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Pondering Pain Care

CMS to announce decision on reimbursing CRNAs for pain interventions in patients with Medicare.

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The eyes of nurse anesthetists everywhere were trained on Washington this November and their focus had little to do with Obama or Romney.

On Nov. 1, the Centers for Medicare and Medicaid Services (CMS) announced their decision that nurse anesthetists will continue to be reimbursed for providing pain relief treatment for patients receiving Medicare.

CRNAs have long administered routine, chronic, pain management services such as opiate and steroid injections and refills for implantable medication pumps, sometimes with the involvement of imaging technology.

Medicare for years hadn't distinguished between reimbursements for acute and chronic pain care given by the nurse anesthetists, mainly because many chronic pain treatments didn't exist when the Medicare rpayment ules were written more than 20 years ago.

But two Medicare contractors serving patients in 17 states acted last year to deny direct reimbursement of CRNA chronic pain management services.

Without advance notice or public comment, the contractors said CRNA pain services could only be billed by supervising physicians, not the CRNA providing treatment.

"Denying patient access to CRNA pain care just doesn't make any sense," said Christine Zambricki, DNAP, CRNA, FAAN, senior director of federal affairs strategies at the American Association of Nurse Anesthetists prior to the CMS decision.

"In remote or critical access areas especially, CRNAs are the only professionals qualified to administer these types of pain management services," she said.

"The alternatives are for patients to travel to great distances (up to 200 miles in many cases) to providers they don't know, undergo major surgery, be institutionalized or suffer in pain. Seniors who need this care should have it." 

The medical community was divided on this issue.

The American Association of Nurse Anesthetists mobilized a campaign to protect patient access to CRNA pain treatments and has the support of the National Rural Health Association, AARP and American Hospital Association.

Meanwhile, the American Medical Association, American Society of Interventional Pain Physicians, North American Neuromodulation Society, American Society of Anesthesiologists (ASA), and some members of the GOP Doctors Caucus of the U.S. House of Representatives opposed the rule on the grounds that nurse anesthetists don't have the appropriate training, and their care would contribute to prescription drug abuse.


Insufficient Training

At issue was the fear that CRNAs don't have adequate training in pain care.

"Even in the hands of specially trained physicians, chronic pain procedures are inherently dangerous due to the anatomy and delicate structure of the spine and nerves upon which chronic pain interventions are performed," said American Society for Anesthesiologists president Jerry A. Cohen, MD prior ot the CMS decision. "Current restrictions on nurse anesthetists providing these services are appropriate and necessary in the interest of patient safety."

Potential complications from pain procedures include allergic reactions, infections, bleeding, nerve damage, spinal cord injuries (e.g., paralysis) and brain stem tissue damage. All of these risks require extensive and costly medical interventions to address.

Numerous studies provide evidence to the contrary, said Zambricki. A study released in August by RTI International found no differences in patient outcomes when anesthesia services are provided by CRNAs, physician anesthesiologists or CRNAs supervised by physicians.

That doesn't necessarily mean more training isn't needed.

According to the 2011 Institute of Medicine (IOM) report Relieving Pain in America, most healthcare professionals are inadequately prepared to provide the full range of pain care or guide patients in self-management. The IOM cited a study finding only five of the nation's 133 medical schools with required courses on pain and just 17 with elective pain course offerings.

Nurse anesthetists gain pain management knowledge through fellowships, continuing education courses, anatomic dissection labs and practicums on imaging radiation, said Zambrecki. All training occurs at the master's level or higher, she noted.

Still, even she acknowledged the need for more interdisciplinary training in this evolving field for physicians and nurses alike.

"Even physicians who are experts in pain care, don't know what the don't know," she reasoned. "The Institute of Medicine is right to say that we have to join together and advance proessional education in diagnosis treatment, prevention and self-management of pain."

 With 100 million Americans experiencing chronic pain, by IOM estimates, the number of providers is admittedly low. The IOM estimated 3,000-4,000 physicians who've undergone formal fellowship training and the number of nurse anesthetists is low in the field as well.

Access Gap

With such a small number of qualified providers as it is, patients in rural or critical access areas are already challenged to find relief from chronic pain.

Zambricki said the cost of alternative treatment could have run up to 150 times higher, citing a recent Lewin Group analysis. But, for many CRNAs, the issue ran deeper than economics.

"It's tempting for policymakers to talk about this in terms of healthcare policy and overlook that human lives are at stake," she said. "They're elderly, they're in pain. They may have lost a spouse or cannot drive.The pain care a CRNA can provide can be a lifeline"

 Robin Hocevar is senior regional editor at ADVANCE.


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