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June 1999
Volume 63 |
Number 6
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WASHINGTON REPORT
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| ASA Legislative
Conferees Focus on Medicare Supervision Rule |
Michael Scott, Director
Governmental and Legal Affairs
More than 325 ASA members from 43 states met in Washington, D.C.,
on April 26-28, to hear presentations from several federal legislators
and, through congressional visits, to help advance ASA's position
on a number of issues currently before Congress. Some 200 meetings
with Senators and Representatives were scheduled, most of them
focused on ASA's support for the Safe Seniors Assurance Study
Act of 1999 (S. 818/H.R. 632) and the passage of effective federal
patient protection legislation.
During the course of the meeting, presentations were made by
all four original sponsors of the anesthesia outcomes study bill:
Senators Mike DeWine (R-OH) and Harry Reid (D-NV),
and Congressmen David Weldon (R-FL) and Gene Green (D-TX).
On the final morning, Congressmen Weldon and Green were presented
by Nona Wegner, Vice-President for Public Affairs of The Seniors
Coalition, with more than 13,000 petitions from senior citizens
supporting passage of their bill. Introduced last February, the
bill is currently supported by 62 members of the House.
As noted in the May issue of the NEWSLETTER, the Senate
bill was introduced just a few days before the opening of the
ASA Legislative Conference, and served as a focus for legislative
efforts in Senate offices. In his presentation, Senator DeWine
- well known for his advocacy of the interests of children - noted
that the study bill was designed to protect the safety not only
of elderly citizens insured under Medicare, but the thousands
of young people insured under Medicaid. He urged conference participants
to press his colleagues in the Senate to join as co-sponsors of
S. 818.
Among the other federal legislators addressing the Conference
was Senator Orrin G. Hatch (R-UT), Chairman of the Senate
Judiciary Committee and a member of the Finance Committee, who
discussed the failure of the presidentially appointed bipartisan
Medicare Commission to achieve consensus on a plan for assuring
long-term solvency of the program. He also devoted a considerable
portion of his remarks to the current state of patient protection
proposals in the Senate, expressing concern that the Democratic
plan too aggressively sought to control market forces and could
lead to unintended consequences.
Patient Protection Bills Debated Among Speakers
Conference attendees heard from a number of speakers offering
different viewpoints on the appropriate content of patient protection
legislation. These included: Charles N. "Chip" Kahn, President
of the Health Insurance Association of America, expressing the
strong reservations of the insurance industry; Congressman Charlie
Norwood (R-GA), a principal sponsor in both the 105th and
106th Congresses of patient protection bills; Congresswoman Diana
L. DeGette (D-CO), a member of the Health Subcommittee of
the House Commerce Committee; and Congressman John D. Dingell
(D-MI), ranking minority member of the House Commerce Committee
and the sponsor of the Democratic leadership bill in the House.
Also addressing the conference was Congressman Fortney "Pete"
Stark (D-CA), ranking minority member of the Health Subcommittee
of the House Committee on Ways and Means. Mr. Stark also urged
passage of effective patient protection legislation and criticized
the failed proposal of the Medicare Commission to establish a
premium support mechanism for the program. Regarding HCFA's proposed
elimination of physician supervision of nurse anesthetists, he
stated his view that an outcome study was the only intelligent
step in resolving the controversy.
HCFA Targets 'Year or More' to Review Supervision Issue
On the Medicare regulatory front, conferees were addressed by
Robert A. Berenson, M.D., Director of HCFA's Center for
Health Plans and Providers, who touched on a variety of issues
concerning management and operation of the Medicare program. Al-though
the matter does not fall within the re-sponsibility of his HCFA
group, Dr. Berenson did allude to the complexity of the matter
related to physician supervision of nurse anesthetists and suggested
that the agency had considerable work to do in deciding how to
deal with this issue.
In this regard, ASA members should be aware of a letter dated
April 15, 1999, from Donna E. Shalala, Secretary of the Department
of Health and Human Services, that came to light during the meeting
- conceding the importance of sound scientific data and indicating
that HCFA was a "year or more" away from any decision. A copy
of the letter appears below.
Office-Based Anesthesia, Medicaid Subjects of Panels on State
Issues
The conference included panels on two state legislative issues
of major current importance to anesthesiologists: one on office-based
anesthesia initiatives and the other on Medicaid reimbursement.
The first panel was moderated by David C. Mackey, M.D.,
President of the Florida Society of Anesthesiologists. Presenters
included Charles J. Coté, M.D., Professor of Anesthesia
and Pediatrics at Northwestern University Medical School; Rebecca
S. Twersky, M.D., Chair of ASA's Committee on Ambulatory Surgical
Care; Alfred Gilchrist, Director of Governmental Affairs
for the Texas Medical Association; and Thomas A. Joas, M.D.,
an ASA member and Chair of the California Board of Medicine. Dr.
Coté reviewed his research findings on principal causes
of morbidity and mortality in office-based procedures involving
young patients, and the remaining panelists reviewed the legislative
and regulatory environment in several states.
Moderator for the second state panel, which focused principally
on Medicaid reimbursement for obstetrical anesthesia, was Randall
M. Clark, M.D., President-Elect of the Colorado Society of
Anesthesiologists. Panelists included David S. Cade of
the Health Care Financing Administration; Gary J. Clarke, Esq.,
former director of the Florida Medicaid program; Neal J. Cohen,
M.D., Chair of the Socio-Economic Committee of the California
Society of Anesthesiologists; William G. Horton, M.D.,
a member of the Anesthesia Technical Advisory Group of the Washington
State Health Care Authority; and Brian T. McGuire, M.D.,
ASA Alternate Director for Montana. Panelists described the evolution
and success of efforts in the various states to achieve more reasonable
Medicaid reimbursement for obstetrical care.
Conference participants were briefed for their congressional
visits by Julius W. Hobson, Jr., Director of AMA's Division
of Congressional Affairs; by ASA's long-time legislative representatives,
Dan Maldonado and Ellen Riker of MARC Associates;
and by David Johnson, principal in the legislative firm
of Griffin, Johnson, Dover & Stewart. Copies of the ASA position
statements developed for use during congressional visits are available
on the ASA Web site <www.ASAhq.org>.
Nurse Anesthetists' Bill Introduced by Senators
Acting so as to coincide with nurse anesthetists' congressional
visits on Capitol Hill on April 25 and 26, three Senators from
two predominantly rural states - Kent Conrad (D-ND), Byron
L. Dorgan (D-ND) and Larry E. Craig (R-ID) - introduced
the "Anesthesia Services Preservation Act of 1999" (S. 866), by
which the Health and Human Services Secretary would be required
to implement by January 1, 2000, the HCFA proposal to eliminate
physician supervision of nurse anesthetists. A virtually identical
bill (H.R. 804) was introduced in the House in late February.
A major emphasis of the nurse anesthetists' campaign against
the proposed anesthesia outcome study has been that implementation
of the HCFA proposal will improve access to anesthesia care in
rural areas. Since the existing HCFA rule permits supervision
of a nurse anesthetist either by an anesthesiologist or
the operating practitioner, it is not clear how access to anesthesia
care would be affected by the proposal. Most supporters of S.
866 and H.R. 804 represent, however, large rural constituencies.
ASA Grassroots Support Urged for S. 818/H.R. 632
By the end of the ASA Legislative Conference, more than 60 members
of the House had agreed to co-sponsor the Safe Seniors Assurance
Study Act of 1999 (S. 818/H.R. 632). The legislative visits of
ASA members attending the conference are most effectively buttressed
by broad-based communications from the ASA membership to their
respective Senators and Representatives. Please take a moment
to call or write your legislators, reminding them that this is
an important safety issue and urging their support for the bill.
All can be reached by telephone at (202) 224-3121; the ZIP code
for the Senate is 20510 and the House is 20515.
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The Secretary of Health and Human
Services
Washington, DC
April 15, 1999
Thank you for your letter concerning
the proposed revision to the Medicare hospital conditions
of participation (CoP). You expressed your support
of the proposed policy to defer to State law on the
issue of physician supervision of Certified Registered
Nurse Anesthetists (CRNAs) and urged the Health Care
Financing Administration (HCFA) to publish such a
final regulation. I regret the delay in this response.
By way of background, when we published
the proposed rule on December 19, 1997, that would
withdraw the federal physician supervision requirement
of CRNAs, we reviewed literature that was available.
Since HCFA's current requirements do not allow CRNAs
to administer anesthesia without supervision by the
operative practitioner or anesthesiologist, there
were no data on independent CRNA practice regarding
patient outcomes. All of the literature reviewed did
agree that anesthesia related death rates are extremely
small, outcomes have improved over the years, and
administration of anesthesia in the United States
is safe relative to surgical risk. There were no studies
published within the last 10 years that link quality
outcomes to the credentials of the anesthesia provider.
The Administration's desire is to maintain patient
safety, decrease regulatory requirements where appropriate,
and increase State flexibility. In light of these
objectives, HCFA believed it was reasonable to propose
to relax the Federal requirement for supervision of
CRNAs and instead defer to State licensure and scope
of practice laws and hospital medical staff by-laws.
In developing the final rule, we will
consider the over 20,000 comments we received on this
issue and the results of reliable, valid, and scientific
anesthesia outcome studies to make the informed decision
for the final requirement. We agree that the 1999
Omnibus Appropriations bill does not require a formal
study of anesthesia outcomes, but the Appropriations
bill does recommend that HCFA base its final policy
decision on scientifically valid outcome data.
CRNA supervision is one of the many
complex issues in the proposed hospital CoPs that
HCFA will have to consider before drafting its final
rule. We expect this effort to take over a year to
complete. In the meantime, I want to assure you that
the final rule will reflect an appropriate balance
between regulatory flexibility and evidence based
requirements which are linked to better outcomes.
Sincerely,
Donna E. Shalala
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