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November 1998
Volume 62 |
Number 11
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WASHINGTON REPORT
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| ASA Supports Coalition
Effort to Defeat Assisted Suicide Bill |
Michael Scott, Director
Governmental and Legal Affairs
Just as the month of September marked the demise of any prospect
for patient protection legislation in the 105th Congress, it breathed
life (no pun intended) into efforts of conservative legislators
in both houses of Congress to pass a bill (S. 2151/ H.R. 4006)
banning physicians from prescribing controlled substances to assist
patients to commit suicide. More specifically, the bill was aimed
at the state of Oregon, where physician-assisted suicide was recently
approved, twice, by voter referendum.
The Senate and House bills languished for some time following
their introduction by Senator Don Nickles (R-OK) and Representative
Henry Hyde (R-IL), but action on the legislation intensified when
Congressman Hyde successfully moved the bill out of the House
Judiciary Committee, of which he is the chair. Although ASA had
no formal position on the issue of assisted suicide (a proposed
resolution against the practice was scheduled for consideration
by the House of Delegates in October), ASA endorsed the American
Medical Association (AMA) efforts to oppose the bill. Principal
AMA concern, shared by the ASA leadership, was that passage of
the bill would have a palpable chilling effect on providers who
are ethically engaged in aggressive pain management for terminally
ill patients.
With the favorable action by the House Judiciary Committee,
the ASA leadership directed the Washington Office staff to step
up its efforts to oppose the bill. In mid-September, ASA joined
a coalition of more than 50 provider organizations and others
concerned with end-of-life care and began to participate in aggressive
lobbying efforts against the bill. Accompanying this column is
a copy of the ASA-financed advertisement (see page 3) that appeared
in the September 28 issue of Roll Call, the Capitol Hill
newspaper.
In late September, the Senate Judiciary Committee also
favorably reported a slightly different version of the bill, with
several members on both the prevailing and losing side expressing
grave reservations about the bill, if it should be brought to
the Senate floor. At the same time, House leaders, after having
placed the bill on the House calendar for a vote (twice), withdrew
it from consideration as opposition to the bill became clearer.
In October, Senate proponents attempted to add an abbreviated
prohibition to the omnibus appropriations bill, but these efforts
failed in the face of opposition, both from the White House and
a large number of senators.
Congress Abandons Patient Rights Bills
By the end of September, it had become clear that any congressional
will to debate patient protection legislation, once widely regarded
as the campaign issue of 1998, had been crowded off the
political docket by the threatened impeachment of the President.
Individual legislators report that the issue remains alive within
their constituencies, but the long delay in crafting a GOP leadership
bill in the House essentially doomed any effort for 1998.
For ASA, this represents both good news and bad news: although
the opportunity for advancing the pro-patient agenda of the Patient
Access Coalition has been lost for another year, it is also true
that no vehicle is provided for nonphysician providers to gain passage
of the antidiscrimination proposals advocated by their coalition
throughout the 105th Congress.
Omnibus Spending Draft Seeks Outcomes Study
In the waning hours of the 105th Congress, conferees on the
giant omnibus appropriations bill for fiscal year 1999 approved
inclusion of language recommending that HCFA base its final decision
to retain or change its current Medicare requirement that a physician
supervise anesthesia services on scientifically valid outcomes
data. At present time, however, final action on the appropriations
bill had not been completed, meaning that the possibility for
change - however unlikely - still exists.
The conferees' tentative recommendation is substantively
identical to the provision approved by the Senate Appropriations
Committee in early September, quoted in
last month's NEWSLETTER. It urges that HCFA and its
Agency for Health Care Policy Research work together, after consulting
with relevant national professional organizations to design and
implement an outcomes study examining mortality and adverse outcome
rates by different anesthesia providers.
During development of the study proposal at ASA's urging
over the past few months, the American Association of Nurse Anesthetists
(AANA) argued that the purpose of the study was merely to delay
implementation of the HCFA proposal to do away with the supervision
requirement. The conferees responded to this concern by adding
a statement to the Senate provision stating that they did not
intend that HCFA be encouraged, discouraged or delayed in determining
whether to retain, revise or eliminate the existing supervision
rule.
Because HCFA has stated its intention to proceed "deliberately"
in considering its ultimate action, ASA believesk this addition
to be of little practical consequence - except possibly to accelerate
HCFA's decision whether to conduct a study.
Senators, Representatives Receive Response From Letter to HCFA
In June 1998, a group of eight Republican Senators signed a
letter addressed to HCFA Administrator Nancy-Ann Min DeParle that
expressed their concern about HCFA's proposed rule on physician
supervision of nurse anesthetists. This letter was published in
the "Washington Report"
of the August NEWSLETTER.
Recently, Senator Connie Mack (R-FL), who initiated the
Senate letter, received a letter of response from Ms. DeParle
regarding the issue at hand (see a copy of the response letter
below).
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U.S. Department of Health and Human
Services
Health Care Financing Administration
The Administrator
Washington, D.C. 20201
The Honorable Connie Mack
United States Senate
Washington, D.C. 20510
Dear Senator Mack:
Thank you for your letter concerning the proposed
rule to revise the current hospital conditions of
participation for Medicare and Medicaid. You expressed
concerns about the volume of letters and visits to
Congress regarding the specific proposal to eliminate
the Federal requirement for certified registered nurse
anesthetist (CRNA) supervision in the administration
of anesthesia and the proposal to defer to State law
and Practice Acts in that regard. I regret the delay
in this response.
The proposed rule elicited 45,000 written comments
from the public; more than one-third of the comments
are on this issue. The physician community is generally
opposed to the proposal and argues that anesthesia
administration requires advanced medical education
that only physicians have. The physicians also argue
that, especially in emergency situations, patient
assessment prior to anesthesia administration is critical
and requires a physician. On the other side of the
issue, nurse anesthetists, representatives of rural
areas, and supporters of State oversight are in favor
of the proposal to defer to State laws and Practice
Acts.
You have asked for an explanation of the scientific
and clinical basis for the proposed rule. HCFA reviewed
the available published literature and found that
studies show a dramatic improvement in anesthesia
outcomes over the past 15 years (J. P. Abenstein,
M.D., and Mark A. Warner, M.D., "Anesthesia Providers,
Patient Outcomes, and Costs." Anesth Analg.
82:1273-83, 1996). There are no studies published
within the last 10 years comparing quality outcomes
between patients who receive anesthesia services from
CRNAs and anesthesiologists. All of the literature
reviewed agreed that the anesthesia-related death
rate is extremely small, and that the administration
of anesthesia in the United States is safe relative
to surgical risk.
Given this, and based on the Administration's desire
to decrease regulatory requirements where appropriate
and increase State flexibility, HCFA proposed to remove
the Federal requirement for supervision of CRNAs and
defer to State licensure and scope of practice laws
and hospital medical staff bylaws.
Thank you for advising me of your concerns on this
important issue. We are currently evaluating all of
the comments to this rule, and I want to assure you
we will consider your views carefully as we make a
decision on how to proceed. I am sending a similar
response to the Senators who co-signed your letter.
Sincerely,
Nancy-Ann Min DeParle
Administrator
[Dated September 25, 1998]
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