Since 2001, 17 state governors have exercised the option to 'opt-out'
of a federal rule that physicians supervise the administration of
anesthesia by nurse anesthetists, most citing increased patient access
to anesthesia care as the rationale for the decision.
The 'opt out' provision was created due to a concern about a
potential shortage of physician anesthesiologists, at least in some
regions and states. The presumption was that allowing nurse anesthetists
to practice without physician supervision would alleviate potential
shortages, and enhance access to anesthesia care.
‘'Opting-out' of the Medicare rule that requires anesthesia to be administered with physician supervision has little or no impact on access to either inpatient or outpatient surgery.’
Additionally, a lower
professional service cost for nurse anesthetists practicing without
physician supervision was presumed to lower anesthesia care costs.
'Opting-out' of the Medicare rule that requires anesthesia to be
administered with physician supervision has little or no impact on
access to either inpatient or outpatient surgery, according to a study
published in Health Economics Review
. Researchers also found
the opt-out policy does not reduce costs, and in some cases may be
associated with higher costs related to inpatient surgical care.
The study did not address why opting-out might increase costs. The
researchers said several factors may contribute to this unexpected
finding, including that nurse anesthetists may take longer to perform
the same services, and working without physician supervision may lead to
worse surgery outcomes, which requires additional treatment.
"The findings of this study underscore the point that before we make
a policy or pass a new rule, we first need to rigorously study what the
potential effects might be," said study lead author John Schneider, CEO of Avalon Health Economics. "A lot of states thought that by
opting-out of the federal requirement, they would be increasing access
to care. It turns out that simply opting-out is not a guarantee of
This is the fourth study in just over a year that looked into
whether the adoption of the opt-out rule impacted access to anesthesia
care. All four studies found that opt-out does not increase access to
anesthesia care. One study found that across urgent diagnoses, opt-out
was not associated with increased access to anesthesia services. Another
study found opt-out was associated with little or no increased access
to anesthesia care for common procedures.
"The new study extends the literature on the impact of state opt-out
policy by adding an assessment of its impact on costs of surgeries, and
by assessing its impact on a wider variety of procedures requiring
anesthesia services than in prior studies," the researchers wrote.
To analyze the effect of the opt-out rule on inpatient surgery,
researchers used the largest publicly available all-payer (including all
types of public and private insurance) health care database in the
United States, which included many opt-out and non-opt-out states. For
outpatient surgery, they used a database of outpatient surgery and
services provided by hospital-owned and nonhospital-owned surgery
The outpatient analysis included three opt-out states (California,
Colorado and Kentucky) and three non-opt-out states (Florida, Maryland
and New Jersey). The analysis used data from multiple years of U.S.
inpatient hospital discharges and outpatient surgeries. The outpatient
database did not provide cost estimates for outpatient procedures, so
the researchers were unable to evaluate the opt-out rule's effect on
outpatient surgery costs.
"Unlike previous opt-out studies, the design of this study allowed
us to better isolate the effect of the opt-out policy across states and
over time," said Dr. Schneider.
"The primary intent of the opt-out rule was to improve access to
anesthesia services by reducing barriers to utilize nurse anesthetists
and increasing their scope of practice. In turn, the hypothesis is that
the reduction in barriers will increase access to surgical care. In
our study, we did not find evidence to support this belief," the