Turf war intensifies between physicians, nurse anesthetists at Stanislaus County hospitals

Modesto has become a battleground for the biggest turf war between anesthesiologists and certified registered nurse anesthetists since California, in a hotly contested decision in 2009, opted out of the federal Medicare rules for administering anesthesia.

The California Department of Public Health surveys at Stanislaus Surgical Hospital and Doctors Medical Center have caught the attention of physician anesthesiologists and nurse anesthetists across the country.

Hundreds of surgeries were canceled or rescheduled locally, as dozens of CRNAs, who are advanced practice nurses were laid off at Stanislaus Surgical as a result of stricter requirements and were sent home from Doctors Medical Center over credentialing issues. Doctors Medical Center has scrambled to hire more anesthesiologists to cover surgeries and other procedures.

CRNAs are concerned the CDPH surveys, done on behalf of the federal Centers for Medicare and Medicaid Services, may change perceptions about their scope of practice.

“We are very concerned the way this may be construed could negatively impact patient care at the statewide level,” said Kaitlin Perry, a communications consultant working for the California Association of Nurse Anesthesiology.

CANA has maintained that media coverage and anesthesiologist lobbying organizations have unfairly cast aspersions on nurse anesthetists. The policies recommended by the survey team favor physician supervision of CRNAs, similar to federal Medicare guidelines, but CANA representatives don’t see how that can be since California opted out of the federal rules almost 15 years ago.

If hospitals, especially those in rural areas, believe nurse anesthetists can’t practice independently, surgeries will be deferred and patients won’t have access to needed care, Perry said.

The California Society of Anesthesiologists countered there are legitimate concerns about patient safety. The group published an “alert” June 11 with excerpts of Modesto Bee coverage of the surveys at the two hospitals. A lobbyist sent the alert to legislative offices, urging them to touch base with hospitals, health systems and surgery centers in their districts “to ensure that patients can access physician-led anesthesia care.”

The CDPH survey at Stanislaus Surgical Hospital in August, January and February, which CANA is disputing, was critical of the practices of CRNAs at the short-stay hospital, including questionable decisions in prescribing drugs, sloppy paperwork and not communicating what drugs were given to patients.

The survey found that CRNAs were given full prescriptive and diagnostic authority at the hospital. The lack of supervision from anesthesiologists resulted in “possible avoidable situations where 10 patients experienced negative health outcomes following care provided by CRNAs and required transfer to a higher level of care,” the survey concluded.

No harm to patients has been established by the ongoing survey at Doctors Medical Center. Inspectors identified flaws in the credentialing process for about 19 nurse anesthetists. According to internal memos, the CRNAs won’t return to Doctors until the CDPH accepts a correction plan, which will include proctoring.

In the past week, Valley representatives including assemblymen Heath Flora, R-Ripon, and Juan Alanis, R-Modesto, and state Sen. Marie Alvarado-Gil, D-Jackson, came to the defense of CRNAs and hospitals that use their services. Their letter Tuesday to Mark Ghaly, secretary of the state Health and Human Services Agency, said a single survey team has targeted hospitals and surgery centers that utilized nurse anesthetists, including Stanislaus Surgical, Doctors and Emanuel Medical Center in Turlock.

According to the letter, the inspectors start by reviewing records of patients who received anesthesia from a CRNA. The nurse anesthetists are interviewed in an intimidating manner and the survey team insists on changing hospital protocols to require physician supervision of CRNAs at a ratio of 1 to 4, the lawmakers claimed.

“We request an investigation into whether this effort was designed in coordination with physician anesthesiologist advocacy organizations and individuals whose stated purpose is to restrict CRNA’s ability to practice independently,” their letter to Ghaly said.

CDPH did not comment Friday on the physician supervision requirement, the allegation of bias and alleged methods of the survey team.

CANA has expressed concerns that, since the end of the pandemic, there’s been a larger campaign by groups representing physician anesthesiologists to discredit CRNAs and take a larger portion of business back from them.

Perry said during the COVID-19 pandemic from 2020 to 2023 there were CRNAs practicing independently in every state. “We have not seen a drastic increase in patient harm since then,” Perry said. “CRNAs are highly qualified and practice safely.”

CANA has gone so far as to claim the chief surveyor for CDPH is an anesthesiologist who’s biased against CRNAs.

Alison McLeod, a spokeswoman for the California Society of Anesthesiologists, said Friday the physicians group is raising legitimate concerns. “We strongly believe all patients in all settings deserve access to physician-led anesthesia care and we should not be lowering our standards to save money or cut corners,” McLeod said.

The group wants to clarify the difference in skills and education between physician anesthesiologists and nurse anesthetists, she said. “The CSA feels it is critically important to educate hospital administrators, policymakers and healthcare leaders about why physician-led anesthesia care matters.”

Becoming an anesthesiologist requires undergraduate studies, medical school and four years of residency training. California now requires a three-year doctor of nurse anesthesia program for CRNAs. Schools require a bachelor’s nursing degree and critical care experience, while some schools accept the nursing experience and a bachelor’s degree in a related physical science.

The Council on Accreditation of Nurse Anesthesia Educational Programs decided in 2009 to require a transition to nurse anesthesia doctoral programs by Jan. 1, 2022.

Hospital entered contract for CRNAs

Last year, Doctors Medical Center dropped a contract with an anesthesiologist group and entered an agreement with Valley Regional Anesthesia Associates to provide CRNAs and anesthesiologists. According to one account, the hospital didn’t think it could recruit seven more anesthesiologists to meet needs, so it chose to rely more on CRNAs to put patients under for surgery.

Dr. Bruce Chou, an anesthesiologist, said he proctored about a dozen of the CRNAs last September at Doctors. “When I worked with the CRNAs, I noticed that a lot of them were very recent graduates (of nurse anesthetist programs.) It was not a problem to me, you have to start somewhere, but it probably was relevant if you are a patient there.”

By “recent,” Chou said, he meant they graduated within the past year. A list of the CRNAs assigned to Doctors, obtained by The Modesto Bee, reveals that five received a state nurse anesthetist license between March and June 2023; seven were issued licenses in the 12 months before September 2023. The 12 other CRNAs had experience averaging 3.7 years.

Joseph Martin, the chief executive officer of Valley Regional, has not returned calls from The Bee seeking comment on the contract with Doctors. A Valley Regional employee said Friday that Martin wasn’t available.

CANA has kept tabs on the ongoing survey at Doctors Medical Center and its attorneys have expressed concerns to top CDPH officials. According to CANA, the survey team told hospital administrators that nurse anesthetists can’t lawfully order pre- and post-anesthesia tests or medications for patients without a signature from a physician or provide anesthesia services without physician supervision.

CANA disputed that position and stressed that a 2011 court decision established that CRNAs are independent practitioners under California law.

For consumers who wonder what the structure might be at Doctors after the survey, the regulatory team has recommended a ratio of one physician anesthesiologist overseeing four CRNAs at the hospital. Doctors Medical Center hasn’t commented on the survey since a statement last month that said it was collaborating with CDPH on an action plan to address issues identified by the investigation.

Sam Singh, who operates a CRNA group in Fresno, said the regulatory surveys in Modesto are aimed at fulfilling an obligation to protect the public. However, he is concerned that media coverage has led people to wrongly assume that CRNAs are unable to practice and are causing harm to patients.

In a state with 3,200 CRNAs and 6,300 anesthesiologists for 39 million residents, Singh noted that hospitals employ various models for anesthesia services. These include anesthesiologists only, blended teams of anesthesiologists and CRNAs, and CRNAs working independently.

“You have to adapt to the needs of the area,” Singh said. “In some locations, such as remote hospitals where recruiting anesthesiologists is challenging, independent CRNA or team models are feasible.”

Kaiser Permanente, which operates one of the six nurse anesthetist schools in California, utilizes CRNAs at its hospitals who earn an average of $132 an hour. They are under the supervision of physician anesthesiologists, spokesman Jordan Scott said.