March 1997
Volume 61 |
Number 3
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PRACTICE MANAGEMENT
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| Hospital Consulting
Firm Advocates Greater Autonomy for Nurse Anesthetists |
Karin Bierstein,
Practice Management Coordinator
A hospital management consulting firm based in Seattle, Washington
is advising clients to adopt anesthesia staffing models that would
limit the role of the anesthesiologist and increase the importance
of nurse anesthetists. To hospitals that employ and bill for the
nurses, the immediate economic benefit is obvious. The consultants,
Charles Pearson Associates, have concluded projects for or are
currently working with at least seven hospitals in the mid-Atlantic
and midwestern regions and have submitted proposals to two more
hospitals. Your own institution may receive a proposal from this
firm or from other consultants with similar views on anesthesiology,
and you should be prepared.
As part of its recommendations for restructuring anesthesiology
departments and their relationships to the hospitals, we understand
that one model proposed by Charles Pearson divides anesthesia
patients into three categories, each entailing different levels
of anesthesiologist involvement. Patients are categorized according
to age, physical condition, complexity of surgery and use of invasive
monitoring procedures:
- The healthiest patients (ASA physical status 1 or 2) do not
see an anesthesiologist. The anesthesiologist reviews the anesthesia
plan and is informed about the case but is not required to be
in the hospital as the nurse anesthetist proceeds independently
with induction, maintenance, emergence and postoperative care.
- Mid-level patients (ASA physical status 3) are assessed preoperatively
by the anesthesiologist, who discusses his or her recommendations
with the nurse anesthetist. The anesthesiologist is only required
to be present during induction if needed for the insertion of
monitoring lines or for other complex activities. Otherwise,
the anesthesiologist is available for consultation but does
not have to remain in the hospital.
- Only those patients classified as ASA physical status 4 or
5 would have their anesthesia plan determined by the anesthesiologist,
and the anesthesiologist would be required to be present during
induction and remain in house for assistance during the case.
This clinical staffing model is clearly at odds with ASA policy.
According to the "Basic Standards for Preanesthesia Care"
approved by the ASA House of Delegates in 1987, "An anesthesiologist
shall be responsible for determining the medical status of the
patient, developing a plan of anesthesia care and acquainting
the patient or the responsible adult with the proposed plan."
The 1984 "Guidelines for Delegation of Technical Anesthesia
Functions to Nonphysician Personnel" state, "Anesthesia,
in all its forms, should be administered by a physician who is
trained in the administration of anesthesia, preferably an anesthesiologist
... Accordingly, an anesthesiologist should be personally responsible
to each patient for all aspects of anesthesia care."
ASA's "Guidelines for Patient Care in Anesthesiology,"
which was last amended in 1996, state that anesthesiologists'
responsibilities to patients include pre- and postanesthetic evaluation
and treatment as well as "on-site" medical direction
of any nonphysician who assists in the technical aspects of anesthesia
care to the patient."
Finally, our policy on "The
Anesthesia Care Team," adopted in 1982 and last amended
in 1995, states, "The Society believes that the involvement
of an anesthesiologist in the care of every patient undergoing
anesthesia is essential," and may be accomplished either
personally or by medical direction of the care team.
Medical direction includes "personal participation in the
most demanding procedures in [the anesthesia] plan, especially
those of induction and emergence." It also includes the other
activities (preanesthetic evaluation, prescription of the anesthesia
plan, periodic checking, remaining physically available for emergencies,
providing postanesthesia care) that must be performed in order
to obtain Medicare payment for medical direction. Thus, the clinical
staffing model described by the Seattle consulting firm is inconsistent
not only with ASA policy but also with Medicare requirements if
the services of both the anesthesiologist and the anesthetist
are to be billed.
Given that the recommended staffing model contradicts ASA policy,
many people have been surprised to see that Charles Pearson Associates
has until now included the names and curriculum vitae of certain
prominent ASA members in its "Statement of Qualifications"
sent to prospective clients, indicating that these anesthesiologists
serve as advisors to the firm. Among the people thus surprised
were the named anesthesiologists themselves; they had worked with
Charles Pearson on previous projects, but in no way were they
involved in recommending the staffing changes in question.
On January 24, 1997, Charles Pearson sent letters to these physicians
and to the hospitals that had been given their names, apologizing
for "the professional discomfort you experienced" and
stating for the record that neither they nor any other anesthesiologists
had participated in the consultations.
The demonstrated lack of any anesthesiologist support for the
new staffing model is no barrier to Charles Pearson's advocacy
of a reduced role for and number of anesthesiologists, however.
As Mr. Pearson wrote in one of these letters, carbon-copying the
director of the ASA Washington Office, "Although I understand
that these individuals would be upset that my recommendations,
which are contrary to the ASA's stated position on the roles and
responsibilities of CRNAs, might have a negative impact on the
staffing and income levels of anesthesiologists in these institutions,
I believe they and their colleagues who practice in these supervising
modes would be better served by trying to adapt their internal
group structures, policies and resultant clinical and staffing
models to better meet the needs of the hospitals and communities
they serve."
One wonders how clinical and staffing models that are at such
variance with the specialty's consensus on the requirements of
responsible patient care can meet the needs of any hospital or
community.
What can you do to protect yourself? If a hospital decides to
implement recommendations such as those discussed here, the battle
is more likely to turn on the anesthesiologists' relationships
with the medical staff and the hospital administration than on
the law. As long as the hospital does not violate an existing
contract with the anesthesiology group or unlawfully terminate
the anesthesiologists' medical staff privileges (see July
1996 NEWSLETTER), or require nurse anesthetists to
assume responsibilities for which they are not licensed under
state law, circumscribing the anesthesiologists' services will
probably not be illegal.
Therefore, the best prophylaxis will involve assuring the support
and loyalty of your medical staff and especially your surgical
community. If the surgeons want an anesthesiologist involved in
the care of their patients, chances are that an anesthesiologist
will be involved. Other physicians will readily see the problems
inherent in hospitals' buying advice from lay persons who cannot
muster professional or specialty support for their recommendations.
If you sense that the hospital administration is restive, you
may want to pre-empt outside efficiency experts and management
consultants by making your own formal proposal for improved services.
It may make more sense for your group than for the hospital to
employ the nurse anesthetists, for example. You will certainly
want to keep your ear to the ground and know as much as possible
about any actions the hospital is taking or contemplating taking.
Lastly, if you are confronted with restructuring proposals of
this nature, please contact Michael Scott, Director of Governmental
and Legal Affairs, or me at (202) 289-2222; e-mail: <mail@ASAwash.org>.
Survey of Reimbursement Patterns: A Warm Thank-You
In early January, we sent a survey to 111 anesthesia practices
around the country, requesting extensive information on the role
of capitation, flat fees, commercial payment based on the Medicare
fee schedule and other alternatives to traditional fee for service
reimbursement. We also sought data on the average, minimum and
maximum time involved in frequently performed services.
The responses are coming in now and will be entered into a database
over the next few weeks. The information will be analyzed and
reported by the Task Force on Procedure-Based Reimbursement Systems,
appointed by ASA President Phillip O. Bridenbaugh, M.D.
On behalf of Dr. Bridenbaugh and Orin F. Guidry, M.D., Task Force
Chair, we would like to thank the anesthesiologists and the administrators
for returning the questionnaires. We recognize the enormity of
the effort requested and the cost of busy administrators' and
computer programmers' time. The commitment of members and their
willingness to devote their resources to ASA goals are the Society's
greatest strengths.
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