Mark J. Lema, M.D., Ph.D.

t the eleventh hour, outgoing Chairman Bill Thomas (R-CA) of the House Ways and Means Committee dropped ASA’s Medicare Anesthesiology Teaching Rule reform bill (H.R. 5246/S. 2990) from the final Medicare SGR and tax-cut package due to intense intervention by the American Association of Nurse Anesthetists (AANA). Up to this point, at the Senate’s insistence, the package had retained our desired teaching rule fix language. While I was disappointed in the failure of Congress to pass this much-needed payment correction, ASA is prepared to carry our message to the new Congress in 2007. I must congratulate the Washington Office staff for aggressively staying on message, honestly presenting our case and almost succeeding in our number-one goal.

Unfortunately, four ASA presidents have been unable to deliver our message to the AANA leadership, despite our best efforts. Instead, AANA continues to blur and distort the issues in an attempt to seek changes for their own wholly separate student nurse programs. In fact, not only have ASA’s efforts to contrast the major differences in the training of physicians and nurses fallen on “deaf ears” among AANA leaders, but their Washington office persuaded a few House members to submit a rival bill, H.R. 6148, the day before the election recess. The AANA bill would have further confused Medicare billing for teaching anesthesiologists who supervise resident physicians.

In the December issue of the AANA NewBulletin,¹ the AANA’s Senior Director of Federal Government Affairs highlighted efforts to capture greater funding for nursing programs but took unacceptable liberties in referring to and speaking on behalf of anesthesiology. ASA’s leadership was not given the opportunity to either preview or comment on his misleading report.

The AANA staffer erroneously compares physician resident training that is heavily regulated and capped by CMS, ACGME and the RRC with graduate nurse training regulated only by a university’s or hospital’s desire to expand tuition-generating slots and their ability to secure clinical training sites with CRNA faculty. He reports that their bill “… extends needed relief to nurse anesthesia education…”. I have repeatedly explained to AANA leadership that physician anesthesiology residency programs must be compared with similar programs in surgery and medicine which allow for 2:1 supervision ratios or greater within the CMS structure. Moreover, I have explained that from 1994 to 2005, resident training programs have suffered both a 20-percent reduction in sites (from 162 down to 130) and in graduating residents (from 1,793 down to 1,390). In that same time period, nurse anesthesia programs have doubled their student nurse graduation rate (990 in 1994, surging to 1,870 in 2004) and are at the 2,000+ graduation rate today – hardly an indication that the alleged restriction on student nurse supervision payment has been an impediment to expanding the number of nurse trainees!

“ … AANA continues to blur and distort the issues in an attempt to seek changes for their own wholly separate student nurse programs.”

More disinformation is spread when the AANA’s lobbyist suggests that a unilateral increase in the payment for physician resident supervision “… would only encourage clinical education of residents and discourage clinical education of [student] nurse anesthetists.” In this matter, I am sure that the AANA’s lobbyists are astute enough to know that 1) according to a SAAC/AAPD survey, few if any co-existing physician and nurse training programs co-mingle the trainees so that there is no competition for cases, 2) the de facto doubling of the number of student nurse graduates over the past decade argues against his suggestion, and 3) CMS has capped the total number of national resident training slots since 1997 making it impossible for anesthesiology residency program directors to replace student nurse slots with resident positions EVEN if they wished to do so.

Finally, the AANA staffer reports anecdotally that “One anesthesiologist estimated the benefit of H.R. 6184 (the AANA bill) over resident-only measures at several hundred thousand dollars annually for his program alone.” In this statement lies the true purpose for the AANA advancing this bill. It is far more likely that hospital CEOs and independent practice CRNA groups will reap the windfall profits from any such nurse-led adjustment, independent of most physician anesthesiologist oversight. Moreover, we have demonstrated that ASA’s teaching rule correction will keep our anesthesiology teaching programs and research activities from folding — the same programs highlighted in the 1999 Institute of Medicine monograph citing anesthesiology’s exemplary safety record — and is not purely for financial gain.

Overall, our anesthesiology faculties are 1) under pressure to train some of the best medical school graduates going into anesthesiology at half the cost of supervising nurse anesthetists and 2) suffering from diminishing numbers of training sites and yearly graduates. During this same time, nurse anesthesia programs have expanded and doubled their yearly graduate numbers.

So, what might be the AANA’s real strategy? From where I sit, it might be an attempt to kick us when we’re vulnerable by hurting our academic programs while alleging that they’re in trouble as well. I also believe that by lumping doctor training with nurse training, they subliminally try to elevate their education to that of a physician, purposefully trying to mislead the public through the legislative process. Finally, they use these legislative issues as a smoke screen to secure windfall profits largely for their hospital employers and independent practice nurses. In short, this stinks!


Reference:
1. Purcell F. AANA NewsBulletin. 2006; 60(12): 22-23.

return to top