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President's MessageScope Of Practice: Challenges from the State Legislature to HCFA OfficesA. Allen Seals, M.D., President |
| Physicians have assisted in the development of allied health fields, and have generally supported the practice of these individuals within their original stated scope of practice. However, organized medicine in almost every state has had the continued challenge to fend off expansions of scope of practice from many allied health providers. Patients remain concerned over this issue, and independent polls have demonstrated that the public is firmly against expanding scope of practice for non-physicians. In Florida, the FMA and DCMS have worked together to defeat repeated attempts to expand scope of practices. Although, these annual attempts to expand scope of practice have occurred in the state legislative arena, we are now witnessing an extraordinary effort in the Health Care Financing Administration (HCFA) offices in Washington with the emergence of the issue of independent practice for Nurse Anesthetists. This issue has been discussed previously. In 1992, HCFA succinctly stated that in view of the lack of definitive clinical studies and the risks inherent in anesthesia administration, it would not be appropriate to allow anesthesia administration by non-physicians unless under close anesthesiology supervision. However, on March 8 of this year, the Administrator of HCFA (Ms. Nancy-Ann DeParle) indicated a sudden reversal in HCFA policy in a letter stating that in June 2000 she would finalize a proposed rule to eliminate the Medicare requirement for physician supervision of Nurse Anesthetists. This proposed dramatic rule change by HCFA is in direct contradiction to all published research and is in direct violation of the wishes of Congress. A recent study conducted at the University of Pennsylvania involved 65,595 Medicare patients in 219 Pennsylvania hospitals. This study, referred to as the Silber study, found a 28% higher death rate and a 27% higher failure-to-rescue rate when an anesthesiologist was not involved in supervising the nurse anesthetist. Last year in Congress, The Conference Report of the Medicare Enhancement Bill of 1999 called for HCFA to conduct an outcome study comparing mortality and adverse outcome rates for Medicare patients in the provision of anesthesia services. HCFA has chosen to ignore this directive from Congress and appears to be proceeding on their own initiative in a reckless manner with little regard for protecting Medicare and Medicaid patients. In the March 8 letter, Administrator DeParle states, "…We proposed the change because the clinical evidence supports that anesthesia outcomes have improved substantially in recent years such that anesthesia is a relatively safe procedure...". Senators Mike DeWine (R-OH) and Harry Reid (D-NV), as well as Representatives Dave Weldon (R-FL) and Gene Green (D-TX), have introduced the bipartisan "Safe Seniors Assurance Act of 1999," (HR 632/S 818). Currently, the U.S. House has recorded seventy-five bipartisan sponsors support the Safe Seniors Assurance Act of 1999 (HR 632) calling for HCFA to do scientifically- based comparative anesthesia outcome studies prior to making this rule change. In response to this threat to patient safety from HCFA, Congressman Weldon and Green have replied in very direct terms to Ms. DeParle as follows: "…We want you to know that we are deeply troubled by the terms of your March 8 letter to Senator Specter, indicating HCFA's intent to finalize by June 2000 its proposal to eliminate its longstanding requirement that nurse anesthetists be medically supervised. Just last November, the Congress recommended that this decision be based upon scientifically-based comparative anesthesia outcomes studies, and except for acknowledging that anesthesia today is "relatively safe", your letter makes no mention of you having considered such studies. When did "relatively safe" become HCFA's standard of care for Medicare beneficiaries? …We are further troubled to find that HCFA is planning to move forward on their plan to remove a quality assurance protection for seniors knowing full well that the publication of a scientific study on this very matter is pending. If for some reason HCFA believes that the study is invalid, when we are talking about a major change in policy that may very well result in the loss of life, HCFA has a responsibility to conduct its own study to determine if there would be an adverse affect on the lives and safety of Medicare beneficiaries … Is HCFA really so intent on eroding quality assurance policies in the Medicare program as to engage in so precipitous an action, when it knows that there is strong evidence that safety will be impaired? We cannot believe that this is true, and we believe you owe the sponsors of HR 632 and more importantly the nation's 40 million seniors, a better explanation than you have given so far, before you move to finalize the proposed rule. The only guiding principle to which HCFA should be committed is patient safety for Medicare beneficiaries. For this reason, as the Congress has already recommended, HCFA should proceed only on the basis of current scientific comparative data. To change this policy before all the evidence is in and has been considered by HCFA is to gamble with the lives of seniors. We urge you in the strongest terms to reject a policy change until the appropriate studies have been conducted and reviewed." The broader issues here are the attempts of non-physicians to extend their scope of practice well beyond the original intent of these allied health fields. This is an issue of concern to all physicians, regardless of specialty, and is clearly one of maintaining quality of care, and protecting the safety of our patients. June, 2000/ Jacksonville MedicineWhat's New
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