In the United States, “Opt-Out” States Show No Increase in Access to Anesthesia Services for Medicare Beneficiaries Compared with Non–“Opt-Out” States

Abstract

In the United States, anesthesia care can be provided by anesthesiologists or nurse anesthetists. Since 2001, 17 states have exercised their right to "opt-out" of the federal requirement that a physician supervise the administration of anesthesia by a nurse anesthetist, with the majority citing increased access to anesthesia care as the rationale for their decision. By using Medicare data, we found that most (4 of 5) cohorts of "opt-out" states likely experienced smaller growth in anesthesia utilization rates compared with non-"opt-out" states, suggesting that opt-out was not associated with an increase in access to anesthesia care.

Anesthesia Care Team Composition and Surgical Outcomes

“…Further work should examine whether these results extend to other patient populations and types of surgery, including, for instance, privately insured patients and outpatient surgeries. Moreover, because improving access to care is a frequently cited rationale for expanding the use of midlevel anesthesia providers, [24][25][26] further research should examine whether the introduction of anesthesiologist assistants has improved access to care. Finally, from a regulatory and antitrust standpoint, understanding the extent to which the introduction of anesthesiologist assistants has impacted competition among groups of anesthesia providers is a fruitful area for further research.…”

Assessing the impact of state “opt-out” policy on access to and costs of surgeries and other procedures requiring anesthesia services

“…[ 6 – 8 ] Clearly, surgical procedures with these complications are likely to entail higher overall costs than procedures without complications. [ 9 ] Thus, the observed higher costs in opt-out states could be a result of the combined effects of these two issues.…”

“…There has been continuous growth in outpatient surgery both in years before and years after passage of the opt-out law. [ 9 ] Thus, we believe that it is important to examine access and cost associated with inpatient and outpatient surgery. We used the Nationwide Inpatient Sample (NIS) for analysis of changes in inpatient surgery volume.…”

“…3 The inpatient models also adjust for lagged (year t-1) facility-level patient summary measures, including the total number of hospitalizations, patient case mix (i.e. percentage of cases were female, mean length of stay, percentage of surgical cases, the mean of the Centers for Medicare & Medicaid Services Hierarchical Condition Category (CMS-HCC) risk score [ 9 ], age distribution [<18, 18 to 44, 45 to 64, 65 to 74, and 75 or older]), admission type [elective, emergency, or other], percentage of routine discharge hospitalizations, health insurance type [Medicare, Medicaid, private insurance, or others], and race [white, black, Hispanic, or others]). CMS-HCC risk adjustment was developed by CMS to produce a health-based measure of future medical need which has shown to be a significant predictor of medical costs and has a better predictive accuracy on mortality than the Charlson and Elixhauser methods [ 10 ].…”

“…Sun et al [ 8 ] utilize data from the National Inpatient Sample (NIS) to assess whether opt-out was associated with an increase in the percentage of patients receiving a therapeutic procedure among patients admitted for appendicitis, bowel obstruction, choledocholithiasis, or hip fracture. In a similar vein, using claims data for Medicare fee-for-service enrollees, Sun et al [ 9 ] examine differences in average anesthesia utilization rates three years before and after out-out for opt-out states grouped by year of opt-out, compared to differences in average anesthesia utilization rates over the same time period in non-opt-out states. Both studies conclude the adoption of the opt-out rule had no significant impact on access to anesthesia care.…”