Overview

COANA at a Glance

It shall be the objective of this Association to promote the best interests of its members, cooperate with the American Association of Nurse Anesthetists, facilitate cooperation between nurse anesthetists and the medical profession, hospitals and other agencies interested in anesthesiology and in general to advance the science and the art of anesthesiology.

History

The History of the Colorado Association of Nurse Anesthesiology

By Cheryl L. Blankemeier, CRNA

I have always been interested in history, and I married a CRNA who should have been teaching history in a university setting had it not been for the interruption of his studies by the Vietnam War. It is important to know about our history so we know of the hard work and dedication that contributed to the development of the profession of anesthesiology nursing in Colorado. We can appreciate that we have very fulfilling careers due to the dedication of those who preceded us as nurse anesthetists.

I would like to start with inserting a copy of the very first Newsletter of our association (six pages follow). This newsletter is from 1949, although our association was established at Presbyterian Hospital on May 5, 1936. I think it is interesting to note the formality of professional relationships. Certainly the authors had a great talent with the written word. Note the lack of the “CRNA” credential—the first credentialing of nurse anesthetists did not occur until 1954.

The development of the profession of nurse anesthesiology in Colorado was developing in tandem with, or because of, activity that occurred at the national level. I would encourage you to read WATCHFUL CARE-A HISTORY OF AMERICA’S NURSE ANESTHETISTS (Continuum Publishing Company). It was written by Marianne Bankert in 1993. Ms. Bankert does discuss the contribution of Roman Catholic and Protestant sisters to our profession in its earliest days. The following is on page 26 of the book:

In 1896 at St. Joseph’s Hospital in Denver, Mary Gonzaga O’Connell (d. 1939) of the Sisters of Charity of Leavenworth took up her duties as anesthetist.

I spent some time doing anesthesiology at the Keefe Memorial Hospital in Cheyenne Wells, Colorado. Often I would drive in the night before a surgical day and spend the night in the old nun’s quarters there. The head nurse of the hospital remembered very clearly working alongside a nurse anesthetist from the Sisters of Charity order. The hospital had a photo of the original group of Charity sisters that helped found the Cheyenne Wells hospital.

You will notice in the last page of the newsletter inserted below that many of the Colorado association members listed were Sisters. One member listed was Evelyn Schultheis from Lamar, Colorado. Mrs. Schultheis served as the hospital nurse anesthetist in Lamar for many years. She contributed to the school of nursing in Lamar, both professionally and financially. She was a continuing member of the AANA and the Colorado Association until her death in 2010 at the age of 91. The Colorado Association of Nurse Anesthetists sent a memorial to the Lamar Community College Nursing Program in her memory.

The Contribution of the United States Military to the Colorado Association of Nurse Anesthesiology

The U.S. Army had a long-standing history of nurse anesthesiology education at Fitzsimons Army Medical Center in Denver. When World War II started, it was a necessity to educate more nurse anesthetists. Fitzsimons Hospital was one of the sites where this education was initiated. U.S. Army Nurses continued their education in anesthesiology at Fitzsimons until 1994. Fitzsimons Army Medical Center closed in 1996. From 1943-1945, over 2500 nurses were given their basic military training at Camp Carson in Colorado Springs. Nurse anesthetists continue to provide anesthesiology services at Ft. Carson in Colorado Springs and the Veterans facilities at the Air Force Academy, Denver, and Grand Junction. Military CRNAs in Colorado have always been, and continue to be, a great force in the clinical/professional arena in Colorado due to the great autonomy of practice afforded military CRNAs.

Colorado Nurse Practice Acts and the Evolution of Advanced Practice Nursing

One of the first revisions of the Colorado Nurse Practice Act that occurred after World War II was in 1980. This iteration of the Act showed some of the first language that supported the performance of independent nursing functions (as opposed to all of nursing being delegated medicine). The first acknowledgement of Advanced Practice Nursing and Prescriptive Authority for Advanced Practice Nurses occurred in 1995. This Act revision was what created the Advanced Practice Nursing Registry. The first registry for prescriptive authority required intense interaction with a supervising physician. Because of this, the Colorado Association of Nurse Anesthetists advocated and secured an exemption to the need for prescriptive authority for CRNAs. That exemption continues today. {Nurse Practice Act 12-38-111.6 (8) (c) (II) Nothing in this section shall be construed to require a registered nurse to obtain prescriptive authority to deliver anesthesiology care}. This is also in keeping with the Drug Enforcement Agency rules that do not require that CRNAs have prescriptive authority in order to render anesthesiology care. Some CRNAs in Colorado have chosen to secure prescriptive authority as it aids their practice. This is often the case for CRNAs doing pain management. With the Nurse Practice Act of 2010, there was some improvement in the process needed to have prescriptive authority. This process was further improved with legislation from 2015, which streamlined the process and somewhat decreased the need for intense physician interaction. The 2010 Nurse Practice Act also clarified the definition of Advanced Practice Nursing. That definition was further refined in 2015 to include the APRN (Advanced Practice Registered Nurse) designation that is consistent with the National Council of State Boards of Nursing Consensus document for Advanced Practice Nursing.

Battles for Ability/Right to Practice for Certified Registered Nurse Anesthetists

Throughout the history of nurse anesthetists, there have been multiple challenges to our right to practice. Of interest, in the late 1980’s, a group of independently practicing CRNAs in Colorado brought an anti-trust lawsuit against a group of anesthesiologists in Denver.

In anesthesiology Advantage, Inc. v. Metz, 708 F. Supp. 1171, 1175 (10^th Cr. 1990), four CRNA’s in the Denver, Colorado area and their professional corporation, The anesthesiology Advantage, Inc. (TAA), brought suit against several anesthesiologists and Humana Hospital. The CRNAs alleged violations of the antitrust laws, including price fixing, market allocation and a group boycott. The charges were based on a hospital-instituted call schedule for anesthesiologists and the anesthesiology staff’s recommendations to adopt guidelines for supervising CRNAs. They also cited a conspiracy to induce another hospital to reject a fee-for-service proposal by TAA to provide out-patient ambulatory surgery anesthesiology on prearranged days. TAA also stated that there was an attempt to persuade a third hospital to reject a proposal that the hospital use TAA for an obstetric epidural anesthesiology service. The CRNAs alleged that they were “illegally squeezed out of business by anesthesiologists because the presence of CRNAs forced down the market price for anesthesiologist services.” The trial court involved dismissed the case. The Tenth Circuit Court of Appeals reversed the trial court’s dismissal of the case, and some of the defendants eventually settled the case. Among other things, they agreed that they would not interfere in the future with CRNAs’ right to practice anesthesiology.

This case was watched nationally, and the American Association of Nurse Anesthesiology aided the CRNAs involved professionally and financially.

1987-Coalition of Colorado Nurses leads to legislation allowing Direct Reimbursement of Nurses in Colorado

Charlotte Winzenburg, CRNA (Denver, CO) was instrumental in the planning and coordination that lead to the passage of Senate Bill 87-47 at the Colorado General Assembly allowing direct reimbursement for nursing services. This has seen some slight changes with succeeding sessions at the Colorado General Assembly, but the original legislation is still a part of the Colorado Nurse Practice Act:

12-38-128. Independent practice - direct reimbursement. Nothing in this article shall be deemed to prohibit any licensee from practicing practical or professional nursing independently for compensation upon a fee for services basis. Nothing in this article shall be deemed to prohibit or require the direct reimbursement for nursing services and care through qualified governmental and insurance programs to persons duly licensed in accordance with this article.

1990-Group of rural Colorado CRNAs lead the way for legislation to allow direct reimbursement of CRNA services by Medicaid

The Colorado Association of Nurse Anesthesiology, at the request of several rural Colorado CRNAs, paved the way for legislation that allowed for CRNAs to be directly reimbursed by Medicaid. The genesis of the legislation was a “follow-on” to the national legislation that was passed in 1986. The federal direct reimbursement legislation enacted at the end of the year 1986 required that all CRNA anesthesiology services and related care furnished to Medicare beneficiaries be reimbursed under Medicare Part B (provider reimbursement). CRNAs were the first Advanced Practice Specialty in nursing to be accorded direct reimbursement. The American Association of Nurse Anesthesiology was instrumental in the passage of the Medicare reimbursement legislation. The 1990 legislation in Colorado evolved in 2009 to include all Advanced Practice Nurses in Colorado. Of note, physician supervision has not been a condition for any of these legislative mandates for direct reimbursement.

1997 and the Health Care Finance Administration—changing the Conditions of Participation for Facilities accepting Medicare assignment to eliminate the physician supervision requirement for CRNAs

In 1997, HCFA proposed a change to existing Conditions of Participation for facilities that accept Medicare assignment for their patients. The proposal brought about a long campaign by the AANA and the American Society of Anesthesiologists on opposite sides of the issue. The change was to eliminate the physician supervision requirement (of CRNAs) for Medicare Part A (facility reimbursement). President Bill Clinton did finally sign the rule change just before leaving the office of President. President George W. Bush, as is the custom for newly elected presidents, froze all recent regulatory activity for review. The rule was reviewed and changed over time to become the rule we know today-the system which allows individual state governors to opt out of the CRNA physician supervision requirement for Part A Medicare reimbursement.

The Centers for Medicare & Medicaid Services (CMS) published in the November 13, 2001 Federal Register a final rule concerning the federal Medicare and Medicaid physician supervision requirement for Certified Registered Nurse Anesthetists (CRNAs). The November 13 rule amended the requirement in the anesthesiology Services Condition of Participation for hospitals, the Surgical Services Condition of Coverage for Ambulatory Surgical Centers, and the Surgical Services Condition of Participation for Critical Access Hospitals.

Requirements for "Opt-Out" Of Federal Supervision Requirement

• The federal requirement has been that CRNAs must be supervised by a physician. The November 13, 2001 rule allows states to "opt-out" or be "exempted" (the terms are used synonymously in the November 13 rule) from the federal supervision requirement.

• For a state to "opt-out" of the federal supervision requirement, the state's governor must send a letter of attestation to CMS. The letter must attest that:

1. The state's governor has consulted with the state's boards of medicine and nursing about issues related to access to and the quality of anesthesiology services in the state; and

2.  That it is in the best interests of the state's citizens to opt-out of the current federal physician supervision requirement; and

3. That the opt-out is consistent with state law.

The 2003 Opt Out Attempt in Colorado

The issue of physician CRNA supervision has always been a barrier to practice for CRNAs. Mandating physician supervision has many side effects, particularly to those in a practice where there are no anesthesiologists. This becomes of concern particularly in rural areas. States like Colorado, with large rural or “Frontier” geography rely on the services of CRNAs. Many of the hospitals in these sparsely populated or geographically isolated areas wish to provide all services to their catchment area. In rural and underserved urban areas, the sources for anesthesiology reimbursement are low enough that it is not possible to attract the services of anesthesiologists. Colorado CRNAs have a long history of service in these areas. In order to meet the requirements of the Conditions of Participation for Medicare Part A (facility reimbursement), CRNAs are required to have physician (not necessarily an anesthesiologist) supervision. In the past, surgeons were willing to play this role. Not so in the modern litigious environment where surgeons fear (unrealistically) that supervision might increase their liability. Many Legal Briefs have been published over the years in the AANA journal addressing surgeon liability when working with CRNAs. I would refer you to read those Briefs to understand the issue from a legal perspective. Suffice it to say, a surgeon is no more liable when working with and anesthesiologist than working with a CRNA. Usually, any liability in the event of a malpractice event relies on the facts of the case, not the credentials of the provider.

With the advent of the ability of states to “opt out” of this onerous physician supervision environment, rural hospitals can increase access to care as they are more desirable practice environments for attracting surgeons.

As a summary of many of the activities of the Colorado Association of Nurse Anesthesiology from 1995 forward, I will insert a copy of the deposition I submitted in early 2011 in support of the lawsuit against Governor Bill Ritter by the Colorado Society of Anesthesiologists. Governor Ritter was sued by the CSA and the Colorado Medical Society as they felt his August 2010 opt out from the Medicare Part A physician supervision rule was against Colorado law. Here is the deposition:

AFFIDAVIT OF CHERYL L. BLANKEMEIER, CRNA

Cheryl L. Blankemeier, CRNA, having been previously sworn, states as follows:

1. I am a Certified Registered Nurse Anesthetist (CRNA) and have been practicing the profession of nurse anesthesiology for approximately 30 years. I received my B.S.N. from the University of Maryland in 1976. After graduation, I became an intensive care nurse for two years, working both in surgical and neurosurgical intensive care units in an Army hospital. I spent a twenty year career in the U.S. Army and attended the U.S. Army Nurse Corps program in nurse anesthesiology. During my army career, I worked at various Army hospitals as a CRNA. After retiring from the military, I worked as a civil servant at Fitzsimons Army Medical Center until 1996. From 1996 until 2005, I practiced nurse anesthesiology as an independent contractor at many facilities in Colorado, including rural hospitals. Since 2005, I have been working for an anesthesiology group in Denver, which consists of both anesthesiologists and CRNAs practicing together. I have worked in team settings with anesthesiologists and also in solo practice with physicians, dentists, and podiatrists.

2. I have been an active member of the Colorado Association of Nurse Anesthesiology (CoANA) since 1995, holding various positions on the Board of Directors, including two terms as the organization’s president. During this time I have served as the Chair of its State Government Affairs Committee since 2001, and as such, I have been involved in many activities, both legislative and regulatory, that apply to the profession of nurse anesthesiology in Colorado.

3. Nurse anesthetists have been providing anesthesiology care in Colorado for well over 100 years. Sister Mary Gonzaga O’Connell of the Sisters of Charity of Leavenworth began her practice as a nurse providing anesthesiology care in 1896 at St. Joseph Hospital in Denver and is believed to be one of the first anesthesiology providers in Colorado. Historically, the delivery of anesthesiology care by nurses developed independently from the anesthesiology care provided by medical practitioners in the course of practicing medicine. Today, anesthesiology care continues to be delivered by registered nurses, who acquire the education, experience and certification to do so in every setting in which anesthesiology can be delivered: hospital surgical suites and obstetrical delivery rooms; critical care access hospitals; ambulatory surgical centers; the offices of dentists, podiatrists, ophthalmologists, and plastic surgeons; and U.S. Military, Public Health Services, and Veteran’s Administration medical facilities.

4. Currently, registered nurses who deliver anesthesiology care in Colorado are categorized as Advance Practice Nurses (APNs) by the state’s licensing law and, once qualified, are designated as Certified Registered Nurse Anesthetists (CRNAs). The education and experience required to become a CRNA include:

–A Bachelor of Science in Nursing (BSN);

–A current license as a registered nurse;

–At least one year’s experience in an acute care setting (emergency room or intensive care unit);

–Graduation from an accredited school providing a nurse anesthesiology program ranging from 24 to 36 months depending on the school’s requirements, that offers a graduate degree and clinical training in university based or large community hospitals;

–Successful completion of a national certification exam following graduation from an accredited school.

5. Because the delivery of anesthesiology care by nurses developed independently from that provided by members of the medical profession, anesthesiology care has never been considered strictly a medical function that can be delegated or performed only by individuals licensed to practice medicine. Neither of the state boards that govern the practice of nursing and medicine in Colorado has ever declared anesthesiology care to be solely within the province of either the practice of nursing or the practice of medicine.   These boards have consistently taken this position when requested, first by former Governor Bill Owens and again by Governor Bill Ritter, to consult with the Governor on the issues associated with the proposal that this state “opt out” of the application of the federal Medicare regulation that requires the delivery of anesthesiology in a hospital participating in the Medicare Program to be supervised by a physician.

6. My first involvement in regulatory activities related to CRNAs occurred in late 1998, when CoANA was notified by the Colorado State Board of Nursing (BON) that the Board had received a letter from a hospital attorney regarding questions about the scope of practice of CRNAs. The attorney’s hospital client utilized CRNAs as independent contractors and there were no anesthesiologists providing anesthesiology services for this hospital. The attorney asked for a written position statement from the BON regarding what anesthesiology services a CRNA could provide under a Colorado nursing license independent of a physician, dentist, or podiatrist. This attorney also asked whether the administration of anesthesiology by a CRNA was an independent nursing function or a delegated medical function, and whether a CRNA could make independent decisions regarding the type and amount of anesthesiology provided.

7. At the BON’s request, CoANA provided information regarding the longstanding practice history of CRNAs in Colorado, along with information related to a CRNA’s educational background and CRNA scope of practice, knowledge, skills, experience, and national certification. The BON, following its own study and inquiries, issued a statement specifically finding that the delivery of anesthesiology care when performed by a CRNA, including the selection and administration of anesthetic agents, is the independent practice of nurse anesthesiology. The BON also stated that CRNAs make decisions concerning the type and amount of medication and anesthetic agents to administer and that CRNAs perform anesthesiology services at the request of and in consultation with the primary care physician or surgeon. [See Attachment A1, August 30, 1999 letter from the BON.]

8. This BON determination was preceded by the General Assembly’s 1995 sunset review of the Nurse Practice Act (“NPA”). At the time, I assisted our association with recording from the audio tapes of some of these legislative sessions from the state capitol archives and providing information to the BON concerning our long-standing history delivering anesthesiology care in Colorado. One of the tapes we recorded contained the testimony of Dr. Randall M. Clark, representing the Colorado Society of Anesthesiologists (CSA), before a House Committee hearing on an amendment to the NPA that would exempt a registered nurse from having to obtain prescriptive authority to deliver anesthesiology care. Dr. Clark stated that this amendment should not be adopted because the amendment would recognize in law that the rendering of nurse anesthesiology care is not a delegated medical function. His argument was rejected by that Committee, and the amendment passed and is now part of the NPA.

9. In 2001, the Colorado Board of Medical Examiners (BME) developed guidelines concerning office based anesthesiology. CoANA, along with many other professional associations, including CSA, provided information and views on this subject to the BME. I attended one or two of the BME meetings when the guidelines were discussed. Dr. Randall Clark also attended these meetings representing CSA. In the draft guidelines, BME initially stated that a “qualified anesthesiology provider” was:
   
   an appropriately trained and qualified physician, a certified registered nurse anesthetist (“CRNA”) or a physician assistant (“PA”) appropriately trained and qualified in anesthesiology working under the onsite supervision of a physician.
   
   I submitted comments to the BME stating that because CRNAs do not require physician supervision under the NPA, the BME should place a “comma” after (“CRNA”) in the guidelines to make it clear that CRNAs are “qualified anesthesiology providers” who do not require physician supervision, unlike a physician assistant. Members of the BON and their legal representative also attended a later meeting to make this clarification. Apparently this recommendation was found acceptable to the BME, as the final guidelines included the requested comma.

10. In May of 2003, the Colorado Board of Health (BOH) conducted a rule making proceeding to consider elimination of the physician supervision requirement that then existed in the “Standards for Hospitals and Health Facilities” at Chapter IV, General Hospitals, Section 7, anesthesiology.   I assisted in providing CoANA’s comments to that Board supporting the removal of the supervision requirement, and testified at the rule making hearing held on May 21, 2003. CSA, again represented by Dr. Randall Clark, also gave written and oral testimony at this hearing urging the BOH not to eliminate the supervision requirement. After the public hearing portion of the rule making proceeding closed, the BOH voted in favor of amending the rule and eliminated the supervision requirement from the referenced section for General Hospitals. To my knowledge, CSA did not pursue legal action at that time or since to challenge the BOH’s action.

11. I was also intimately involved in CoANA’s efforts in 2003 to encourage then Governor Bill Owens to “opt out” of the Medicare Part A regulation for participating hospitals that requires physician supervision of CRNAs. The Governor consulted under the opt-out procedures with both the BME and BON, who in turn held public hearings to consider their advice on whether an opt-out was consistent with state law and in the best interests of the citizens of the state. I testified at the BON meeting. CSA also attended these meetings to give their comments against the “opt-out.” Both Boards concluded that the “opt-out” was in the best interests of the citizens of the state and was consistent with state law. [See Atts. A2 and A3, BME and BON 2003 letters to Governor Owens.] However, Governor Owens did not take the matter further at that time.

12. I was again intimately involved in CoANA’s effort in 2010 to encourage Governor Bill Ritter to opt out of the Medicare Part A regulation for participating hospitals that requires physician supervision of CRNAs. The Governor consulted under the opt-out procedures with both the BME and BON, who in turn held public hearings to consider their advice on whether an opt-out was consistent with state law and in the best interests of the citizens of the state. I attended these meetings as a representative of CoANA. Both Boards concluded that the “opt-out” was in the best interests of the citizens of the state and was consistent with state law. [See Atts. A4 and A5 – BME and BON 2010 letters to Governor Ritter.]

13. In paragraph 7 of his affidavit supporting CSA’s Motion for Summary Judgment in this matter, which I have reviewed, Dr. Clark alleges that having a CRNA work without physician supervision is not safe. There are no credible studies that can support such a conclusion. To the contrary, in the past few years, several well-conducted studies have been published that show the safety and quality of anesthesiology care when provided by CRNAs. These studies include:

(a)  anesthesiology Staffing and Anesthetic Complications During Cesarean Delivery by Daniel Simonson, CRNA, MHPA, et al., [Att. A6], published in the January/February 2007 issue of Nursing Research (Vol. 56, No. 1, pp. 9-17).  The results of that Washington state-based study revealed no difference in OB anesthesiology complication or mortality rates between hospitals that employed only CRNAs to perform OB anesthesiology and hospitals that employed only anesthesiologists to perform OB anesthesiology.

(b)  anesthesiology Provider Model, Hospital Resources, and Maternal Outcomes [Att. A7], examined anesthesiology provider models and hospital resources to explain maternal outcome variations. The authors are Jack Needleman, PhD, MS, associate professor, Director PhD and MS Programs, UCLA School of Public Health, Department of Health Services, and Ann Minnick, PhD, RN, FAAN, Senior Associate Dean-Research, Chenault Professor of Nursing, Vanderbilt University, School of Nursing. This study was published in 2008 and involved more than 1.14 million OB patients from 369 hospitals in seven states. The authors sought to identify any systematic differences in anesthesiology outcomes between hospitals using CRNA-only, anesthesiologist-only, and CRNA/anesthesiologist models.  anesthesiology complication rates in CRNA-only hospitals were 0.23 percent compared with 0.27 percent in anesthesiologist-only hospitals.  Complication rates among other provider models varied from 0.24 percent to 0.37 percent with none statistically different from the anesthesiologist-only hospitals.

(c)  One article published this year spoke to the cost effectiveness and safety of anesthesiology performed by CRNAs and was conducted by Virginia-based The Lewin Group and published in the May/June 2010 issue of the Journal of Nursing Economics. The study, titled Cost Effectiveness Analysis of anesthesiology Providers [Att. A8], included a thorough review of the literature that compares the quality of anesthesiology service by provider type or delivery model.  This review of published studies shows that there are no measurable differences in quality of care between CRNAs and anesthesiologists or by delivery model.

(d)  Another study published in the Journal of Health Affairs 2010(20):1469-1475 by authors Brian Dulisse and Jerry Cromwell entitled No Harm Found When Nurse Anesthetists Work Without Supervision by Physicians [Att. A9], analyzed Medicare data for 1999-2005. The study compared patient outcomes in states where the supervision requirement is in place with patient outcomes in the 14 states that had opted out of the requirement between 2001 and 2005, and found that patient outcomes did not differ.

14. Plaintiffs appear to confuse, or attempt to confuse, elimination of supervision with the idea that CRNAs practice nurse anesthesiology alone if they are not supervised. By Colorado law, a CRNA may provide anesthesiology care in various settings, including with physicians, dentists, or podiatrists. CRNAs are a part of a health care team assembled to serve the needs of a patient. We practice in cooperation with physicians, dentists, or podiatrists per their request for our nurse anesthesiology services.

15. The physician, dentist, or podiatrist who is performing the procedure requiring anesthesiology services does have the responsibility to make sure that the patient is an appropriate risk for the procedure. It is his/her responsibility to make sure the patient has been appropriately evaluated as to health status and is in the best possible condition prior to the procedural intervention. Typically, the physician, dentist, or podiatrist is expected to examine the patient within twenty-four hours prior to the procedure to make sure the patient has not had any changes in status that would make him or her a bad candidate for surgery. These responsibilities of the operating practitioner occur whether the anesthesiology is provided by a CRNA or by an anesthesiologist.   The approach to anesthetizing the patient is decided based on consultation by the operating practitioner with the CRNA or anesthesiologist, taking into account the patient’s preferences for the type of anesthesiology. These activities do not comprise physician supervision of the anesthesiology provider – whether a CRNA or an anesthesiologist. Rather, these are the responsibilities of the operating practitioner based on his or her own commitment to doing the best by the patient.

Further Affiant Says Not

Dated this   day of January 2011.

Cheryl L. Blankemeier CRNA

State of Colorado ss.

County of __________

Sworn and signed before me by Cheryl L. Blankemeier CRNA this _____ day of January, 2011.

________________________________

Notary Public

My commission expires: ____________________

Colorado Opt-Out from Federal anesthesiology Rule Upheld

 Colorado Opt-Out from Federal anesthesiology Rule Upheld

District court dismisses lawsuit filed by state's physicians over supervision of nurse anesthetists

Park Ridge, Ill. - Ruling in favor of the Colorado governor and the Colorado Association of Nurse Anesthesiology (CoANA), the Denver District Court has affirmed that Colorado state law does not require nurse anesthetists to be supervised by a physician. The court also ruled that former Gov. Bill Ritter acted within his rights by opting out of the federal physician supervision requirement for these advanced practice registered nurses in September 2010.

On March 31, 2011, the court granted a motion to dismiss in favor of the governor, CoANA, the Colorado Nurses Association, and the Colorado Hospital Association, affirming Colorado’s opt-out of the federal supervision requirement in September 2010. Judge Ann Frick stated that in Colorado the administration of anesthesiology by a Certified Registered Nurse Anesthetist (CRNA) is an independent nursing function and does not require physician supervision, an important requirement for seeking an opt out of the federal supervision rule from the Centers for Medicare & Medicaid Services (CMS).

“We are pleased that Judge Frick has confirmed what has always been the scope of practice for Colorado’s CRNAs—that we are legally entitled to provide anesthesiology care to patients without being supervised by a physician,” said Jennifer Harenberg, CRNA, president of CoANA. “We will continue to protect our members from anyone who would assert otherwise.” The judge’s ruling dismisses the lawsuit filed in September 2010 by the Colorado Society of Anesthesiologists (CSA) and the Colorado Medical Society (CMS). Judge Frick cancelled all other hearings on this matter and declared all pending motions moot as a result of her ruling.

Certified Registered Nurse Anesthesiology (CRNAs) are advanced practice registered nurses who personally administer approximately 32 million anesthetics to patients across the United States each year. Two recent national anesthesiology studies confirmed the safety and cost-effectiveness of CRNAs, who practice in every type of setting in which anesthesiology is delivered and are the sole anesthesiology professionals in most rural hospitals.

The federal supervision rule, however, is not a regulatory measure designed to ensure patient safety; in reality it is a requirement that hospitals must meet in order to receive Medicare reimbursement for anesthesiology services, unless a state chooses to opt out of the rule as Colorado has done.

Colorado was the 16th state to opt out of the federal rule, following Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, Montana, South Dakota, Wisconsin, and California.

Colorado Appellate Court Upholds Opt Out from Federal anesthesiology Rule

New state policy upheld despite opposition from physicians groups to block governor’s actions

Park Ridge, Ill.— Today the Colorado Court of Appeals has upheld the previous ruling in favor of the Colorado governor and the Colorado Association of Nurse Anesthesiology (CoANA). The Colorado Court of Appeals has affirmed that Colorado state law does not require Certified Registered Nurse Anesthetists (CRNAs) to be supervised by a physician. The court also ruled that former Gov. Bill Ritter acted within his rights by opting out of the federal physician supervision requirement for these advanced practice registered nurses in September 2010.

“We are pleased that the Appellate Court has upheld the lower court’s decision to continue to allow CRNAs to administer anesthesiology without the supervision of a physician, which has always been the scope of practice the Colorado nurse anesthetists,” said Scott Shaffer, CRNA, president of CoANA.

On March 31, 2011, a district court granted summary judgment in favor of former Gov. Ritter and CoANA, the Colorado Nurses Association and the Colorado Hospital Association affirming Colorado’s opt-out of the federal supervision requirement. The district court judge stated that in the state of Colorado that the administration of anesthesiology by CRNAs is an independent nursing function and does not require physician supervision, an important requirement for seeking an opt out from the Centers for Medicare & Medicaid Services (CMS).

Nurse anesthetists provide anesthesiology services to 99 percent of the communities with surgical services throughout the state. This ruling is particularly important for rural communities, as CRNAs are the sole provider of anesthesiology services in over 70 percent of hospitals. The court’s ruling dismisses the lawsuit filed in September 2010 by the Colorado Society of Anesthesiologists (CSA) and the Colorado Medical Society (CMS).

Certified Registered Nurse Anesthetists (CRNAs) are advanced practice registered nurses who personally administer approximately 32 million anesthetics to patients across the United States each year. Two recent national anesthesiology studies confirmed the safety and cost-effectiveness of CRNAs, who practice in every type of setting in which anesthesiology is delivered and are the sole anesthesiology providers in most rural hospitals.

The federal supervision rule, however, is not a regulatory measure designed to ensure patient safety; in reality it is a requirement that hospitals must meet in order to receive Medicare reimbursement for anesthesiology services, unless a state chooses to opt out of the rule as Colorado has done.

Colorado is the 16th of the 17 states to opt out of the federal rule, following Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, Montana, South Dakota, Wisconsin, California, and Kentucky.

At the writing of this history summary, the lawsuit advanced to the Colorado Supreme Court. We are currently waiting for the outcome of the deliberations of the Colorado Supreme Court.

In 2012, the Colorado Society of Anesthesiologists pushed legislation to license Anesthesiologist Assistants in Colorado during that year’s session of the Colorado General Assembly. The CSA has introduced AAs to Colorado as retribution for the opt out. The legislation passed, despite efforts to stop the licensure legislation by COANA. After garnering licensure, the anesthesiologists started a school for AAs at University Hospital, which has currently been problematic for University CRNAs.

In 2013-2014, the Colorado Association of Nurse Anesthesiology funded a film to showcase the contributions to CRNAs. This film has been used to educate legislators, the public, and other nurses about our profession. It is hoped that this film will continue to be a useful tool for education and advocacy:

https://m.youtube.com/watch?v=CYHovRk7Oms.  Long version (30 minutes)

http://youtu.be/MWhdSBetX2M for short version (11 minutes).

With the writing of this history, it is my hope that Colorado CRNAs will understand how important it is for each individual CRNA to “do their part” in supporting COANA and its activities to support our profession. Vigilant observation of legislative and regulatory activity related to our practice of anesthesiology nursing is important if we are to remain a vital asset as anesthesiology providers in Colorado. Pay your dues, attend state meetings, volunteer (even if it is something small) to support association activities. Contribute to AANA and COANA PACs so that your voices can be recognized and heard in the legislative arena. Contribute to the AANA Foundation so that we can support research done by CRNAs to advance our clinical knowledge. We are blessed by our volunteers—remember no member is paid to work for our association.

Cheryl Blankemeier (CRNA retired)