Rural hospitals face serious and growing challenges. Hospital closures, financial pressures and workforce shortages are forcing patients in many communities to travel farther and wait longer for essential services. These problems deserve urgent attention and real solutions.
But too often we are seeing policy attempts aimed at expanding access that would lower the standard of care that patients rely on. Policymakers should not accept a false choice between making anesthesia services available and ensuring physicians remain meaningfully involved in patient care.
Anesthesiology is a critical care medical specialty. It extends well beyond “just putting someone to sleep.” Anesthesia care begins with evaluation of the patient’s health history and a physical exam to identify and assess conditions that determine what location is safest for the patient to have the procedure performed, how they should be cared for before, during and after the surgery, and what equipment, people and medications will be needed to perform these functions in the safest manner possible. Anesthesiology is the practice of medicine and it includes diagnosis of intraoperative conditions, monitoring of the patient’s condition throughout the procedure, anticipating next steps in the procedure and leading care for the overall anesthetic plan for the patient.
Patients deserve both access and safety when it comes to anesthesia care.
Nurse anesthetists are valued members of the healthcare workforce and play an important role in delivering anesthesia care. Anesthesiologists value their expertise and work alongside them every day.
But expanding the scope of practice for nurse anesthetists by eliminating physician involvement creates unintended consequences for patients. It risks creating a two-tiered system in which some patients receive physician-led anesthesia care while rural, lower-income and ethnically diverse communities are expected to accept something less.
As policymakers consider ways to expand access, they must also protect the safeguards that help keep patients safe. In California, those safeguards include legislation and regulations that have repeatedly confirmed that nurse anesthetists must practice under the order of a physician, dentist or podiatrist. While California has “opted out” of the Medicare requirement for physician supervision of nurse anesthetist for billing purposes only, nurse anesthetists must still abide by state law. The Drug Enforcement Administration license of the ordering physician is required for the nurse anesthetist to administer controlled substances as nurse anesthetists cannot prescribe, diagnose or practice medicine in the state of California.
That physician involvement requirement is not an unnecessary barrier – it is a proven safety standard that exists to protect lives. Research found that the odds of death were 8% higher and the odds of preventable deaths due to a complication (failure to rescue) were 10% higher among patients whose anesthesia was not provided by a physician anesthesiologist. And patients want access to physicians: a survey by the American Medical Association found that 91% of respondents said that a physician’s medical education and training are vital to optimal patient care, especially in the event of a complication or medical emergency.
Expanding independent practice for nonphysician providers is too often presented as a quick answer to workforce shortages in rural areas. But the evidence suggests the issue is far more complicated.
There has been research into the claim that eliminating physician supervision improves rural access. Multiple studies compared various aspects of access to care involving anesthesia in states that choose to be exempt from the longstanding Medicare requirement for physician supervision of nurse anesthetists. Research shows that patients did not receive increased access to surgical care and anesthesia in opt-out states. Furthermore, inpatient surgical care costs were 8.7% higher in opt-out states. Another study found that patients in opt-out states traveled the same distance for care as those in non-opt-out states.
That means we need to really look at solving the deep challenges facing rural healthcare.
Real solutions include expanding residency and training opportunities for physician anesthesiologists; educating more nurse anesthetists to serve within physician-led teams; creating loan repayment and other incentives for healthcare professionals who practice in underserved communities; improving Medicaid and Medi-Cal reimbursement; ensuring the rural pass through applies to physicians in the same manner it does to nurse anesthetists; supporting financially vulnerable rural hospitals; and authorizing certified anesthesiologist assistants in more states.
These solutions require investment, collaboration and sustained effort. Simply removing safety standards may seem like a convenient answer, but it does not make it better policy.
Every patient deserves timely anesthesia care, close to home whenever possible, with strong safety standards and access to physician expertise. A patient’s ZIP code, income or background should never determine the level of care available to them.
The bottom line is that rural and underserved patients should not be asked to choose between access and physician-led care. They deserve the same commitment to safety, quality and medical expertise as patients anywhere else. We should be willing to do the real work required to deliver it.
Dr. Menor is president of the California Society of Anesthesiologists.
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