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November, 2007
To: Region 5 CRNAs
From: Todd Herzog, CRNA, ARNP
It is my great pleasure to make this report to you, the AANA members of
Region 5.
I have served as your Region 5 Director for nearly a year now. Soon we
will be gathering in Minneapolis for yet another AANA Annual Meeting. This
first year of my tenure on the AANA Board of Directors has been filled
with meetings and conference calls, reading what seems to be unending
reams of documents and emails and (my very favorite part) traveling to
meet with the members of Region 5 and to present the AANA Update. This
experience has proven what I already knew…CRNAs are the most cordial,
outspoken, honest, compassionate, engaged, involved, and inherently
interesting group of health care professionals I have ever known! Over the
past year I have had the great pleasure of presenting the AANA Update to
the Washington Association, the Montana Association, the Idaho
Association, the Oregon Association, the California Association, and the
Alaska Association of Nurse Anesthetists. I have enjoyed the sunshine, the
rain, and a starry night on a frozen lake outside of Anchorage Alaska
where I viewed the Aurora Borealis at 4:00 am at minus 24 degrees
Fahrenheit! I have represented the interests of the members of Region 5 at
the national meeting in Denver, the Joint Committee Conference in Chicago,
the Fall Assembly, the Assembly of School Faculty in Newport Beach,
California, the AANA Mid Year Assembly in our Nation’s Capitol, and the
AANA Board of Directors Meeting in Chicago. I have participated in
legislative hearings in Nevada with regard to the Hepatitis C outbreak
there. All of these experiences have provided an opportunity to see,
learn, and to engage in advancing CRNA interests within Region 5.
The AANA Board of Directors has addressed many significant issues of
interest to CRNAs. The following is a synopsis of our recent activities:
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Pain Management - As you know, the Louisiana Association of Nurse
Anesthetists, The Louisiana Board of Nursing and an individual CRNA were
the subject of legal action brought by a group of anesthesiologists
engaged in interventional pain management and supported by the Louisiana
Society of Anesthesiologists. Their position was that the practice of
interventional pain management is exclusively the practice of medicine.
Further, they opined that the Louisiana Board of Nursing exceeded its
statutory authority in ruling that the practice of interventional pain
management is within the CRNA scope of practice. Unfortunately, an initial
judgment in favor of the Nursing Board and the CRNA has been reversed on
appeal. The Louisiana Association of Nurse Anesthetists is currently
considering its options.
The AANA Board has been following these developments closely and is
integrally involved in taking steps to protect the practice rights of
CRNAs with regard to interventional pain management.
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Medicare Conditions of Participation - Currently, Medicare rules for
Ambulatory Surgery Centers require that each patient be evaluated for risk
of proposed surgery and anesthesia. The same rule also requires that a
physician evaluate patients’ fitness for discharge from post-anesthesia
recovery. This rule has always presented a threat to CRNAs independently
providing care in ASCs. Last summer several AANA members of our region
were displaced from their workplace by anesthesiologists hired by the ASC
because surgeons there were unwilling to accept liability for the
patients’ anesthesia care. In this case, a Medicare reviewer cited the ASC
for being out of compliance with Medicare regulation. Most CRNAs in
Opt-Out States believed that because Governors in their States chose to
relieve them of the requirement for physician supervision, the rules
stated above did not apply to them. The fact is, however, the requirement
for physician evaluation at admission and discharge never applied to
CRNAs. It applies only to facilities. So, how do we handle this threat?
First, due in part to assertive lobbying by AANA leadership, the Centers
for Medicare and Medicaid Services has proposed a change in the existing
regulation. This change would, if enacted, allow a CRNA the authority to
evaluate the patient preoperatively. Unfortunately, the language which
would allow the CRNA to independently discharge a patient from recovery to
home remains murky. In a letter written to CMS, President Wilson pointed
out that “Fundamentally, however, we advise the agency that a CRNA is
qualified to determine anesthesia recovery. This service lies well within
the CRNA scope of practice. Permitting ASCs to have CRNAs determine
anesthesia recovery ensures a qualified professional is making this
determination for each patient in the interest of patient safety while
extending ASCs the flexibility to arrange their delivery of services in
the most efficient manner compliant with the CfCs.” We expect CMS to make
a final ruling on this proposed change sometime this year. In the
meantime, we would recommend that CRNAs providing services in ASCs discuss
this regulation with ASC managers, Medical Directors, and surgeons. One
solution would be to create a form to be included in the patient’s chart
which documents the required the pre-operative and pre-discharge
evaluation and signed concurrently by both the CRNA and the surgeon.
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Member Advocacy - At our last meeting in Newport Beach, California, the
AANA Board of Directors expanded the scope of the Anesthesia Payment
Advisory Panel, added three new members, and renamed the panel. The panel
is now called the Anesthesia Payment and Practice Advisory Panel. The
purpose of the panel is to provide immediate evaluation of policy issues
which affect either payment for CRNA services or the effect of those
policy issues upon CRNA practice. This evaluation will assist the Board of
Directors and staff to properly frame policy decisions. I am very happy
and proud to welcome my friend Juan Quintana to the APPAP!
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Aetna and GI Endoscopy - In December of 2007, the Aetna Insurance Company
published its plan to cease payment for anesthesia services for GI Endoscopy on April 1, 2008 unless there the patient had one of ten
diagnoses. The AANA responded by letter to the Aetna corporate
headquarters in Hartford, CT. Additionally, AANA leadership held a
conference call with Dr. Troyen Brennan, Aetna’s Senior Vice President and
Chief Medical Officer. I am pleased to report that on February 27th Aetna
reversed its course and will not suspend payment for anesthesia services
for routine GI endoscopy. Stay tuned however, because we believe that
Aetna may be awaiting the new CAPS device currently under evaluation by
the FDA and the marketing of fospropofol.
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Reuse of Syringes and Needles - In late February, a national television
news broadcast contained a story about a GI endoscopy center in Las Vegas,
NV where due to reuse of needles and syringes from patient to patient as
well as inadequate sterilization of endoscopy equipment, six patients, all
having endoscopies on the same day, had been diagnosed as having
contracted hepatitis C. A total of 40,000 patients have been exposed to
potential infection. CRNAs are known to be employees of this practice. The
AANA wishes to be exceptionally clear. Needles and syringes are single use
items. They are meant to be used once, on a single patient, and then
discarded in an approved biohazard container. Further, a multi-dose vial
must never be re-entered with a syringe and/or needle which has been used.
A syringe and/or needle used for one patient must never be reused for a
second patient or even the same patient. To engage in any of these poor
practices constitutes unsafe practice, places your patients at risk, and
is condemned by the American Association of Nurse Anesthetists.
I had the privilege of representing the AANA at two meetings of the Nevada
Legislative Committee on Health Care, one in March and one in April.
Clearly, the Nevada Legislature is actively engaged in the process of
formulating new laws which would hope to prevent a recurrence of this
tragic event. Stay tuned. We have not felt all of the ramifications of
this crisis.
I would like to once again encourage you to donate generously this year to
CRNA PAC! As many of you know, I serve as the junior Board member of the
CRNA-PAC Committee. At a recent meeting of the committee, I asked Frank
Purcell seated next to me to envision an annual PAC fund of $5 million. I
asked him what AANA could do differently with a 5 million dollar PAC fund
that we can’t do with a 1.5 million dollar PAC fund. He sat back in his
chair, breathed a huge sigh and became a bit starry-eyed. He said that a
PAC fund of that magnitude would put us in a very exclusive league. AANA
would have the attention of every member of Congress. We would be able to
purchase television and radio slots thus serving both a public relations
purpose as well as forwarding our Federal Government Affairs agenda. When
I calculated what it would take to join that league, I found that if every
member of AANA would make an annual donation of just $132.00, CRNA-PAC
would enter that league. This is $11.00 per month folks! I don’t know
about you, but I spend that much every week on lattes! Think about
it-CRNA-PAC in the exclusive league. Won’t you join me this year and
become a member of either the Congressional (a $200 donation) or
Presidential ($1,000 donation) Club and make our PAC shine particularly
brightly this year. And remember, each of your family members can donate
as well. My wife Marge and I each became Presidential members this year!
On behalf of CRNA PAC, I thank you in advance.
Soon we will depart for Minneapolis, Minnesota for the AANA Annual
Meeting! While you are there, please stop me and say hello. The most
enjoyable and personally rewarding part of my duties as your Region 5
Director is meeting you and discussing your hopes and desires for the
AANA. These opportunities form the cornerstone of representative
leadership. My door is always open to you and I want you to feel free to
contact me by telephone, email, FAX, carrier pigeon, smoke signal, or
telegram…seriously, I want to hear from you.
Thanks again for giving me the honor of working for you as a member of the
AANA Board of Directors. Remember…It’s a GREAT DAY to be a CRNA!!
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