by STUART HAYMAN, M.S.
As I write this column, we are in the middle of what has already become one of the worst flu seasons in more than a decade. The number of flu-related hospitalizations and deaths has been front-page news for weeks, and will likely continue to grip our attention as we head toward spring.
As we collectively turn our attention to the havoc wrought by a particularly deadly flu season, however, it’s easy to forget about the other public health emergency that so many Americans are facing every day: the opioid epidemic.
The rate of opioid overdose deaths has increased 200 percent since 2000. From 2000 to 2016, more than 600,000 people died from drug overdoses. According to the U.S. Centers for Disease Control and Prevention (CDC), opioids were involved in 42,249 deaths in 2016 alone. Today it is estimated that more than 2 million Americans abuse opioids.
New York has not been spared from the opioid epidemic. In fact, the CDC identified New York as one of the states that experienced a statistically significant increase in drug overdose deaths from 2015 to 2016.
In 2012 Gov. Andrew Cuomo signed legislation aimed at overhauling the way prescription drugs were distributed and tracked in the state. At the time, New York state Sen. Kemp Hannon noted the alarming fact that in the previous documented year, 22 million new prescriptions for painkilling drugs (not including refills) had been written in a state that is home to 19.5 million people.
The legislation signed in 2012 created a new, updated prescription monitoring program (I-STOP) that made it harder for patients to “doctor shop” to illegally obtain prescriptions from multiple practitioners. Through the Prescription Monitoring Program (PMP) Registry, information about dispensed controlled substances is reported by pharmacies in “real time,” and both practitioners and pharmacists can view a patient’s controlled substance history. As of
August 27, 2013, most prescribers were required to consult the PMP Registry when writing prescriptions for Schedule II, III, and IV controlled substances.
In addition to I-STOP, New York’s legislation made it one of the first states to mandate electronic prescribing (e-prescribing) for all controlled substances with limited exceptions. The legislation also expanded the functions of a workgroup established by the Department of Health under the existing Prescription Pain Medication Awareness Program with the goal of increasing education among healthcare providers about the potential for abuse of controlled substances, and the proper balancing of pain management with abuse prevention.
Healthcare provider education is now mandatory in New York, where those licensed to prescribe controlled substances, including medical residents who prescribe controlled substances under a facility DEA registration number, must complete at least three hours of course work or training in pain management, palliative care, and addiction. The initial deadline for the completion of the course work or training was July 1, 2017, and then once every three years thereafter. Prescribers licensed on or after July 1, 2017, must complete their course work or training within one year of registration, and then once within each three-year period thereafter.
New York City also recently announced a lawsuit against eight companies that make or distribute opioids, joining a growing list of cities and states across the country that are attempting to hold drug manufacturers and distributors at least partially responsible for actions that many believe contributed to this epidemic. The lawsuit seeks $500 million in damages, money that Mayor Bill De Blasio says will be used to help fight the crisis.
In a sign that these lawsuits may be starting to influence how drugmakers market opioids, Perdue Pharma, the maker of OxyContin, announced on February 10, 2018, that it will no longer promote OxyContin to physicians. According to The Associated Press, the company “acknowledged that its promotions exaggerated the drug’s safety and minimized the risks of addiction.” While this is a welcome, albeit long overdue, acknowledgment, there is no indication if other pharmaceutical companies will follow suit.
Lawsuits aimed at forcing the drug industry to take ownership of its role in this crisis are just the beginning. As states look for creative ways to mitigate the toll of opioid abuse, physicians must be part of these discussions. To that end, on the national level the ASA partnered with the hospitals of Premier Inc. to launch a national opioid safety pilot. The six-month pilot, which began in September 2017, is geared toward addressing opioid misuse, dependence and addiction by improving pain management and reducing opioid prescriptions after surgery.
The ASA also collaborated with the CDC on “Guidelines for Prescribing Opioids for Chronic Pain,” which provides recommendations for primary care providers on opioid prescribing as well as information regarding the risks of opioid use. In addition, the ASA is working with other pain societies, through the Pain Care Coalition, to support policies to further responsible pain care.
Where do we go from here? The opioid crisis was finally declared a public health emergency in late 2017; however, no new resources were allocated on a national level to combat this epidemic. Tragically, while we wait for federal authorities to take action, thousands more will die. As experts in pain medicine, physician anesthesiologists are in a unique position to influence local and national efforts to curb opioid abuse and save lives. We welcome the input and ideas of all NYSSA members, and hope to share your constructive feedback in future issues of Sphere
by STUART HAYMAN, M.S.
Every year, members of the NYSSA find themselves attempting to educate New York state legislators as part of the ongoing discussions regarding nurse anesthetist title and scope of practice. Given the potential harm to patients from allowing non-physicians to practice medicine, one could easily question the motivation of politicians who support legislation that would grant a nurse anesthetist the ability to practice as a physician. Personally, I believe the vast majority of legislators have the desire to do good for their constituents. That said, before any well-meaning legislator acts on a piece of legislation, he or she should first be certain to “do no harm.”
The current debate revolves around the governor’s budget proposal. We are concerned about Part H of the health budget, which would allow nurses to administer anesthesia without supervision. This change to the nurse anesthetist’s scope of practice has repeatedly been defeated in recent years in the New York Legislature, as well as by the Veterans Health Administration. The proposal goes dangerously beyond the recognition of nurse anesthetists’ title by attempting to grant nurses the full practice privileges of physician anesthesiologists.
As Dr. Rose Berkun so eloquently stated while testifying in front of key legislators at the New York state healthcare budget hearings, “If nurse anesthetists wanted to work independently as physicians, they should have gone to medical school and completed a residency. The practice of medicine should be determined by education and NOT by politics.”
Dr. Berkun and Dr. Vilma Joseph both sacrificed their personal time to represent the association, the profession, and New York patients when they joined NYSSA Legislative Counsel Chuck Assini, Esq., NYSSA lobbyist Bob Reid, and me to attend a nine-plus-hour hearing in Albany on the healthcare budget. These two dedicated NYSSA leaders deserve the thanks and respect of every NYSSA member. Dr. Berkun drove five hours from western New York after working all day in order to be in Albany the night before her Tuesday testimony at the hearing. Dr. Joseph was on call and working all Monday night in the Bronx prior to driving up to Albany at 7 a.m. They were then forced to wait through nearly 10 hours of testimony before it was their turn to speak. (While they waited, Drs. Berkun and Joseph visited with key legislators and participated in a television interview.)
The hearings began with the testimony of Commissioner of Health Dr. Howard Zucker, who also happens to be an anesthesiologist. After Dr. Zucker spoke for about 30 minutes, he and New York Medicaid Director Jason Helgerson were peppered with questions from legislators for more than four hours.
The testimony was something to behold. The amount of misinformation was eye opening. That being said, I do believe a few legislators deserve credit for trying to get honest, “full disclosure” answers out of the state employees who were testifying.
Sen. Kemp Hannon asked Dr. Zucker why the commissioner buried the proposed $10 million change on nurse anesthetist scope of practice in the middle of the $64 billion healthcare budget. Assemblywoman Rodneyse Bichotte asked Dr. Zucker if this proposal would negatively impact patient safety, create a two-tiered system with a reduced level of care for people with less resources, and potentially add to New York’s opioid crisis. Assemblyman Phil Steck asked whether the proposal provided for physician oversight of nurse anesthetists. Dr. Zucker offered many muddled, indirect answers to these questions. When pressed about whether the supervision standard would be preserved, the commissioner confessed that, at best, it would be up to each hospital. One Assembly member noted that it sounded like the decision would be influenced by economics and that “collaboration” was not the appropriate standard.
Assemblyman Andrew Garbarino wanted to know how New York would save $10 million if the reimbursement for anesthesia is exactly the same under Medicaid whether it’s delivered by a physician anesthesiologist or a nurse anesthetist. In response to this question, Director Helgerson indicated that he assumed the state would lower the reimbursement to CRNAs who provided the service.
The first eight hours of testimony and questions on this proposal involved various staff members representing different government departments (financial services, health, Medicaid inspector general, etc.). These individuals were unable to answer many of the questions asked of them, repeatedly telling legislators that they would have to get back to them. Finally it was time for the list of approximately 40 special interest groups to testify.
It was after the ninth hour of testimony that we heard from someone who truly surprised us. Jill Furillo, RN, executive director of the New York State Nurses Association, told legislators that her organization is opposed to the proposal, saying it could do harm. She testified that the CRNA expansion of scope should be removed from the governor’s budget and that there are specific issues in this proposal that need to be addressed and clarified by the Legislature.
Representatives from the New York State Association of Nurse Anesthetists testified next. Their president, Cheryl Spulecki, claimed that New York was one of only two states in the country that didn’t provide nurse anesthetists the title “CRNA” and then inaccurately and deceptively correlated that with unsupervised independent practice for nurse anesthetists in New York. Spulecki claimed that all but two states allow nurse anesthetists to practice independently. The truth is that only four states allow independent practice, and they are rural states with small populations. Spulecki also stated, erroneously, that nurse anesthetists provide the majority of anesthesia services to rural and poor communities, adding that they do so as safely and more cost effectively than physician anesthesiologists. She then introduced Juan Quintana, a CRNA from Texas and the 2016 president of the American Association of Nurse Anesthetists (AANA). He testified that he had his own business providing anesthesia services in Texas, an interesting statement given the fact that Texas does not allow non-physicians to own businesses that provide medical services unless these services are supervised by physicians.
We next heard from Drs. Berkun and Joseph. They concisely and effectively disputed each and every assertion by the nurse anesthetists. They explained that this initiative has previously been rejected for numerous good reasons:
TRAINING: Nurses are trained to work under the supervision of physician anesthesiologists, not independently. They have far less education and hands-on training. This proposal would grant authority for nurse anesthetists to perform pre-anesthesia evaluations, anesthetic induction and emergence. These are functions that they have not been trained to perform or allowed to do without direct supervision.
SAFETY: Independent studies have shown that the chances of an adverse outcome are significantly higher when anesthesia is provided by an unsupervised nurse anesthetist.
COST SAVINGS: There is a claim that this proposal would save New York $10 million. Under Medicare and Medicaid, the reimbursement for anesthesia services is exactly the same whether it is administered by a physician anesthesiologist or an anesthesia care team.
EXPANSION OF ACCESS: We do not have a shortage of anesthesia providers in New York. Our association survey of New York hospitals found that NO hospitals in the state are performing surgeries without access to a physician anesthesiologist. They either had anesthesiologists on staff or are affiliated with other hospitals that do. In 2016 the American Medical Association’s workforce study determined that out of 1,276 nurse anesthetists practicing in New York, more than two-thirds (870) practice in Albany and to its south — meaning downstate. This proposal would not expand coverage to the western part of the state.
DISCRIMINATION: This proposal will create a two-tiered healthcare system where the quality of anesthesia care will be determined by a patient’s insurance or other economic considerations. Those with resources will be cared for by physicians while those without will see nurses.
SCOURGE OF OPIOIDS: We are in the peak of an opioid epidemic that has caused many unnecessary deaths. This expansion of scope would allow approximately 1,300 undertrained and unsupervised prescribers to write opioid pain medication prescriptions, thereby exacerbating this crisis.
PATIENTS’ RIGHTS: Anesthesia patients are at their most vulnerable while rendered unconscious in surgery. They should continue to have the right to receive care from a physician anesthesiologist who is properly trained to supervise their anesthesia.
Drs. Berkun and Joseph ended their testimony with the following statement:
Every day anesthesiologists work with nurses on our anesthesia care team. We respect their work and their participation. However, the medical practice of anesthesia is not a collaborative practice. There is no room for a discussion between doctors and allied health professionals when a patient’s life has only seconds to be saved. When things fail in the operating room and the patient’s life is on the line, there is no time for discussion. As anesthesiologists and as physicians, we are trained to act decisively in these dire situations. Nurses do not receive the same level of training and are not equipped for this level of practice expansion. This proposal dangerously weakens anesthesia care in New York and will lead to a higher rate of mortality.
We thank Drs. Berkun and Joseph for attending this grueling hearing and for their excellent testimony. We left the hearing feeling that the day was a positive one for New York’s patients. Many legislators seemed to understand that this proposal was nothing more than a special interest group attempting to practice medicine without the benefit of a doctor of medicine degree. Our advocacy efforts will continue, and we will keep the membership informed about our progress.
Sphere is published four times per year by the New York State Society of Anesthesiologists, Inc.
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