Health National Pain Report — 05 November 2012

A federal agency’s decision to allow Medicare funds to be used to pay nurse anesthetists when they treat chronic pain is getting a mixed reaction from health care providers and some patients. Critics say it jeopardizes patient safety, while supporters say it extends health care to pain patients who are often underserved by the medical community.

Last week the Centers for Medicare and Medicaid Services (CMS) said it would allow Medicare payments to certified registered nurse anesthetists (CRNAs) when they provide advanced services to pain patients. Many states already allow Medicare funds to be used to reimburse nurses who write prescriptions, perform epidurals and provide other pain management services. The CMS ruling, which becomes effective January 1, makes it a uniform policy for the entire country.

“America’s 45,000 nurse anesthetists administer some 33 million anesthetics every year. They’re a crucial part of our nation’s pain-care infrastructure, particularly in rural and medically underserved communities,” says Janice Izlar, CRNA, president of the American Association of Nurse Anesthetists. “Thanks to (the CMS) ruling, our patients can be secure in the knowledge that they’ll continue to have access to the nurse anesthetists they know and trust.”

Crystal Gisewhite is one patient who doesn’t trust them.

“Don’t let a nurse anesthetist put a needle in your spine,” she says.

In 2006, Gisewhite went to a hospital to deliver her second baby. A nurse named Annette gave her an epidural injection, a common procedure to alleviate pain during labor.

“When the needle went into my body I heard a loud pop and at the same time my entire left side felt like it had been struck by lightning.  I couldn’t move my arm or leg and the pain was like nothing I had ever felt before,” Gisewhite recalls.

“Annette said ‘oops’ and the nurse in front of me held me tight and whispered ‘I am so sorry honey.’  They laid me back down in the bed.  I was unable to move that side of my body during the remainder of my labor and the epidural didn’t work.”

Gisewhite says the epidural triggered a chain of events that left her permanently disabled with chronic pain. Fluid leaked from her spinal column and an infection developed. She was eventually diagnosed with Adhesive Arachnoiditis, a painful and crippling inflammation of the spinal cord.

“Had a doctor performed my epidural, would things have been different?  I don’t know for sure, but they have more training and experience in spinal conditions.  A doctor may have picked up on something the nurse missed and I could be fine right now,” Gisewhite wrote in an email to the National Pain Report. “My disease is permanent and I will forever be injured because the hospital let a nurse anesthetist put a needle in my spine.  I beg anyone who reads this to not let the same thing happen to you.”

In addition to spinal cord injuries, potential complications from pain procedures include allergic reactions, infections, bleeding, and nerve damage.

Daniel Bennett, MD, DABPM

Dr. Daniel Bennett, a Denver area pain physician, thinks patients are being shortchanged when they are diagnosed and treated by a nurse anesthetist.

“There is a reason people spend years to obtain a doctorate in medicine,” says Bennett, who is the Chief Medical Officer of American News Report. “A person with a complex disease like chronic pain deserves a physician to diagnose and treat their condition.  Although nurses are professionals, their role is supportive, not primary. If a person wants to diagnose and treat complex medical conditions, they should go to medical school and then complete their training with a residency.”

Bennett believes the CMS is more concerned about the bottom line – saving money – than it is about health care.  He said nurse anesthetists were “lower tier providers” who would charge Medicare less for their services.

“Government has no role in medicine,” Bennett said. “People should realize this and protest that the standards in medical care are being lowered and refuse to allow anyone other than a competent physician to direct and control their well-being.”

Bennett’s comments were echoed by the American Society of Anesthesiologists (ASA), which called the CMS ruling a “new and untested national policy” that lowers the quality of health care and raises the risk of prescription drug abuse.

“Current restrictions on nurse anesthetists providing chronic pain services are appropriate and necessary because nurse anesthetists simply lack the training and education to accurately diagnose, evaluate and treat patients with chronic pain,” said John Zerwas, MD, president of the ASA.

Even the CMS expressed some doubt about the nurses’ training in its ruling.

“We are unable, at this time, to assess the appropriateness of the CRNA training relating to specific procedures. We are also unaware of any data regarding the safety of chronic pain management services when furnished by different types of professional,” the CMS said.

About 100 million Americans suffer from chronic pain, according to the Institute of Medicine, which recommended that Medicare cover services provided by advanced practice nurses when allowed by state law.

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About Author

Pat Anson, Editor

Pat is Editor in Chief of American News Report. He is a veteran journalist and a former correspondent and producer for HealthWeek (PBS), Nightly Business Report (PBS) and other nationally syndicated shows. Pat has won numerous journalism awards, including a Golden Mike award for investigative reporting.

(2) Readers Comments

  1. As Obama medicare health care plans are came into picture then health care costs are increased very fast. Most of the health care officers are looking for personal income.

  2. This article does a grave disservice to the public, stealing well-earned trust from CRNA’s (who have been providing anesthesia for over 150 years in the US). I would expect more from Pat Anson, who has over 35 years experience in journalism. To take one patient’s unfortunate story and twist it into a scare tactic is irresponsible. Just how rare is Adhesive Arachnoiditis? The incidence of permanent nerve damage from epidurals is about 1 in 240,000 (Anesthesiology. 2006 Aug;105(2):394-9). Therefore, the incidence of this particular injury must be far less. What a hatchet job on Nurse Anesthetists.
    So why don’t you tell the public what this pain management issue is really about? Money, that’s what. Pain management is a very lucrative business for anesthesia providers. Anesthesiologists want to keep it to themselves, even if that means many patients in rural America will be denied care, or forced to pay for substandard methods of treatment. Do Anesthesiologists have more training than CRNA’s? Absolutely. Are CRNA’s mid-level providers? Yes. Physician extenders? Without a doubt. However, to slam them as unsafe and instill undue fear in the public is not right.
    I would direct anyone wondering about the safety of CRNA’s as compared to Anesthesiologists to the “Quality of Care in Anesthesia” report: http://www.aana.com/resources2/professionalpractice/Documents/Quality%20of%20Care%20in%20Anesthesia%2012102009.pdf
    Mr. Anson, you know better. You were a correspondent for Healthweek on PBS, and have won awards for investigative journalism. This article is garbage.