Anesthesiologists Are Affiliated with Many Hospitals Only Reporting Anesthesia Claims Using Modifier QZ for Medicare Claims in 2013

Miller, Thomas R.; Abouleish, Amr E.; Halzack, Nicholas M.

doi:10.1213/xaa.0000000000000223

Cited by 9 publications

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“…In states that have not chosen to "opt out" of federal regulations requiring physician supervision of nurse anesthetists, nurse anesthetists must practice under the supervision of a physician, although not necessarily an anesthesiologist. In states that have opted out of federal regulations requiring physician supervision of nurse anesthetists (see appendix table A.1 in the Supplemental Digital Content, http://links.lww.com/ALN/B729), nurse anesthetists have the de jure ability to practice without any physician supervision, although even in these states, de facto supervision is common, 11 particularly because hospitals, insurers, patients, and surgeons may impose additional restrictions limiting the ability of nurse anesthetists to practice independently. The scope of practice laws that define the legal ability of nurse anesthetists and anesthesiologist assistants to provide care remain contested at the state level.…”

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confidence: 99%

Anesthesia Care Team Composition and Surgical Outcomes

et al. 2018

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Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background In the United States, anesthesia care can be provided by an anesthesia care team consisting of nonphysician providers (nurse anesthetists and anesthesiologist assistants) working under the supervision of a physician anesthesiologist. Nurse anesthetists may practice nationwide, whereas anesthesiologist assistants are restricted to 16 states. To inform policies concerning the expanded use of anesthesiologist assistants, the authors examined whether the specific anesthesia care team composition (physician anesthesiologist plus nurse anesthetist or anesthesiologist assistant) was associated with differences in perioperative outcomes. Methods A retrospective analysis was performed of national claims data for 443,098 publicly insured elderly (ages 65 to 89 yr) patients who underwent inpatient surgery between January 1, 2004, and December 31, 2011. The differences in inpatient mortality, spending, and length of stay between cases where an anesthesiologist supervised an anesthesiologist assistant compared to cases where an anesthesiologist supervised a nurse anesthetist were estimated. The approach used a quasirandomization technique known as instrumental variables to reduce confounding. Results The adjusted mortality for care teams with anesthesiologist assistants was 1.6% (95% CI, 1.4 to 1.8) versus 1.7% for care teams with nurse anesthetists (95% CI, 1.7 to 1.7; difference −0.08; 95% CI, −0.3 to 0.1; P = 0.47). Compared to care teams with nurse anesthetists, care teams with anesthesiologist assistants were associated with non–statistically significant decreases in length of stay (−0.009 days; 95% CI, −0.1 to 0.1; P = 0.89) and medical spending (−$56; 95% CI, −334 to 223; P = 0.70). Conclusions The specific composition of the anesthesia care team was not associated with any significant differences in mortality, length of stay, or inpatient spending.

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Anesthesia Care Team Composition and Surgical Outcomes

et al. 2018

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“…as the only indicator of whether a case involved an anesthesiologist's medical direction or supervision does not capture the true level of involvement of each participating anesthesia provider. Miller et al (2016) find that even facilities exclusively billing CRNA services without medical direction (QZ) often have affiliated anesthesiologists. However, the contribution, if any, of anesthesiologists in these cases is unclear based on the claims.…”

Section: Anesthesia Safety Outcomesmentioning

confidence: 99%

Advocacy, Research, and Anesthesia Practice Models: Key Studies of Safety and Cost-Effectiveness

Hoyem

Quraishi

Jordan

et al. 2019

Policy, Politics, & Nursing Practice

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The practice of anesthesia includes multiple competing practice models, including services delivered by anesthesiologists, independent practice by certified registered nurse anesthetists (CRNAs), and team-based approaches incorporating anesthesiologist supervision or direction of CRNAs. Despite data demonstrating very low risk of death and complications associated with anesthesia, debate among professional societies and policymakers persists over the superiority or equivalence among these models. The American Society of Anesthesiologists uses published findings as evidence for claims that anesthesia is safer when anesthesiologists lead in providing care. The American Association of Nurse Anesthetists cites its own research on safety and cost-efficiency outcomes to defend against these claims. We review and critique studies of the safety outcomes and cost-effectiveness of anesthesia delivery that have been cited in the Federal Trade Commission comment letters related to competition in health care, where each profession has laid out their case for how they ought to be recognized in the market for anesthesia services. The Federal Trade Commission has a role in protecting consumers from anticompetitive conduct that has the potential to impact quality and cost in health care. Thus, it is important to evaluate the evidence used to make claims about these topics. We argue that while research in this area is imperfect, the strong safety record of anesthesia in general and CRNAs in particular suggest that politics and professional interests are the main drivers of supervision policy in anesthesia delivery.

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