But in any case, more intense coverage from anesthesiologists would cost each of his hospitals $1 million a year, and for two of them, that's 3% of their $30 million annual budget, he says. "If you need anesthesiologists, if you can find them, you have to pay whatever they cost—and those costs are spiraling out of control," he says.
It's impractical for a small rural hospital, such as his 64-bed Hanford Community Hospital, 57-bed Selma Community Hospital or 49-bed Central Valley General Hospital to pay for an anesthesiologist to be present long before a patient needs surgery, long before the surgeon arrives.
Bottom line, Rawson says: if the doctors get their way, two of his facilities would have to stop providing surgery, and the third would have to cut back surgery by nearly half. For the most part, that surgical volume is what keeps the hospital viable.
With the new interpretation, he says, Medicare "applies the standard to bread and butter cases where there's no benefit at all in having an anesthesiologist."
"If they win the lawsuit, we can't go back to the way it was," he says. The tighter restrictions, he says, "would be devastating."
Keep in mind that the 14 other opt-out states are largely rural: Alaska, Iowa, Idaho, Kansas, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Washington and Wisconsin. California is the first largely urban state to opt-out.
Mark Odden, a CRNA in Iowa, the first state to exercise the opt-out nearly 10 years ago, works with a company that provides nurse anesthetist services to 13 rural hospitals as far as 75 miles away from Manchester.
If Iowa didn't have the opt-out, Odden says, those hospitals "would have to hire anesthesiologists to travel to all those hospitals." Practically speaking, the patients are mostly older and on Medicare or are uninsured and they "would have to go elsewhere."
"We handle farming accidents or a drug overdose. And we're the first line people who are called," Odden says. "We can do the resuscitation and complications that come, and sometimes it's just me and a another nurse practitioner, taking care of a massively damaged patient while we wait for a helicopter."
Just recently, he says, nurse anesthetists helped saved a life of a teenager with asthma, who came in to a 29-bed hospital when there was no doctor around. The CRNA had to intubate the patient because he was so unstable. "We had to do ground transport to a hospital in bad weather, 70 miles away to the University of Iowa," Odden says.
Now, tensions among hospitals, doctors and nurse anesthetists are raw over this issue. But eventually, common sense and practicality must prevail. For many hospitals that already struggle to have trained, licensed professionals available to treat patients, removing the option that a CRNA can practice without physician oversight could be devastating both to the patients and to the facilities where they practice.
Physicians need to show proof of the cause of their disdain for the use of CRNAs. Perhaps they can point to some real evidence that patient safety is increased when they are there. If they can't, they should accept the probability that patient care can and should be—especially in rural areas—a shared, cooperative responsibility.
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