things together and the incentive to the hospital would result in very substantial savings, Senator.

Senator DOLE. Are you in essential agreement with the statement of Mr. Constantine? Do you have any different view?

Mr. CAULK. If a physician has utilized the services of a nurse anesthetist in a small community hospital; and if the physician cannot get something for collecting the fee for the nurse anesthetist then he refuses to collect and the nurse anesthetist has no alternative for being paid, because they cannot bill themselves. They have no way to be paid for their service.

Mr. WILLIAMSON. I think at a meeting you can come away with different understandings of what you agree to, but in our reading of the bill, we do not think it helps the individual nurse practitioner and I think apparently Jay thinks it does.

As a matter of fact, the words added to the bill, "who need not be his employee," would likely result in the Government's paying twice for one procedure. They would have to pay the anesthesiologist and then the hospital would be entitled to bill a second time for the services of the nurse anesthetist. We do not see those words as helping the freelance nurse anesthetist at all, unless there is some other understanding, which we do not have, of those words.

Senator TALMADGE. I would like Mr. Constantine to comment on that. Mr. CONSTANTINE. The point there is the nurse anesthetist who is a salaried staff member is paid on a cost basis, fringe benefits and other costs, not on a given procedure. The incentives in the bill are obviously for the anesthesiologist to use a staff nurse and, in most cases, in discussing the matter with the leadership of anesthesiology, they agreed.

If the same fee is paid for the procedure and in one instance the anesthesiologist has to pay the employee out of his fee, and in the other instance he does not have a pay, where we will wind up will be for him in most cases-for large hospitals, not the smaller hospital, not talking about that-that they will start to use, obviously, staff nurses. The economic incentives-if that needs clarification

Mr. WILLIAMSON. I think that is what we are saying. We think it needs clarification. We do not think it will accomplish that purpose. Senator TALMADGE. Would you work with the staff and try to clarify that?

Do you have any questions, Senator Curtis?

Senator CURTIS. No.

Senator TALMADGE. Senator Dole?

Senator DOLE. Aside from that, you are in essential agreement with what Mr. Constantine has started this morning You did not address the one issue of fee-for-service? That was not the purpose of the meeting, even though you raised it in this testimony.

Of course, we will consider it.

Aside from that, there is a basic understanding?

Mr. WILLIAMSON No, I would not say so, Senator-no. The area that Mr. Constantine touched upon, the free-lance nurse anesthetist, we do not think is clarified and the ability of hospitals to bill on a charge basis is not clarified.

We do not think the economics for the nurse anesthetist are improved at all. We thought, from our conversations, that they would be.

Senator DOLE. You can still pursue that and try to clarify those points. It would certainly be helpful to the members of the committee. Mr. WILLIAMSON. Yes.

Senator TALMADGE. Thank you very much. We appreciate your contribution to our deliberations.

[The prepared statement of Ms. Ecklund follows:]

STATEMENT OF RUTH E. ECKLUND, PRESIDENT OF THE AMERICAN ASSOCIATION OF NURSE ANESTHETISTS

SUMMARY

This statement constitutes a summary of our presentation to the Committee concerning S. 1470. We shall limit our remarks to those provisions of the Bill dealing with anesthesia services for which we have a special competency and particular interest. Secondly, we are submitting for consideration amendments to the Social Security Act which would authorize the payment of charges by Nurse Anesthetists under Title XVIII and XIX.

Purpose: To address and make recommendations to effect change which would bring about equity and fairness and the removal of discrimination in the treatment and reimbursement of Nurse Anesthetists for services rendered. The present language of S. 1470 may be interpreted in such a way so as to hinder the delivery of quality anesthesia care to the American people.

Basis: Certified Registered Nurse Anesthetists administer nearly half of all anesthesia in the United States.

Sixty percent of the hospitals in the United States are without the services of an American trained Anesthesiologist.

S. 1470 does nothing to change the existing and very unfair treatment accorded Nurse Anesthetists under Medicare/Medicaid.

With the interest of the Administration and Congress in cost containment, it would appear to be advantageous to look to those areas where the full potential of health professionals can be realized without altering quality so as to reduce the cost of health care to Government and the consumer.

The annual cost of anesthesia services is in excess of $2 billion. Changes achieved can result in savings of several hundred million dollars. The recommendations we are making can result in such savings and, therefore, are fully in the public's interest.

Recommendations

I. We recommend, therefore, that on page 31 line 18 the word "only" be inserted between the words "physician" and "where".

II. We recommend, therefore, that the language for activity (B) appearing on line 21 of page 31 be amended to read "writing an anesthetic management care plan".

III. We recommend, therefore, that the language of activity (C) appearing on line 22 of page 31 be amended to read as follows: "personal participation in the induction, management, and emergence and assuring that a qualified Nurse Anesthetist perform any of the procedures which the physician does not personally perform".

IV. We recommend, therefore, that the words appearing on line 25 on page 31 "who need not be his employee" be deleted.

V. We recommend, therefore, that the language appearing on lines 3-4 of page 32 by amended to read as follows: "remain physically available during the course of anesthesia administration".

VI. We recommend, therefore, that the language on lines 8-20 of page 32 be made more specific so as not to diminish the quality assurances which the Bill proposes and impede the administration of the Law.

VII. We recommend, therefore, that on line 13 of page 32 the words "another individual" be deleted and the words "a qualified Nurse Anesthetist" be inserted. VIII. We recommend, therefore, that amendments to the Social Security Act submitted in this Statement be considered so as to prived equity and fairness to Nurse Anesthetists and remove existing discrimination.

IX. We recommend, therefore, that the Law be amended to enable the selfemployed Nurse Anesthetist to bill directly for services in much the same way as other individual practitioners.

X. We recommend, therefore, that this Committee direct the appropriate persons in H.E.W. to see that a nationwide study on the quality of anesthesia is undertaken without further delay.

We appreciate this opportunity to present our views to you and would be pleased to be of all possible asistance in working with the Committee and its staff to attain the very laudable goals set forth by the Chairman of the Committee in the statement he made upon the introduction of the Bill.

Mr. Chairman, I am Ruh E. Ecklund, CRNA, President of the American Association of Nurse Anesthetists and Chief Nurse Anesthetist, Family Hospital, Milwaukee, Wisconsin. Accompanying me are Ronald F. Caulk, CRNA, who is President-Elect of the Association, J. Martin Stone, who is Executive Director of the Association, and Kenneth Williamson, who is the Washington Consultant for the Association. We appear here today in behalf of the Association.

The Association is a professional organization whose membership is comprised of Certified Registered Nurse Anesthetists (CRNA's), practitioners and educators who are engaged in anesthesia practice. The Association's two major goals, both of which serve the public interest, are, first, to promote the continued existence of quality education in the schools of nurse anesthesia and, secondly, to enhance and further develop the clinical skills of individual Nurse Anesthetists to provide quality care for patients. This testimony suggests the Association is also directing its activities toward obtaining greater equity and degree of fairness for Nurse Anesthetists which does not exist in the present Law.

Nurse Anesthetists are a major group in the delivery of anesthesia services. There are over 16,000 practicing CRNA's and there are approximately 10,840 Anesthesiologists (M.D.'s). The largest percentage of anesthetics administered to patients in the United States is provided by Nurse Anesthetists. Approximately 16,500,000 surgical procedures were performed in 1974, and CRNA's provided the anesthesia services in 48.5 percent of these cases. In 40 percent of the hospitals in the United States a Nurse Anesthetist is the sole provider of the anesthesia services, working as a member of the operating team along with the surgeon in performing a highly essential service to hospital patients.

In hospitals of less than 50 beds Nurse Anesthetists administered 67 percent of the anesthetics, in hospitals with from 50 to 90 beds 65 percent of the anesthetics, in hospitals with 100 to 250 beds they administered 50.4 percent of the anesthetics, and in hospitals of over 250 beds they administered 42.5 percent of the anesthetics. Thus, Nurse Anesthetists provided a substantial portion of the total of the anesthesia care in the large medical centers where the most complicated surgery is performed as well as in smaller hospitals.

Approximately 100,000 patients are receiving care each day in hospitals of less than 100 beds. A substantial number of these patients, of course, do have surgical procedures requiring anesthesia services. As we have indicated, the anesthesia required by these patients is in the main provided by Nurse Anesthetists and it is to the Nurse Anesthetist that the surgeon looks for responsible competency in providing this phase of an operation.

CRNA's are officially recognized by the U.S. Department of Education, the Federation of Specialty Nursing Organizations and the American Nurses' Association, the American Society of Anesthesiologists, the American Hospital Association, the American College of Surgeons and the Joint Commission on Accreditation of Hosiptals. The performance of CRNA's and the quality of the services they render is attested by their widespread use in university medical centers, community hospitals, the veterans administration and armed services. CRNA's by their education are fully prepared and competent to provide anesthesia services utilizing the various anesthetic agents. Attached for your information is a copy of the Standards for Nurse Anesthesia Practice which gives a good indication of the preparation of the Certified Registered Nurse Anesthetist and the guidelines by which they practice. We have previously provided various supportive materials to the members of the Committee.

We wish at this time to direct our testimony to S. 1470 and we will limit our comments and recommendations to those provisions of the Bill which deal with anesthesia services as a part of section 12 entitled "Hospital-Associated Physicians" starting on page 31 of the Rill.

In July of last year. we appeared before the Committee and discussed S. 3205. We made a number of recommendations which we felt would improve the Bill and its administration, which gave some recognition to the major role of Nurse Anesthetists and which, most importantly, were essential to protect the public and assure quality of anesthesia services. We are, of course, quite disappointed

that none of our recommendations are incorporated in S. 1470. Thus, we believe the same weaknesses exist in S. 1470 that were part of last year's Bill. In various ways, our reading of the Bill suggests that insufficient attention is directed to the effect of the Bill's provisions upon patient care or the quality of that care. Thus, S. 1470 shows no concern for half the patients receiving surgery because it contains nothing pertaining to those professionals who provide the anesthesia to these patients, the Nurse Anesthetists. Once again, the Bill does absolutely nothing to bring a degree of fair treatment and equity to Nurse Anesthetists. In fact, it totally ignores them. Therefore, we wish to present our specific comments and recommendations.

We recommend that:

I. On line 18 of page 31 the word "only" be inserted between the words "physician" and "where" as it appeared in the Bill introduced last year. We believe that the deletion of the word "only" substantially changes the requirements to be considered in stipulating those services to be "personally performed” by a physician and is not in the public's best interest.

II. The language for activity (B) appearing on line 21 of page 31, be amended to read "writing an anesthetic management care plan." The present language which requires the writing of a prescription would seriously harm the orderly process of providing anesthesia because Nurse Anesthetists cannot write prescriptions, whereas they can and do formulate management care plans.

III. The language of activity (C) appearing on line 22 of page 31 should be amended to read as follows: "personal participation in the induction, management, and emergence and assuring that a qualified nurse anesthetist perform any of the procedures which the physician does not personally perform;"

This change would assure the continued presence of a qualified physician or nurse anesthetist who would be responsible for the anesthetic throughout its full course. The language of the Bill appears to be intended to assure the continued presence of a qualified person who is requested by the physician to be responsible for the anesthetic throughout the remainder of its course. The words qualified “individual" do not provide such assurance and therefore, we have recommended that the Bill stipulate that a "qualified nurse anesthetist" perform any of the procedures which the physician does not personally perform. This is absolutely essential to protect patients and assure quality of care which the present language of the Bill may deny.

IV. That the words "who need not be in his employee" which appear on line 25 of page 31 be deleted. Our reading and attempts to find a meaning of the words left us confused. We do not believe that they serve any desired purpose, nor are they in any way beneficial to patients. In contrast to the purpose of the Bill, these words will likely result in the government paying twice for the anesthesia, i.e., the physician could collect his fee and in addition the hospital could bill the government for the costs of the Nurse Anesthetist. We believe also that words "less demanding" in this same sentence are most demeaning and misleading. Our concern is for the patients and there are no minor or less important aspects of their anesthetic.

V. The language of lines three and four on page 32 should be amended to read as follows: "remaining physically available during the course of anesthesia administration". Just as activity (E) requires the physician to remain "physically available", such physical availability is absolutely essential throughout the course of the anesthetic.

VI. The language of S. 1470 commencing on line 8 of page 32 with the words "provided however", substantially diminishes the quality assurances which the Bill proposes in (Activity A through F) and vitiates what we believe is surely a central purpose of the Bill, that of assuring quality of patient care. The language of this Bill commencing on line 8 and continuing through line 20 on page 32 is most unclear as to its purpose. It is unclear as to whether the language is intended to refer to reimbursement procedures for physicians or is also intended to include quality of practice. We believe this uncertaintly will result in making the administration of the law very difficult. The language may read as permitting a physician to be responsible in whole or in part for the anesthetic being administered to six different patients simultaneously only one of which he is required personally to administer. This is simply not good practice and certainly it is not in the best interest of the patient. We believe the language needs to be much more specific.

VII. The words "another individual" appearing in line 13 on page 32 be deleted and the words "a qualified Nurse Anesthetist" be inserted. Such activities as those enumerated in (A)-(F) of the Bill are in a great many instances performed by the Nurse Anesthetist. In nearly half of all the anesthetics administered, an Anesthesiologist is neither present nor available.

For ease of reading, we have appended to this testimony a statement incorporating the recommended changes in the language in Section 12 of the Bill (Appendix A).

EQUITY & FAIRNESS FOR NURSE ANESTHETISTS

Mr. Chairman, over the past several years, we have met with representatives of the Social Security Administration. We have also spent a great amount of time in discussion with the staff of the House Ways and Means Committee and the Senate Finance Committee and we have given testimony at hearings before both committees. In all of this, we have tried to provide some understanding of the role of the Nurse Anesthetists and of what we believe to be a simple right for them to be accorded fairness and equity under the Law. Notwithstanding all of these efforts, we were advised that it was unlikely that our appeals for fairness and equity and removal of discrimination would be entertained unless we provided specific legislative language. Therefore, we turned to a highly skilled and experienced draftsman who performed such activities for the Congress for a number of years and he drafted the specific recommendations for amending Titles XVIII & XIX of the Social Security Act which we wish to present.

It is recommended that the Social Security Act be amended to authorize the payment of charges by Nurse Anesthetists under Title XVIII and XIX of that Act:

Section 1814 (b) of the Social Security Act is amended by inserting immediately below paragraph (2) thereof the following: "Notwithstanding paragraph (1) of this subsection, a hospital which uses the services of a nurse anesthetist who is its employee may be reimbursed for such service on the basis of a fee schedule established by such hospital which provides for payment to the hospital for such services in amounts not exceeding the reasonable charge therefor as set forth in the last sentence of Section 1842 (b) (3).”

Sec. 2. The last paragraph of Section 1812(b) (3) of the Social Security Act is amended by adding at the end thereof the following new sentence: "The charge for the services of a nurse anesthetist shall be deemed to be reasonable if such charge does not exceed the percentage of the charge for those services which could have been made by a physician who is a Board Certified Anesthesiologist which the Secretary determines is reasonable."

Sec. 3, Section 1861 (b) of the Social Security Act is amneded (1) by striking out "and" at the end of paragraph (4), (2) by striking out the period at the end of paragraph (5) and inserting in lieu thereof"; and", and (3) by inserting immediately below paragraph (5) the following: "(5A) the service of a nurse anesthetist who is not an employee of the hospital."

Sec. 4 (a) Section 1861 (s) of the Social Security Act is amended (1) by striking out "and" at the end of paragraph (8), (2) by striking out the period at the end of paragraph (9) and inserting in lieu thereof"; and", (3) by redesignating paragraphs (10) and (11) as paragraphs (11) and (12), respectively, and (4) by adding below paragraph (9) the following:

"(10) the services of a nurse anesthetist who is not an employee of the hospital in which the services are performed."

(b) Section 1864 (a) of the Socia! Security Act is amended by striking out "(10) and (11)" and inserting in lieu thereof "(11) and (12)."

Sec. 5. Section 1902 (a) of the Social Security Act is amended (1) by striking out "and" at the end of paragarph (35), (2) by striking out the period at the end of paragraph (36) and inserting in lieu thereof "; and", (3) by inserting immediately below paragraph (36) the following:

"(37) Provide with respect to the services of a nurse anesthetist employed by a hosiptal that the hospital may bill separately and be reimbursed for such services in amounts not more than the reasonable charge for such services as determined under the last sentence of Section 1842 (b) (3), and provide with respect to the services of a nurse anesthetist not employed by the hospital, that such nurse anesthetist may bill separately and be reimbursed for such services in amounts not more than the reasonable charge for such services as determined under the last sentence of section 1842 (b) (3).