CRNA Practice in Massachusetts is Governed in 2 ways:

1. Laws & Regulations Governing CRNA Practice in Massachusetts & How they would change with HB 1996/SB 1207: An Act to Remove Restrictions on the Licenses of NP’s and CRNA’s as recommended by the Institute of Medicine & Federal Trade Commission

2. CRNA Practice in Massachusetts is Governed in 2 ways: • Statute • Massachusetts General Laws (MGL’s) • Laws are passed by the Massachusetts Legislature • Massachusetts Board of Registration in Nursing (BoRN) • The agency responsible for enforcing and regulating the MGL’s

3. Massachusetts General Laws Governing CRNA Practice • MGL 112 Section 80B • Generally defines the requirements to practice as a nurse in Massachusetts • Requires advanced practice nursing regulations which govern the ordering of tests, therapeutics and prescribing of medications be promulgated by the board in conjunction with the board of registration in medicine • This means that the BoRN has to get approval from the BoRMto create regulations for APRN’s to write orders……in other words requires physician supervision of APRN prescriptive authority • Take note: this law does not require supervision of APRN Practice, just prescriptive authority

4. Massachusetts General Laws Governing CRNA Practice (cont’d) • MGL 112 Section 80H • Further restricts prescriptive authority only for CRNA’s • CRNA’s may issue written prescriptions and order tests and therapeutics for the immediate perioperative care of a patient in addition to requiring physician supervision •  the immediate perioperative care of a patient shall be defined as the period commencing on the day prior to surgery and ending upon discharge of the patient from post-anesthesia care • Take note: this law does not require supervision of CRNA Practice, just prescriptive authority

5. Massachusetts Board of Registration in Nursing(BoRN) • Pursuant to MGL’s, the BoRN is authorized to regulate nursing education and practice in the state. • Regulations for all licensed disciplines in the state are defined in the Code of Massachusetts Regulations (CMR’s) • APRN (which includes CRNA’s) regulations are listed in 244 CMR 4.0

6. Massachusetts General Laws Governing CRNA Practice Summary • MGL 112 Section 80B – definition of nursing in Massachusetts, BoRM oversight of BoRN for APRN (including CRNA’s) prescriptive practice • MGL 112 Section 80H – describes further restrictions of CRNA prescriptive authority to immediate 24-hour peri-operative only in addition to requiring physician supervision • There are NO Massachusetts laws that require physician supervision of CRNA practice

7. What about “Medical Direction” and “Medical Supervision”? • These are FEDERAL Medicare billing terms only that define the requirements to submit claims (get paid) for anesthesia services provided by CRNA’s. • These billing terms are MISNOMERS in that these rules DO NOT govern CRNA practice. They simply provide a means to submit claims to Medicare for reimbursement • Medical Direction • Most common billing arrangement in Massachusetts • Pays the highest Medicare reimbursement • Anesthesiologist may participate in up to 4 concurrent cases • Anesthesiologist must participate in 7 specified activities in each case • Medical Supervision • Pays less than Medical Direction • Anesthesiologist may supervise more than 4 CRNA’s • Opt Out • A letter from a state governor to the Centers for Medicare and Medicaid Services allows hospitals and Ambulatory Surgical Centers to opt out of Medicare supervision rules • 17 states have opted out as of this presentation • Usually in rural areas • These billing terms are often confused and/or falsely represented as practice laws or regulations

8. Let’s put it all together… VS CRNA Practice in MA Current Laws & Regulations Federal Medicare Billing Rules For Anesthesia Provided by CRNA’s • MGL 112 Section 80B • Defines nursing practice in Massachusetts • Requires oversight of the Board of Registration in Medicine for development of regulations for prescriptive authority for APRN’s • These billing terms are MISNOMERS • DO NOT govern CRNA practice • They simply provide a means to submit claims to Medicare for reimbursement. • Medical Direction, Medical Supervision, Opt Out • Often confused and/or falsely represented as CRNA practice laws or regulations • MGL 112 Section 80H • Further restricts CRNA’s prescriptive authority • CRNA’s prescriptive authority limited to immediate post op period in addition to requiring physician supervision Board of Registration in Nursing Agency authorized to enforce the MGL’s associated with nursing Section 244 CMR 4.00: Regulations for advanced practice nursing

9. Current Legislation House Bill 1996/Senate Bill 1207 An Act to Remove Restrictions on the Licenses of NP’s and CRNA’s as recommended by the Institute of Medicine & Federal Trade Commission

10. HB 1996/SB 1207: What will change? CRNA Practice in MA Current Laws & Regulations Medicare Billing Rules For Anesthesia Provided by CRNA’s VS • MGL 112 Section 80B • Defines nursing practice in Massachusetts • Requires oversight of the Board of Registration in Medicine for development of regulations for prescriptive authority for APRN’s • These billing terms are MISNOMERS • DO NOT govern CRNA practice • They simply provide a means to submit claims to Medicare for reimbursement. • Medical Direction, Medical Supervision, Opt Out • Often confused and/or falsely represented as CRNA practice laws or regulations • Requires oversight of the Board of Registration in Medicine for development of regulations for prescriptive authority for APRN’s HB 1996/SB 1207 changes • MGL 112 Section 80H • Requires physician supervision of CRNA’s prescriptive authority • Further restricts CRNA’s prescriptive authority limited to immediate post op period • MGL 112 Section 80H • Requires physician supervision of CRNA’s prescriptive authority • Further restricts CRNA’s prescriptive authority limited to immediate post op period HB1996/SB1207 does not change Federal Medicare Billing Rules • Board of Registration in Nursing • Agency authorized to enforce the MGL’s associated with nursing • Section 244 CMR 4.00: Regulations for advanced practice nursing

11. Joint Committee on Health Care Policy hearingheld in November, 2015 Please refer to www.masscrna.com to read the written and verbal testimony from the Massachusetts Society of Anesthesiologists What is the Massachusetts Society of Anesthesiologists saying about you?

12. Are you asking these questions? • “I don’t really need or want to write prescriptions.” • “How is this going to change practice where I work?” • “This is just another unnecessary expense.” • “I’m going to retire soon, so why should I bother?”

13. Why is the passage of HB 1996/SB 1207 so important? • Laws like MGL 112 sections 80B & 80C lead to arbitrary restrictions upon the licenses of all APRN’s (including CRNA’s) • These restrictions • DO NOT lead to increased safety or expedient care for our patients • DO lead to FINANCIAL advantages for physicians • Let’s look at how this plays out…

14. NP’s CRNA’s • Pretesting: even with a DEA license AND a supervising physician, CRNA’s CANNOT write orders for day of surgery (i.e.; scope patch, last minute K+ level, EKG, etc.) • PACU: CRNA’s can write PACU orders ONLY with a DEA license AND a “Supervising Physician” • Retrospective “review” of all orders written by CRNA’s must be conducted by “supervising” physician” • Neither scenario makes patient care more safe or efficient, so who benefits from this law? • DEA license and “Supervising” physician is required for NP’s to write prescriptions in all practice settings • Retrospective “review” of all prescriptions written by NP’s must be conducted by “supervising” physician at regular intervals • Many NP’s pay OUT OF POCKET for “supervision services” – some up to $500/month in private clinic settings • None of this makes patient care more safe or efficient, so who benefits from this law? The “Supervising” physician GETS PAID for his/her “supervision” services The “Supervising” physician GETS PAID for his/her “supervision” services

15. Why is this important? • Most importantly, these license restrictions do not help our patients • CRNA’s (and all the other APRN’s in Massachusetts) earned our scope of practice through education, board certification, and licensing – NOT by the Board of Registration in Medicine • The federal government has granted APRN’s prescriptive authority – why do physicians in Massachusetts want to restrict it? • Does the Board of Registration in Nursing really need oversight from the Board of Registration in Medicine? • These are arbitrary and unnecessary barriers to the practice that YOU earned • Massachusetts is the ONLY state in New England with these antiquated laws

16. Healthcare delivery in the Unites States is rapidly changing • Health care systems are looking to save $$$$$$$, while still providing safe care to patients • There is overwhelming evidence that removing restrictions on the licenses of APRN’s SAVES $$$$ • There is no difference in the quality and safety of anesthesia care when delivered by a CRNA with or without physician supervision • Removing restrictions from the licenses of CRNA’s provides an opportunity to demonstrate to the health care system at large that CRNA’s can answer the call for safe care that saves money • All we have to do is continue providing the best care for our patients like we have all along • Elimination of physician supervision of CRNA prescriptive practice does not prevent CRNA’s from working in collaborative teams with our physician colleagues in the safe delivery of anesthesia

17. Guess who supports our legislation? • Partners Health Care • Chief Medical Officers and Chief Nursing Officers of Brigham & Women's Hospital, South Shore Hospital, Sturdy Memorial Hospital, Cooley Dickinson Health Care • The Institute of Medicine • The Federal Trade Commission • Massachusetts Health Policy Commission 2015 Report • Many more – a complete list can be found on the MANA website www.masscrna.com – click on Legislation -> HB 1996/SB 1207 toolkit

18. Follow the status of HB 1996/SB 1207 • What’s happening with the legislation? • Go to the MANA website www.masscrna.com click on Legislation -> Legislation Tracker • Follow the progress of HB 1996/SB 1207 from it’s filing date to the present • Find out what to expect next • The bill needs to be released from the Joint Committee on Health Care Finance by April 27, 2016 • This legislation must pass by the end of the current legislative session on July 31, 2016 • YOUR efforts have brought us this far – we have gained some traction – LET’S KEEP IT GOING!

20. References • 189th General Court of the Commonwealth of Massachusetts - General Laws. (2016). Retrieved February 8, 2016, from malegislature.gov: https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXVI/Chapter112/Section80B • 189th General Court of the Commonwealth of Massachusetts - General Laws. (2016). Retrieved February 8, 2016, from malegislature.gov: https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXVI/Chapter112/Section80H • Department of Health and Human Services/Rules and Regulations. (1998, November 7). Federal Register, 63(211), pp. 58814-59187. • Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Services. (2009, November 20). Retrieved February 8, 2016, from cms.gov: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf • Mass.gov. (2014, August 29). Retrieved from Massachusetts Court System: http://www.mass.gov/courts/case-legal-res/law-lib/laws-by-source/cmr/200-299cmr/244cmr.html • U.S. Government Publishing Office - Code of Federal Regulations. (2007, November 27). Retrieved February 8, 2016, from gpo.gov:https://www.gpo.gov/fdsys/pkg/CFR-2015-title42-vol5/pdf/CFR-2015-title42-vol5-sec482-52.pdf • U.S. Government Publishing Office - Code of Federal Regulations. (2014, May 12). Retrieved February 8, 2016, from gpo.gov: https://www.gpo.gov/fdsys/pkg/CFR-2015-title42-vol3/pdf/CFR-2015-title42-vol3-sec416-42.pdf