Nurses and Patience

Health professionals have been stepping up their lobbying of state and federal legislators for the right to administer medical treatments historically provided only by MDs. So far, officials have responded in a balanced way--not shutting the door on them but not opening it wide. For instance, last year California legislators passed a bill crafted to let optometrists prescribe certain low-risk antibiotics, but defeated a less-focused bill to allow psychologists to prescribe any “drugs for the treatment of [psychological] disorders.”

In the latest struggle, doctors have been fighting a Clinton administration plan to eliminate a federal requirement that MD anesthesiologists oversee all nurse anesthetists treating elderly Medicare patients. The plan would let states give more authority to certified registered nurse anesthetists--nursing school graduates who have gone on to complete two years of specialized training in anesthesia.

At present, when a Medicare patient receives anesthesia, half of the fee generally goes to the certified nurse who administers it while the other half goes to the supervising anesthesiologist, who must examine the patient beforehand but whose subsequent involvement may be minimal.

With managed care forcing anesthesiologists to supervise several operations at once, the nurses’ responsibilities have expanded in hospitals: They now administer about 65% of the anesthetics given to all patients each year.

Certified nurse anesthetists say their growing authority benefits patients and claim that reducing physician supervision requirements would improve access to anesthesia: Think of the stories two years ago about Los Angeles Medicaid patients in labor who were denied epidural anesthesia unless they could pay anesthesiologists on the spot in cash.

Most health experts, however, say it is impossible to assess the relative quality of physician- and nurse-administered anesthesia because the nation has no effective system for tracking medical errors.

That’s why the Bush administration and Congress should not yet remove existing supervision requirements in Medicare. Until the nation improves its primitive system for monitoring patient safety, it is premature to make fundamental changes in the way nurse anesthetists or any other hospital personnel are credentialed.

Sen. Charles Grassley (R-Iowa) will be the new chairman of the Senate Finance Committee, which has jurisdiction over Medicare. Legislation that he introduced last year offers a model for the better medical error reporting that should be in place. The bill, S. 2378, requires all health providers participating in Medicare to establish patient safety programs and report all serious medical errors. Legislation by Reps. Dave Weldon (R-Fla.) and Gene Green (D-Texas) would specifically address the Medicare rule change, barring the executive branch from expanding nurses’ authority until a “comprehensive anesthesia outcomes study” is completed.

Too often it sounds like a copout to call for “more study.” In this case, it is the only reasonable solution.