Medical Examining Board decides physician supervision not required for some certified registered nurse anesthetists

On August 15, 2007, the Medical Examining Board entered a decision and order concluding that Wisconsin law permits a CRNA who is certified as an Advanced Practice Nurse Prescriber (APNP) and who administer anesthesia to do so without a license to practice medicine and without physician supervision. A CRNA who is certified as an APNP must work in a collaborative relationship with a physician. A CRNA who is not certified as an APNP and who administers anesthesia is not required to have a license to practice medicine, but must provide patient services including the administration of anesthesia under the direction, supervision and inspection of a physician.

For many years federal regulations imposed a condition requiring that an anesthesiologist or operating practitioner such as a physician, dentist, oral surgeon or podiatrist supervise a certified registered nurse anesthetist (CRNA) who administers anesthesia in Medicare participating hospitals. In 2001, the federal regulations were amended, allowing CRNAs to administer anesthesia without physician supervision, in states where the Governor submits a letter to the Centers for Medicare and Medicaid Services (CMS) requesting an exemption from the supervision rule. Federal law requires that the letter from a Governor requesting an exemption attest that the Governor consulted with the State Boards of Medicine and Nursing about issues relating to access to and the quality of anesthesia services in the State. The law also requires that the letter demonstrate the Governor’s conclusion that an exemption from the physician supervision rule is in the best interests of the State’s citizens and is consistent with State law.

On June 6, 2005, Governor Doyle submitted a letter to CMS requesting an exemption from the federal requirement that physicians supervise CRNAs who administer anesthesia in hospitals. The Wisconsin Society of Anesthesiologists (WSA) filed a petition on July 25, 2005, which was subsequently amended on January 13, 2006, requesting that the Medical Examining Board issue an order declaring that the administration of anesthesia by CRNAs must be performed under the supervision of a physician, except in cases where Wisconsin law would permit supervision by a podiatrist or dentist.

The Medical Examining Board examined several statutes to reach its conclusions. It noted that the administration of anesthesia is within the scope of the practice of medicine, but also falls within the scope of the practice of professional nursing¹. The decision noted that the practice of health care professionals might overlap without a requirement that the health care professionals maintain licenses for both professions. According to the Medical Examining Board, Wisconsin law prohibits the practice of medicine without a valid medical license, but grants exceptions to the license requirement in circumstances where the scope of practice of other medical professionals might overlap, such as persons practicing with a license, permit or certification to practice nursing, midwifery, chiropractic care, dentistry, dental hygiene, acupuncture, persons providing care under the direction, supervision and inspection of a physician and others².

A CRNA is a registered nurse with additional training and certification to administer anesthesia. While the administration of anesthesia is within the scope of the practice of medicine, a CRNA is not required to hold a medical license when administering anesthesia, if the CRNA provides such patient services under the direction, supervision and inspection of a physician³. The Medical Examining Board determined that a CRNA who is also certified as an APNP is not required to have a medical license, but is allowed to administer anesthesia without physician supervision. The rationale for the Medical Examining Board’s decision is that Wisconsin law imposes a requirement that an APNP collaborate with a physician rather than have physician supervision⁴.

The Medical Examining Board dismissed WSA’s petition based on the conclusion that physician supervision is not required for a CRNA who is also certified as an APNP and who administers anesthesia. A copy of the complete decision and order can be found by clicking here. WSA and other interested parties in the case have the right to file a request for rehearing on or before September 6, 2007 or file an appeal to circuit court on or before September 17, 2007. At this point, there is no indication that WSA or any other party will appeal the Medical Examining Board’s decision.

1. According to Wisconsin Statute § 448.01(9) the practice of medicine and surgery means: (a) To examine into the fact, condition or cause of human health or disease, or to treat, operate, prescribe or advise for the same, by any means or instrumentality. (b) To apply principles or techniques of medical sciences in the diagnosis or prevention of any of the conditions described in par. (a) and in sub. (2). (c) To penetrate, pierce or sever the tissues of a human being. (d) To offer, undertake, attempt or do or hold oneself out in any manner as able to do any of the acts described in this subsection.
2. The practice of nursing includes: (a) The observation and recording of symptoms and reactions. (b) The execution of procedures and techniques in the treatment of the sick under the general or special supervision or direction of a physician, podiatrist licensed under ch. 448, dentist licensed under ch. 447, or optometrist licensed under ch. 449, or under an order of a person who is licensed to practice medicine, podiatry, dentistry, or optometry in another state if the person making the order prepared the order after examining the patient in that other state and directs that the order be carried out in this state. (c) The execution of general nursing procedures and techniques. (d) Except as provided in s. 50.04 (2) (b), the supervision of a patient and the supervision and direction of licensed practical nurses and less skilled assistants.
3. Wisconsin Statute § 448.03(2) provides a lengthy list of exceptions to the requirement of maintaining a license to practice medicine to perform certain health care services.
4. Wisconsin Statute § 448.03(2)(e), exempts from the medical license requirement “any person other than a physician assistant who is providing patient services as directed, supervised and inspected by a physician who has the power to direct, decide and oversee the implementation of the patient services rendered.”