Nurses Seek Expanded Role

A federal agency is weighing whether to reimburse a specialized type of nurse for giving chronic-pain treatments, a move opposed by some doctors and one that critics say could complicate the battle against prescription painkiller abuse.

By Nov. 1, the Centers for Medicare and Medicaid Services is expected to decide whether nurse anesthetists should be directly reimbursed by Medicare for evaluating, diagnosing and treating pain with epidural injections or prescription painkillers called opioids. Medicare is the federal health program for the elderly and disabled.

The current guidelines, from 1989, are unclear as to whether nurse anesthetists may only treat pain in the operating room, or whether they can help people manage chronic pain problems such as back or neck aches.

There are about 45,000 nurse anesthetists in the U.S. They work predominantly in hospitals and surgery centers, where they numb pain for patients undergoing procedures such as hip replacements or births. They also create treatment plans for some patients with acute pain.

The CMS rule, which would take effect Jan. 1, 2013, would reimburse nurse anesthetists on a par with doctors, signaling to private insurers and states that they are qualified to treat pain and may assume a more active role with such patients.

Nurse anesthetists in nearly every U.S. state currently can provide some chronic-pain treatment such as injecting steroids to reduce swelling or refilling implanted pumps with pain medications. In 24 states they also can write prescriptions for controlled substances, such as oxycodone. But under the new rule, far more nurse anesthetists could write prescriptions, if more choose to treat chronic pain.

In 2010, only about 4,000—or 0.17%—of the nearly 2.4 million Medicare claims for commonly billed chronic pain procedures were from nurse anesthetists, according to CMS.

Doctor groups, including the American Medical Association, sharply oppose the CMS proposal, arguing the change could lead to a surge in painkiller prescriptions. They say nurse anesthetists lack sufficient training and education, and that the powerful narcotic drugs could end up in the hands of more patients who don’t need them.

“This proposal is turning nurse anesthetists into doctors,” said Laxmaiah Manchikanti, chief executive of the American Society of Interventional Pain Physicians, who practices medicine in Paducah, Ky.

Unnecessary tests or inappropriate pain-dulling injections approved by nurse anesthetists could drive up health costs and ultimately lead to more people being pushed onto prescription painkillers, Dr. Manchikanti said.

Thirteen U.S. House representatives from the GOP Doctors Caucus sent a letter opposing the rule change last month to Marilyn Tavenner, the acting CMS administrator.

Meantime, AARP and the National Rural Health Association have written letters to CMS in support. The American Association of Nurse Anesthetists says the country doesn’t have enough board-certified pain doctors to meet demand. Without nurse anesthetists, patients sometimes have to travel long distances for care, or forgo treatment altogether, said Christine Zambricki, AANA’s senior director of federal affairs strategies.

“If you’re saying I can’t treat chronic pain, you’re telling me I’m a fireman but can only put out fires in the living room and bathroom,” said Brian Bradley, a nurse anesthetist in Butte, Mont., who is one of the few charging Medicare for chronic-pain treatment. Some patients travel up 100 miles to see him.

The potential expanded role of thousands of nurse anesthetists comes as doctors have come under fire from states looking to crack down on prescription painkiller abuse. The White House’s Office of National Drug Control and Policy wants to make it mandatory for any physician writing painkiller prescriptions to receive additional training.

Health professionals who are sufficiently trained in pain care are “few in number,” according to a report published last year by the Institute of Medicine, a federal advisory body. The report was commissioned by the Department of Health and Human Services.

Currently, medical professionals don’t need to be certified to treat chronic pain. The AANA doesn’t have specific training requirements for nurse anesthetists who want to treat chronic pain. Doctors who don’t specialize in pain treatment might receive only several weeks of training while in medical school or in their residency.

Allowing nurse anesthetists to write painkiller prescriptions is “loosening the controls on these medications, when there needs to be a tightening,” said Michael C. Barnes, interim executive director of the Center for Lawful Access and Abuse Deterrence, a nonprofit that works to cut down on misuse of prescription drugs.

When CMS wrote its 1989 payment guidelines for pain treatment, it stated nurse anesthetists could be reimbursed for “anesthesia services and related care.” But back then, today’s $9 billion industry of chronic pain medications didn’t exist and the statute referred to acute pain. Nurse anesthetists say the statute’s original wording allows for them to provide chronic pain treatment.

Medicare for years hadn’t distinguished between reimbursements for acute and chronic pain care given by the nurse anesthetists. But last year, two local administrators of Medicare services, Noridian Administrative Services LLC and Wisconsin Physicians Service Insurance Corp., stopped reimbursing nurse anesthetists for chronic pain services.

A CMS spokeswoman declined to comment because regulators are still finalizing the rule.