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‘Turf War’ pits rural, urban hospitals against each other

JEFFERSON CITY, Mo. — In 2012, Missouri lawmakers created a new regulation that stipulated that only licensed physician anesthesiologists could administer certain types of procedures instead of their counterparts, certified registered nurse anesthetists.

That law is set to sunset next year, and fight is now underway to extend the sunset. In 2012, the Missouri Society of Anesthesiologists argued that CRNA’s needed more advanced training to perform a handful of procedures that involved injections near the spinal cord. CRNA’s promised to formulate new training by the time the legislation expired.

The bill’s impact is felt almost exclusively in rural communities, where CRNA’s perform much of the pain-management procedures commonly needed. Thirty-nine Missouri counties are serviced only by CRNA’s. Former President of the Missouri Association of Nurse Anesthetists, Robert Walsh, said the restrictions were forcing pain patients to undergo unnecessary burdens of travel and costing rural hospitals business.

“The Missouri Society of Anesthesiologists have made it a mandate to carve nurses out on the whole,” Walsh said. “And this is coming from [anesthesiologists] on a national level. It’s a turf war between nurse anesthetists and physician anesthesiologists.”

Rep. Elijah Haahr is sponsoring HB393, which he will eliminate the sunset on the legislation. Haahr said his goal isn’t to permanently disqualify CRNA’s from performing the procedures, but to protect Missourians, because they haven’t met their promise for better training.

“We make people drive for open heart surgery, brain surgery, and other highly technical procedures,” Haahr said. “We do that because if something goes wrong with those highly technical and complex procedures, there’s going to be life altering consequences.”

CRNA’s have made some strides since 2012. In that time, CRNA’s have developed an examination that must be taken in order to be qualified in sub-specialty allowing spinal cord procedures. They have also designed criteria for new curriculum for those in school seeking CRNA certification. The curriculum has yet to be broadly adopted, something Haahr cited as an issue.

CRNA’s say they’ve approached the MSA with their new certifying exams and criteria and were rebuffed, which the MSA has contended is because the new criteria were unsatisfactory.

The ‘turf war’ has some real implications. In Walsh’s current hospital, Ste. Genevieve County Memorial Hospital, the pain physician is only available two days per month. Walsh says that CRNA’s who meet the appropriate standards are more than qualified to do spinal cord procedures, and that the fight to keep them out of the MSA’s customer base is hurting rural Missourians. The MSA, and Haahr, both claim that the CRNA’s standards are too low, and that sometimes, technical procedures can’t be done at the local hospital.

The fight is playing out in both chambers and with some powerful players. The CRNA’s have tapped Bardgett & Associates, a powerhouse Missouri lobbying firm, to make sure the sunset remains in place for next year. The MSA has brought in the Gateway Group, a firm with plenty of its own clout, to repeal the sunset.

Haahr’s bill has already had its public hearing and now needs only a formal vote to move through committee. Haahr said that, based on committee chairman Eric Burlison’s support for the 2012 language, he was confident the bill would make it to the floor. Walsh said he felt the chances of success for CRNA’s was “about 50-5o” at the moment, but noted that there is still next year’s legislative session before the complete sunset is enacted.