VOLUME 37, ISSUE 1

I was recently asked to participate to the Texas Rural Maternal Care Assembly to create, with other healthcare providers, a document “the Rural Texas Maternal Health Rescue Plan” that will be submitted to legislators with the purpose to adopt some of the recommendations made by the group. The goal of this initiative is to close the healthcare disparity gap of parturients in the rural setting in Texas.

Thanks to this opportunity, I was able to offer some suggestions directly related to increasing the presence of anesthesiologists and, more specifically, obstetric anesthesiologists in the rural setting. Some of the recommendations adopted in the final document include the following:

*Increase Medicaid payments for rural obstetrical anesthesia services to help hospitals recruit and retain this crucial specialty.

*Increase availability of all health care professionals who provide preventive healthcare, primary care, and/or maternal health services to women in rural areas by 1) enhancing education and training opportunities in rural areas; and 2) establishing innovative recruitment and retention strategies, focusing specifically on anesthesiologists and certified registered nurse anesthetists (CRNAs).

*Increase funding available to recruit anesthesia professionals, obstetrical care nurses, and respiratory therapists. Provide incentives for anesthesiology fellows and nurses pursuing CRNA training to practice in rural settings through funding of rural practice electives.

*Provide funding to Texas Department of State Health Services to establish obstetric-related rural “refresher” courses for anesthesiologists and CRNAs to help maintain the knowledge and skills necessary to promote safe anesthetic care during obstetrical emergencies. Rural hospitals with low obstetrical volume do not have dedicated obstetrical anesthesia teams. Instead, the anesthesiologist or CRNA provides care for any surgical service or emergency. Without the volume of obstetrical cases needed to maintain vital clinical skills, practitioners in rural hospitals must find other means to preserve critical obstetric anesthesia skills. Given that obstetrical anesthesia carries unique risks, continuing education in this subspecialty is especially important for those who must be counted on to provide this care.

Likewise, hospitals that do not provide labor-and-delivery services must, nevertheless, periodically provide stabilization service for obstetrical emergencies prior to transfer to a higher maternal-level-of-care facility. Small rural hospitals struggle with the costs of providing such training. Refresher courses, including simulations, are a critical and cost-effective tool to maintain important obstetrical anesthesia clinical expertise.

Unfortunately, there are several parts of the document that could be construed as expansion of scope of practice. Strategies consistently recommend expanding access to nurse anesthetists to increase coverage. Specifically, the second Code Red Priority  does not promote increasing physician anesthesiologists in rural settings but instead recommends expanding access to nurse anesthetists.

The document ignores that the funding process from CMS for anesthesia services in rural settings has created a health disparity in the rural setting. The federal Rural Pass-Through legislation is a program that incentivizes anesthesia care for practitioners in rural areas.  However, the legislation only funds nurse anesthetists and does not provide similar funding for physician anesthesiologists in rural settings. This creates a disincentive for rural hospitals to choose an anesthesiologist for the care of their patients because the federal funding will be less.  The TSA believes strategies to improve maternal care in rural settings need to include advocacy to change the way these funds are administered, and we should all support HR 5256 introduced by Rep. John Moolenaar (R-MI-2) and Rep. Jared Huffman (D-CA-2), which would correct this longstanding oversight.

Further, educational efforts should be led by obstetric anesthesiologists who are subject experts in obstetric anesthesia. In many of the academic centers, obstetric anesthesiologists lead simulation training on multispecialty team response to obstetric anesthesia care/emergencies. The document does not recognize that obstetric anesthesiologists are the subject experts.

The document includes language that confuses nurse anesthetists with anesthesiologists. Recommendation 2.E. suggests “incentives for anesthesia fellows and nurses pursuing a Certified Registered Nurse Anesthetist (CRNA) degree…”. The term “fellow” is reserved for physician anesthesiologists who are in an accredited obstetric anesthesiology fellowship. There are no “post-graduation residencies” in accredited programs in obstetric anesthesia for nurse anesthetists.

In summary, the Texas Rural Maternal Care Assembly are creating a document to assist with addressing limitations in obstetrical care in rural areas.  However, at this time, we as the Texas Society of Anesthesiologists, will not be signing off on this document until further clarifications are made to address the aforementioned problematic areas within the document as it currently exists.  We hope to have more updates in the near future.