improve pain care in the United States. Efforts are already under way to create this strategy at the Interagency Pain Research Coordinating Committee (IPRCC), a federal advisory committee based at the National Institutes of Health. CMS, before finalizing this proposal, should have waited for this strategy to be completed to ensure that Medicare payment policies support optimal pain care and are consistent with the federal government’s other pain-related initiatives.

Next Steps: What Can You Do to Help?
It is integral for anesthesiologists to get involved at the state level even if they do not provide interventional pain management services. Anesthesiologists should work with their state components, state medical organizations, patient organizations, other interested physician stakeholders and policymakers to advance patient access to quality chronic pain care through physicians with appropriate clinical education and training in chronic pain management. To support this effort, ASA will soon have available a Chronic Pain Tool Kit. The kit will serve as a resource for ASA members and state components working to advance safe, high-quality chronic pain services in their state.

To learn more about CMS’ new payment policy, visit To find out more about ASA advocacy efforts and sign up to receive advocacy communications, please contact or call (202) 289-2222.

Lisa Pearlstein, J.D. is ASA Pain Medicine and Regulatory Lobbyist.

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