Regulation vs. Self Interest

Interesting article by Tim Noah at Slate (Anesthsleazeology) regarding the inter-profession conflicts and how they influence healthcare regulation. Noah, like most writers, is pretty confused about a lot of things (the difference between RNs and CRNAs for example) but he brings up a couple good points about the future of healthcare. Alabama  is proposing regulations that would prohibit CRNA's and NPs (and presumably PAs) from doing interventional pain management.: It states:  "The interventional treatment of pain may be performed and provided only by qualified, licensed medical doctors and doctors of osteopathy" because it "constitutes the practice of medicine."


Of course CRNA's do a lot of work in rural areas. I worked at a rural hospital that had a busy surgery running all week. We used nothing but CRNA's and most were fantastic. Noah says the Alabama law is born out of a conflict between CRNA's and Anesthesiologists.

 Unsurprisingly, the Alabama medical board's proposed rule arose from a complaint by an anesthesiologist about a "disturbing situation occurring in several facilities in Alabama where … [a CRNA] was providing epidural steroid injections to patients." The anesthesiologist claimed this practice threatened patient safety and asked the Alabama Board of Nursing to stop it. The state nursing board ruled that the anesthesiologist appeared to have an economic interest in preventing nurses from performing these procedures, said the nurses were authorized to perform them and had been doing so for some time, and told the anesthesiologist to buzz off. The spurned doctor got a more sympathetic hearing from the more physician-centric State Board of Medical Examiners.

There's no evidence that CRNA are any less safe in performing the interventions in question, Noah writes. Indeed he cites evidence to the contrary.

Earlier this year, the peer-reviewed journal Health Affairs ran an article under the self-explanatory headline "No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians." The article drew on the experience of 14 states that let nurse anesthetists work unsupervised by doctors when treating Medicare patients.  

Advanced practice nurses are often seen as a solution to two of the big problems in the American healthcare system - cost and access to primary care. CRNAs are well paid, but cheaper both to educate and to pay than MDs. There's also the question of access, Nurse practitioners are increasingly becoming the only accessible primary care providers because more and more MDs specialize and avoid primary care. Similarly, you're going to see more CRNAs out in rural areas that cannot afford to have Anesthetists.

The notion of allowing nurses and doctors' assistants to perform routine medical tasks in order to reduce medical costs and make certain services more widely available is controversial only to the particular doctors whose economic interests are at stake (and not even always to them). It has no discernable left-right valence, and the FTC has promoted it under presidential administrations both Democratic and Republican.