The Colorado Court of Appeals issued its opinion in Colorado Medical Society v. Hickenlooper, Governor of Colorado on July 19, 2012.

Dismissal for Failure to State a Claim—Social Security Act.

The Colorado Medical Society and Colorado Society of Anesthesiologists (collectively, Doctors) appealed the district court’s order dismissing their complaint for failure to state a claim against the Colorado Governor John Hickenlooper. The Colorado Association of Nurse Anesthetists, Colorado Nurses Association, and Colorado Hospital Association (collectively, Nurses) joined the Governor’s motion to dismiss. The order was affirmed.

Under the Social Security Act (Act), ambulatory surgical centers, hospitals, and critical access hospitals must fulfill certain conditions of participation to receive Medicare reimbursement. One condition is that certified registered nurse anesthetists (CRNAs) administering anesthesia must be supervised by a physician. However, states may opt out of the physician supervision requirement if “the State in which the [facility] is located submits a letter to [the Centers for Medicare and Medicaid Services] signed by the Governor, following consultation with the State’s Boards of Medicine and Nursing, requesting exemption from physician supervision of CRNAs.” The letter must attest that the Governor consulted the Boards and concluded the opt-out “is in the best interests of the State’s citizens” and “consistent with State law.”

Fifteen other states have opted out of physician supervision of nurses administering anesthesia. On July 19, 2010, former Governor Bill Ritter, Jr. requested advice from the Colorado Medical Board and the Colorado Board of Nursing about whether the opt-out was consistent with the law and in the best interests of Colorado’s citizens. In August, both recommended the opt-out. On September 27, 2010, Governor Ritter notified the Centers for Medicare and Medicaid Services about his consultation with the Boards and exercised the opt-out as to all critical access hospitals and thirteen rural general hospitals (later adding a fourteenth).

On September 28, 2010, the Doctors filed this action for declaratory relief, arguing the opt-out was inconsistent with Colorado law. The Nurses intervened and joined Governor Hickenlooper in a motion to dismiss. The district court granted the motion to dismiss, and the Doctors appealed.

The Court of Appeals first rejected an argument raised only by the Colorado Hospital Association: that the decision to opt out is “a decision committed to political branches and is not subject to judicial review.” The Court found no “textually demonstrable constitutional commitment” that expressly or impliedly vests the Governor with the sole discretion to determine whether CRNAs may administer anesthesia without physician supervision.

The Court rejected the Governor’s argument that the Doctors lacked standing to challenge the opt-out decision. The Court found the Doctors’ alleged injuries to their medical licenses and reputations sufficient to establish both tangible and intangible injuries concerning a legally protected interest (their medical licenses).

The Doctors argued it was error to dismiss their complaint, contending the Act requires physician supervision of CRNAs because (1) anesthesia is a medication; (2) medication is part of a medical plan; and (3) the administration of anesthesia is a “delegated medical function” subject to physician supervision. The Court disagreed, noting that the Act defines professional nursing as, in part, the performance of “delegated medical functions.” Such a function is defined, in part, as “an aspect of care that implements and is consistent with the medical plan as prescribed by a licensed or otherwise legally authorized physician.” Physician supervision is required when a nurse performs a delegated medical function. A CRNA, however, is an “advanced practice nurse,” which means a professional nurse “who obtains specialized education or training.”

The Court agreed with the district court that the Doctors’ argument cuts too broadly, because a CRNA never would administer any treatment unless implementing a medical plan. In addition, the Act’s definition of “practice of professional nursing” clearly recognizes many independent functions that are different from delegated medical functions. The Court concluded that CRNAs who administer anesthesia are conducting independent nursing functions within the scope, role, and population focus that the Nursing Board has approved for them. They are not conducting delegated medical functions and therefore do not require physician supervision. The order of dismissal was affirmed.

Summary and full case available here.