Medicare payments favor opioids over alternatives, and that’s a problem

By Angelarosa G. DiDonato

Our country in struggling with an opioid epidemic. An estimated two million Americans suffer from opioid use disorder, and opioid overdoses kill more than 130 Americans each day, on average.

Studies show that opioid addiction can occur from the very first exposure --- and sometimes, that first exposure may be during anesthesia for a necessary surgical procedure.

Certified Registered Nurse Anesthetists (CRNAs) operate in every setting where anesthesia is administered: hospital operating and delivery rooms; ambulatory surgical centers; the offices of dentists, podiatrists, ophthalmologists, and plastic surgeons; pain management centers and more. With such widespread influence among so many health-care settings, CRNAs play a major role in curtailing the opioid epidemic. We understand the risks and effects of the medications we administer, which is why we’re changing the way we operate. Nurse anesthetists today can manipulate their anesthetic to provide narcotic-sparing and often narcotic-free anesthesia. Our nation’s health programs should be doing the same. Unfortunately, federal regulations from the Centers for Medicare and Medicaid Services (CMS) fail to address a number of outdated regulations that put Pennsylvania’s pain patients in harm’s way. Over the last decade, many non-opioid pain treatment options have been developed, including single-dose injectables that release slowly over the course of up to 90 hours. For many patients, these promising alternative therapies can take the place of traditional more-addictive opioid painkillers. However, CMS rules fail to adequately cover the cost of administering these medications, leaving Pennsylvania’s more than 2.7 million Medicare beneficiaries without the option of affordable, non-addictive pain treatment. In a decade that saw drug overdose deaths skyrocket across the nation, Pennsylvania was among the worst in mortality increases, according to the U.S. Centers for Disease Control and Prevention. Last year, 4,125 Pennsylvanians died, according to the state Department of Health, and two-thirds of those deaths involved opioids. Recently, drug overdoses have spiked in Pennsylvania, with the rise coinciding with stay-at-home orders brought on by COVID-19. Treatment centers closed and counseling and support-group sessions went online. The stress and social isolation of being stuck at home also created a dangerous environment for those suffering from opioid use disorder. Beyond the human toll, the costs of opioid addiction are staggering. The CDC estimates the misuse of opioids costs our nation $78 billion annually in lost productivity, health-care services, addiction treatment, law and justice, and much more. Making alternative treatments more affordable and accessible can make a big difference. National studies suggest a 10 percent reduction in surgery-related opioid prescribing will result in 300,000 fewer people annually developing an opioid addiction, and keep over 330 million opioid pills out of American households, where they are often stolen or abused. These aren’t just numbers on a page --- they speak to lives saved, families preserved, and bright futures kept intact. Given the very real risks of opioid medications and the severity of Pennsylvania’s addiction crisis, we can’t wait to act. Antiquated federal regulations have helped to create our nation’s over-reliance on opioids, which remain the cheapest option for health-care providers because of how insurance payments are administered under the current Medicare reimbursement rule. The federal NOPAIN Act, which has bipartisan congressional support, would change that by requiring Medicare to cover non-opioid treatment alternatives for all Medicare recipients. It’s as simple as that. As a nurse anesthetist who specializes in anesthesiology and non-opioid therapies, I’m worried. I know all too well that legal opioid prescriptions and an over-reliance on pain management with narcotics too often can lead patients down a path of years-long addiction. There is only so much I can do in the operating room. We need help fixing laws that discourage alternatives to have a fighting chance. Passing the NOPAIN Act is a critical step in combatting the addiction epidemic nationwide and deserves our support. Angelarosa DiDonato, DNP, CRNA is president of the Pennsylvania Association of Nurse Anesthetists, online at https://www.pana.org.

Guest column: Eliminate barriers to crisis-ready health care

An emergency is no time to trifle with bureaucratic red tape. At the outset of the COVID-19 crisis, many feared a surge of patients would overwhelm hospital capacity. Health officials sounded the alarm and identified policy changes that would enable them to meet the coronavirus challenge. And, in many cases, government responded.

In March, Gov. Tom Wolf issued executive orders designed to expand the state’s health care capacity, including temporarily suspending regulations that restricted where and how nurses and other health care professionals could practice.

For those aiming to ensure our health care system is always prepared, this raises an important question: If we cut the red tape during times of crisis, why not cut it permanently?

The fact is, before these regulations were suspended, our health system was suffering serious consequences. In April, PennLive reported that thousands of medical professionals across the country were getting furloughed or laid off. Though postponed elective procedures were partially responsible, another major factor was licensing requirements that made it difficult for medical staff to transition from their previous roles to help care for those suffering due to COVID-19.

Jess Poole, who previously worked out of Greensburg, is one such medical professional. Despite being a licensed nurse anesthetist with the training to intubate and manage patients, Pennsylvania wouldn’t recognize her specialty. Licensing restrictions made it impossible for her to contribute.

Health care heroes like Jess were forced to sit on the sidelines just when they were needed most. Thankfully, some state lawmakers are determined to keep this from happening again.

State Rep. Christopher Quinn (R-Delaware County) recently introduced legislation, HB 2779, that everyone concerned about conquering the virus should care about. Rep. Quinn’s bill would extend the suspension of certain bureaucratic regulations holding back our health system for one year — and establish a panel to determine which of those counterproductive regulations should be done away with for good.

Telehealth, or remote medical appointments often conducted via video calls, is a great example of a health care innovation that would have been limited under prior overly-restrictive regulations. The contagious nature of COVID-19 made telehealth an essential service in 2020, and utilization skyrocketed by 50 to 175 percent. This expanded use was made possible because Pennsylvania took steps to guarantee provider reimbursements by insurance companies and relaxed licensing restrictions that prevented providers from serving patients across state lines.

Even after the crisis subsides, telehealth promises increased access to care and reduced patient costs. For example, a Vermont Veterans Association saved almost $19,000 a year from reduced travel costs after offering telehealth options. A 2017 study found that patients experienced a cost savings of $156 per consultation due to reduced time and travel burden.

The removal of antiquated barriers to telehealth and the lifting other unnecessary regulations should be made permanent to expand access to care. For example, maintaining newly-increased practice flexibility for Advanced Practice Registered Nurse Practitioners would empower over 7,000 nurse practitioners in Pennsylvania to care for more patients.

Rep. Quinn isn’t alone in seeing an opportunity to improve health care access and reduce cost for all Pennsylvanians. Senate Bill 25 and HB 100, together sponsored by over 70 lawmakers, create a path for nurse practitioners to practice independently after a minimum of 3 years and 3,600 hours under the supervision of a physician. Empowering them to provide primary care could bring down the patient load per primary care provider from almost 1,000 patients per provider to 667 patients per provider.

Two other proposals, HB 1997 and HB 1998, would give doctors more flexibility over how to work with physician assistants. The result? Greater access by patients to customized care.

Another bill would allow pharmacists to offer flu shots to individuals 9 years of age or older, creating an additional 9,000 access points for flu vaccinations across the state. Empowering pharmacists to provide vaccinations to a wider age range can free up physicians to focus on their most urgent cases.

It is impossible to predict what the future holds for COVID-19. But by repealing unneeded health care regulations that are barriers to patient care, lawmakers can ensure Pennsylvania’s health system is always prepared for crisis.

Stephen Bloom is vice president for the CommonwealthFoundation, Pennsylvania’s free market think tank.

Published in The Pottstown Mercury

Pa. should utilize nurse anesthetists in COVID-19 response | Opinion

Published in the Pennsylvania Capital-Star

By Jessica Poole, Capital-Star Op-Ed Contributor

As the COVID-19 pandemic continues to increase exponentially in Pennsylvania, certified registered nurse anesthetists (CRNAs) are uniquely prepared to provide care for the surge of critically ill patients. Unfortunately, the full contribution of CRNAs is being limited.

There are approximately 3,700 CRNAs and students in Pennsylvania, making us one of the largest contingencies of CRNAs in the nation.

In fact, anyone having a surgery or procedure requiring anesthesia was likely under the direct care of a CRNA. However, due to widespread cancellations of elective surgery throughout Pennsylvania, many CRNAs are off the job, creating an untapped resource for fulfilling critical roles outside of the operating room during this crisis.

CRNAs possess a skillset uniquely suited to aid in management of this crisis. Most have cared for patients as sick as, or even more acutely ill than, the COVID-19 patient. In the operating room, the nurse anesthetist serves as the frontline, critical care intensivist; surveilling, assessing and implementing appropriate interventions.

Much has been said about the importance of ventilators during this crisis, and CRNAs not only routinely use them, but they tailor their complex settings to each patient. Due to a nurse anesthetist’s science-based education and clinical experience, CRNAs understand the why and how of their equipment, allowing them to manage complex patients.

The CRNA possesses hands-on skills extending far beyond their already vast critical care experiences. CRNAs perform rapid physical assessments, airway and ventilatory management, volume resuscitation and hemodynamic management, patient triage, emergency preparedness, and procedural skills that include central and arterial invasive line placement.

Furthermore, a skill unique to the nurse anesthetist is our ability to lead and manage the care of a critical patient. Health care is experiential, and CRNAs have the experience of critical care nursing with further graduate level education in the application of medical skills beyond that of a critical care nurse. This level of expertise places the CRNA in a position of leadership and management extending beyond the operating room.

As frontline health-care professionals, we play a crucial role in the state’s response to this pandemic, especially one related specifically to respiratory failures. Facing unprecedented challenges in our medical communities, health-care systems must prepare to fully utilize the unique skill set of CRNAs.

Pennsylvania remains a state that still requires supervision of a CRNA by a physician. However, under the directive of President Donald Trump, the Centers for Medicare and Medicaid Services removed the national physician supervision requirement for CRNAs and encouraged states to allow CRNAs to practice to the fullest extent of their education and training to best care for patients during this crisis.

States like New York, West Virginia, Maine, Michigan, New Jersey and Arizona have already acted to remove barriers, allowing them to better utilize all available health-care providers without risking patient safety. It is imperative for Pennsylvania to do the same.

Gov. Tom Wolf and his administration should lift the requirement that Pennsylvania CRNAs be supervised by a physician to ensure that CRNAs can respond immediately to the COVID-19 health-care crisis using their advanced education and training to provide expert anesthesia and emergency airway management.

In Pennsylvania, education and clinical training for CRNAs is extensive. Unlike physicians, national board certification is required for CRNAs to practice. In total, CRNAs complete approximately 9,000 clinical hours.

Numerous scientific research studies have shown no statistical difference in patient outcomes when a CRNA provides anesthesia care compared to a physician anesthesiologist, even for rare and difficult procedures. In fact, the Federal Trade Commission cautioned states against policies that restrict the scope of advanced practice nurses. Direction from the President supports this.

More importantly, this crisis requires an all-hands-on-deck approach, and removing the supervision requirement of CRNAs in Pennsylvania will avail more physicians to provide hands-on care, expand the capacity of both CRNA and physician providers, and augment our system to meet the growing demands of this pandemic.

Our health-care systems are challenged to function above capacity, and untethering Pennsylvania CRNAs from unnecessary statutory and regulatory requirements will allow CRNAs to contribute more efficiently to the rapid response needed.

Wolf and his administration should follow the lead of our federal government and several other states by finally permitting CRNAs to serve to the full capacity of their education and training. CRNAs are prepared and eager to help keep Pennsylvania residents healthy and safe.

Jessica Poole is the director of State Government Affairs for the Pennsylvania Association of Nurse Anesthetists.