Questions and Answers

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Questions & Answers About Certified Registered Nurse Anesthetists (CRNAs)

Q. Why does Michigan need to eliminate physician supervision to create a smart, safe anesthesia delivery model?

Michigan’s anesthesia regulations are antequated — from the dark ages and anti-patient. They limit access to anesthesia services at a time when more Michigan citizens have health insurance than ever before. Adopting regulations that create a smart, modern anesthesia delivery model would put Michigan patients first, ahead of an out-dated anesthesia model that favors turf wars over what is best for patients and taxpayers. It would put Michigan’s anesthesia model in line with 40 other states.


At a time when healthcare delivery is changing, a smart, new anesthesia model would improve access to needed, often life-saving, anesthesia care for thousands of patients at Michigan hospitals. It would give Michigan hospitals the flexibility to meet patient needs in underserved rural and urban communities alike.


This effective and proven model would not end physician supervision of CRNAs in Michigan. In fact, Michigan hospitals could choose the same supervision delivery model that exists in the state today.  Hospitals would also gain the flexibility to choose the best anesthesia delivery model for their patients and communities— as is the case in 40 other states.


Based on experiences in other states, there is evidence this effective and proven anesthesia delivery model will contain, and even lower, health care costs related to anesthesia and surgeries. Substantial scientific and medical research has found no differences in patient safety and surgical outcomes in states with and without CRNA supervision.

Q. What is a Certified Registered Nurse Anesthetist?

Certified Registered Nurse Anesthetists (CRNAs) are highly skilled advanced practice registered nurses who specialize in the field of anesthesia and pain management. As licensed independent practitioners, CRNAs undergo significant post-graduate education and training resulting in a master’s or doctoral degree in nurse anesthesia. They are required to pass the National Certification Examination in order to practice. CRNAs provide the same anesthesia services as physician anesthesiologists, based on a foundation of acute care nursing and graduate education. CRNAs practice in all 50 states and safely administer more than 34 million anesthetics to patients each year in the United States.

CRNAs have been providing anesthesia care to patients in the United States for 150 years. The CRNA credential came into existence in 1956.

Q. What is the CRNA’s role?

CRNAs are responsible for the safety of patients before, during and after surgery. They administer every type of anesthesia to all types of patients in any health care setting where anesthesia is required. CRNAs provide continuous pain relief and anesthesia, while sustaining patients' critical life functions throughout surgical, obstetrical and other medical procedures.

In addition to anesthetic agents, CRNAs select and administer adjunct drugs to preserve life functions; they also use technologically advanced monitoring equipment and interpret a vast array of diagnostic information throughout the course of the anesthetic process.

 

Q. What does a CRNA do during surgery?

As anesthesia professionals, CRNAs stay with their patients throughout the entire procedure, administering their anesthesia and monitoring their vital signs to ensure maximum safety and comfort.

During surgery, the patient’s life often rests in the hands of the CRNA. This awesome responsibility requires CRNAs to fully utilize every aspect of their anesthesia education and training, nursing skills, and scientific knowledge.

In addition to vigilantly monitoring the patient’s vital signs and modifying the anesthesia as needed, CRNAs also analyze situations, make decisions, communicate clearly with the other members of the surgical team, and respond quickly and appropriately in an emergency.

Q. Do CRNAs work with physicians?

Yes. Like all anesthesia professionals, CRNAs collaborate with other members of the surgical team including surgeons, endoscopists, radiologists, podiatrists, obstetricians and other physician specialists. State laws and regulations vary on requiring CRNAs to be supervised by a physician; well over half of all states do not require physician supervision. In any case, CRNAs are always independently responsible for their own actions. Surgeons quite properly defer to CRNAs as the experts in anesthesia care. Under state nurse practice acts or board of nursing rules as well as in accordance with their licensure, CRNAs deliver comprehensive anesthesia care consisting of all accepted anesthetic techniques including general, regional (e.g., epidural, spinal, peripheral nerve block), sedation, local, and pain management.

Q. Is anesthesia safe?

Advances in pharmaceuticals, technology and training for CRNAs and anesthesiologists have contributed significantly to improvements in patient safety. According to the Institute of Medicine (IOM), the American Association of Nurse Anesthetists, and the American Society of Anesthesiologists, anesthesia care is nearly 50 times safer than it was just 30 years ago, and in a 1999 report the IOM identified anesthesia as one of the safest health care specialties.

Today, perioperative deaths attributed to anesthesia occur approximately once for every 250,000-300,000 anesthetics provided, representing a dramatic increase in patient safety despite an aging U.S. population and older, sicker patients being treated in operating rooms nationwide. Numerous outcomes studies have confirmed the safety record of CRNAs and demonstrated that there is no difference in the quality of anesthesia care provided by CRNAs and anesthesiologists.

Q. How do CRNAs impact healthcare?

CRNAs are the primary providers of anesthesia care in rural America, affording tens of millions of rural Americans access to surgical, obstetrical, trauma stabilization, and pain management services without having to travel long distances to receive needed care.

In some states, CRNAs are the sole anesthesia professionals in nearly 100 percent of rural hospitals.

CRNAs also provide a significant amount of anesthesia and related care in urban and suburban health care facilities, and are the primary anesthesia professionals in many medically underserved inner city areas.

Q. How do CRNAs impact insurance?

The importance of access to CRNA care has been recognized by the inclusion of “non-discriminatory” language in the federal Affordable Care Act. This provision ensures that a group health plan or an insurance issuer will support a competitive, high-quality health care marketplace by recognizing CRNAs who provide covered services within their scope of practice.

In 2010, Congress enacted into law a Provider Nondiscrimination provision that prohibits health plans from discriminating against qualified licensed healthcare professionals, such as CRNAs, solely on the basis of their licensure. This bipartisan law took effect Jan. 1, 2014, and it is supported by the American Association of Nurse Anesthetists (AANA) and the Patients Access to Responsible Care Alliance (PARCA), a major coalition of advanced practice registered nurses (APRNs) and allied health professionals recognized by Medicare as Part B providers. The law promotes access to healthcare and consumer choice of healthcare professionals, and helps reduce healthcare costs through competition.

Managed care plans recognize CRNAs for providing high quality anesthesia care with reduced expense to patients and insurance companies. The cost efficiency of CRNAs helps control escalating healthcare costs.

Q. How do CRNAs affect medical liability?

The same legal principles that govern the liability of surgeons working with CRNAs apply to surgeons working with anesthesiologists. An examination of relevant case law supports the fact that surgeons are no more liable when working with a CRNA than with an anesthesiologist.

CRNAs are responsible for securing their own liability coverage, just as physicians are, when working in nonhospital settings. In part because the care delivered by CRNAs is getting safer all the time, CRNAs professional liability premiums are 33 percent lower today than 25 years ago (or 62 percent lower when adjusted for inflation).

While the practice of nurse anesthesia is safer than ever on a nationwide basis, it is even more so in the state of Michigan.  On a nationwide basis, the average 2014 malpractice insurance premium for self-employed CRNAs was 33% less than it was in 1988.  In Michigan, it was 63% less.  Whe trended for inflation through 2014, the nationwide reduction in premium was 66%.  In Michigan the reduction was 81%.

Q. Is there a cost differential between an anesthesiologist and a CRNA? If the cost is the same, why not get a physician?

Yes, there is a cost differential between an anesthesiologist and a CRNA. The mean annual compensation for an anesthesiologist is about $400,000, nearly two and one-half times that of a CRNA, whose median total compensation is about $165,000. Because Medicare pays the same fee for an anesthesia service whether it is provided by a CRNA, an anesthesiologist, or both working together, the higher cost of the anesthesiologist is borne by someone – the hospital, the health care facility, or the patient.

Another perspective on the cost differential between CRNAs and anesthesiologists is found in the landmark 2010 study titled “Cost Effectiveness of Anesthesia Providers” conducted by The Lewin Group and published in the Journal of Nursing Economic$. The study showed that the most cost-effective anesthesia model is a CRNA practicing solo, which was 25 percent less expensive than the next lowest-cost model (an anesthesiologist directing four CRNAs), and far more cost-effective than the most expensive model (an anesthesiologist directing a single CRNA). In terms of cost to society, this same paper found that the marginal cost of pre-anesthesia and anesthesia graduate education for a CRNA is $161,809 compared to the comparable cost of educating an anesthesiologist: $1,083,795.

Q. Where do CRNAs work?

CRNAs practice in any health care setting in which anesthesia is delivered, including traditional hospital surgical suites and obstetrical delivery rooms, ambulatory surgery centers, pain clinics and physicians' offices.

CRNAs are the hands on providers of more than 34 million anesthetics delivered each year in the United States. They provide the majority of anesthesia care in the Veterans Administration and U.S. Military.

CRNAs are the primary anesthesia providers in rural America, enabling health care facilities in these medically underserved areas to offer obstetrical, surgical, trauma stabilization. In some states, CRNAs are the sole anesthesia providers in nearly 100 percent of the rural hospitals.

Q. How long does it take to become a CRNA?

It typically takes seven to eight years of education, training, and experience to become a CRNA: four years to earn a bachelor’s degree in nursing (or other appropriate baccalaureate degree) and become licensed as a registered nurse; an average of 3.5 years of practice as an RN in an acute care setting; and two to three more years of graduate-level education and training culminating in a master’s or doctoral degree from an accredited nurse anesthesia educational program. To become certified to practice as a CRNA, the graduate must pass the National Certification Examination.

Q. Is it possible for a nurse to ever be as well trained as a physician?

CRNAs and anesthesiologists undergo similar education and training, and research shows that CRNAs deliver anesthesia care that is the same high quality as that of anesthesiologists. The focus should be on outcomes, not titles.

CRNAs are highly educated advanced practice registered nurses who specialize in anesthesia, have extensive experience in acute care settings, and hold advanced degrees in addition to their undergraduate nursing education and training. America’s 50,000 CRNAs administer approximately 34 million anesthetics to patients each year in the United States. CRNAs are the primary anesthesia providers in rural America, the military and the Veterans Administration. Additionally, CRNAs practice in collaboration with other healthcare professionals in every setting where anesthesia is delivered.

In 2010, North Carolina based Research Triangle International (RTI) published the results of a research study on anesthesia safety in opt-out states. The paper, titled "No Harm Found When Nurse Anesthetists Work Without Supervision by Physicians" (Health Affairs, August 2010), shows that patient outcomes in states that have opted out of the Medicare physician supervision requirement for nurse anesthetists are the same or better than outcomes in states that have not opted out.

This landmark study (and many others) confirms that there are no measurable differences in the quality or safety of anesthesia services delivered by CRNAs, by anesthesiologists, or by CRNAs being supervised by anesthesiologists. In fact, the RTI results show that, all other things being equal, anesthesia delivered only by CRNAs is as safe as – and in some cases safer than – anesthesia delivered only by anesthesiologists or by CRNAs supervised by anesthesiologists.

About Mandatory Physician Supervision of CRNAs

Q. Medicare requires CRNAs to be supervised by an anesthesiologist, right?

No. The Medicare physician supervision requirement for CRNAs does NOT mean “supervision by an anesthesiologist.” An anesthesiologist is one type of physician who may supervise CRNAs, but there is NO federal requirement that CRNAs be supervised by anesthesiologists.


Additionally, 17 states have opted out of the Medicare physician supervision requirement, meaning in those states nurse anesthetists do not need to be supervised by any type of physician in order for facilities to be reimbursed by Medicare for anesthesia services.(A federal rule implemented by the Bush administration in 2001 gives governors the ability to opt out of the Medicare requirement that CRNAs be supervised by a licensed physician to deliver anesthesia care. Michigan’s current law would not permit the Governor to request an “opt out” of CRNA supervision.)

 

Q. Why are rules for Medicare and Medicaid reimbursement of CRNAs linked to physician supervision? Why do these rules differ from state to state?

Physician supervision of CRNAs is required for facility reimbursement of anesthesia services by Medicare; it is not required for safety reasons. Under current Medicare rules, CRNAs must be supervised by a physician when delivering anesthesia services unless a state has opted out of this federal requirement and allows CRNAs to work without physician supervision. To date, 17 states have opted out of the supervision requirement, as permitted by a CMS rule published in 2001. In states that have not opted out, the supervising physician may be a surgeon, anesthesiologist, or other qualified professional.

In recent years there has been a trend away from physician supervision of CRNAs. In 33 states, the nursing, medical and hospital licensing laws and regulations do not require physician supervision of CRNAs for non-Medicare cases. As previously noted, 17 of these states have opted out of the federal Medicare supervision requirement as well.

Q. So federal rules do not require physician supervision of CRNAs?

In January 2001, under the Clinton Administration, CMS published a final rule that allowed facility reimbursement for services provided by CRNAs who were not supervised by a physician. This rule sought to eliminate the federal supervision requirement for all 50 states, thereby allowing the individual states to regulate anesthesia practice according to their own specific needs. Then, in November 2001, the Bush Administration adopted a final rule allowing states to "opt out" of the Medicare physician supervision requirement by meeting certain criteria. To date, 17 states have exercised this opt out via letters from their governors to the Medicare agency.

Q. What does "opt out" mean?

When a state "opts out" of the federal Medicare supervision requirement it means the state is no longer required by CMS to have CRNAs supervised by physicians in the administration of anesthesia.

Q. Why have states opted out?

Opting out of the physician supervision requirement for CRNAs helps ensure patient access to safe, cost-effective anesthesia care in all healthcare settings, while providing healthcare facilities greater flexibility in the delivery of anesthesia services based on individual patient needs and facility characteristics.

Eliminating the federal Medicare physician supervision requirement altogether would allow each facility to determine how anesthesia should be delivered to best meet the diverse needs of its patients.

Q. How does opting out affect access to care?

Hospitals and ambulatory surgical centers, particularly in rural and other medically underserved areas, have difficulty retaining and recruiting surgeons. This situation is exacerbated due to a misperception some physicians have that supervising CRNAs puts them at increased risk of liability. Although case law does not support this contention, when states opt out of the supervision requirement it removes this misperception and helps ease recruitment and retention problems for some healthcare facilities. Repealing the federal physician supervision requirement would allow medical facilities nationwide to make their own decisions on how best to staff their anesthesia departments based on state laws and patient needs, thereby increasing access to care.

Q. Do all states require supervision?

In recent years there has been a trend away from physician supervision of CRNAs. In 33 states, the nursing, medical and hospital licensing laws and regulations do not require physician supervision of CRNAs for non-Medicare cases; the number increases to 40 states if only the nursing and medical laws and regulations are considered. As previously noted, 17 of these states have opted out of the federal Medicare supervision requirement as well. It is important to note that there is no state or federal requirement that an anesthesiologist supervise CRNAs.

Q. What is the process for a state to opt out of the Medicare physician supervision requirement for CRNAs?

For a state to opt out of the Medicare physician supervision requirement, the governor must send a letter of attestation to CMS. The letter must attest that: 1) The governor consulted with the state boards of medicine and nursing about issues related to access to and the quality of anesthesia services in the state; 2) opting out is consistent with state law; and 3) it is in best interests of the state’s citizens.

Q. Is the governor required to obtain the approval of the state’s boards of medicine and nursing?

The governor is not required to obtain the approval of either; the governor is simply required to consult with them.

Q. How has the opt out affected the rate of medical malpractice for CRNAs in those states?

Liability insurance premiums have gone down for CRNAs in the opt out states, as well as overall.

Q. Is there any difference in patient safety between anesthesiologists and CRNAs?

A study of anesthesia patient outcomes in opt out states and non opt out states conducted by RTI and published in the journal Health Affairs shows that nurse anesthesia care in the opt-out states is as safe as ever.

This landmark study (and many others) confirms that there are no measurable differences in the quality or safety of anesthesia services delivered by CRNAs, by anesthesiologists, or by CRNAs being supervised by anesthesiologists. In fact, the RTI results show that, all other things being equal, anesthesia delivered only by CRNAs is as safe as – and in some cases safer than – anesthesia delivered only by anesthesiologists or by CRNAs supervised by anesthesiologists.

Q. Why should CRNAs be allowed to practice without a physician present?

In most instances, CRNAs practice with a surgeon or operating practitioner present. Instances where CRNAs practice without a physician present may include obstetric anesthesia or chronic pain management. CRNAs can be trusted to provide the anesthesia service safely because they have extensive training in their field, and data show that they have outstanding patient safety outcomes. CRNAs are also cost effective, which leads to lower costs and less waste in the healthcare system.

Q. Why shouldn’t CRNAs be supervised by physicians? Don’t physicians know more than nurses?

Surgeons and CRNAs work together in the patient’s interest. But the CRNA is the expert in the patient’s anesthesia care, just as the surgeon is the expert in the patient’s medical procedure. The presence of the Medicare supervision rule contributes to confusion over who is responsible for what. The rule currently requires physician supervision except in states that have opted out of this requirement. So far 17 states have opted out.

It is important to note that "physician supervision" does not mean “supervision by an anesthesiologist.” An anesthesiologist is one type of physician who may supervise CRNAs, but there is no federal requirement that CRNAs be supervised by anesthesiologists.

With regard to your question, "Don’t physicians know more than nurses?" a more appropriate question related to the supervision issue would be “Don’t surgeons know more about anesthesia then CRNAs?" The answer to that question is, "No, they do not." CRNAs are advanced practice registered nurses who complete an average of 30 months of classroom and clinical education and training specific to providing anesthesia. A surgeon doesn’t have nearly that level of preparation in the art and science of anesthesia, and is not equipped to tell CRNAs how to provide anesthesia to their patients.

Q. If CRNAs can do this job, then why have anesthesiologists? Are they redundant?

With an aging population and more procedures than ever moving from traditional settings such as hospitals into outpatient facilities, there is more than enough work for the nation’s 80,000+ anesthesia professionals. Each type of provider adds value to the health system.

Q. What’s the big deal? Can it really hurt to have supervision?

In this day and age, when ensuring access to safe, cost-effective healthcare (including anesthesia care) is of paramount importance, continuing with the unnecessary and expensive supervision requirement is neither effective nor efficient. CRNAs provide anesthesia with a safety record that is at least equal to that of anesthesiologists, and therefore should be the ones staffing the ORs and the OB suites while anesthesiologists use their medical backgrounds to serve as intensivists, hospitalists, and in other more expansive roles. In the long run, eliminating the supervision requirement will reduce costs and ensure patient access to safe, high-quality healthcare services.

According to a comprehensive study on the cost-effectiveness of anesthesia providers conducted by the The Lewin Group and published in the Journal of Nursing Economic$, a CRNA acting as the sole anesthesia provider is the most cost-effective anesthesia delivery model. Costs for this model are 25 percent less than the second lowest-cost model in which an anesthesiologist directs four CRNAs. Since safety is not a factor, there is no need to pay anesthesiologists two to three times as much as CRNAs to do the same work, or to merely look over the CRNAs’ shoulder as they work with patients.

Q. Are CRNAs really as safe as anesthesiologists?

Numerous studies demonstrate that CRNAs are as safe as anesthesiologists. Most recently, the RTI study published in Health Affairs showed that anesthesia delivered only by CRNAs is as safe as – and in some cases safer than – anesthesia delivered only by an anesthesiologist or by a CRNA working with an anesthesiologist. Numerous other studies and data analyses have shown that there are no measurable differences in the quality of anesthesia services delivered by CRNAs and anesthesiologists. For example, studies about obstetrical (OB) anesthesia demonstrate the safety of CRNA-delivered anesthesia. A 2007 study published in Nursing Research shows no difference in OB anesthesia complication or mortality rates between hospitals that use only CRNAs compared with hospitals that use only anesthesiologists.

Q. Why is it important for those in rural areas to have access to CRNAs?

Rural areas need access to CRNAs for several reasons. One is that for various reasons few anesthesiologists practice in rural America. Second, if there are not CRNAs working in these rural areas, then there is no surgical, labor and delivery, trauma stabilization, or interventional pain management care. Without those services, local rural hospitals could not exist. And without local rural hospitals, the viability of rural communities is very much at risk.

Q. How many areas are there where there are no anesthesiologists? No CRNAs? Neither?

Across the United States, 21 percent of counties have CRNAs only, 8 percent have anesthesiologists only, 38 percent have both CRNAs and anesthesiologists, and 33 percent have neither provider. (Source: 2012 HRSA ARF and 2010 CMS NPI files, 2010 Physician Master File)