1. CRNA Value in a Changing Environment:
Competition and Opportunity in Nurse Anesthesia to the Benefit of Patients
Frank Purcell, AANA Senior Director
Federal Government Affairs

2. Our Agenda Today Additional focus on CRNA reimbursement
Regulatory reform, supervision, medical direction and opt-out
Current issues with anesthesiologist assistants
Q&A time

3. Economic Factors Shaping Health
Going Up
Going Down
Elderly as a share of the population
Workers / retiree
Per-capita health spending, more slowly
U.S. health compared with industrialized world
U.S. debt, >$17TN
U.S. deficits annually
Economic growth
Public coverage
Private coverage

4. What about CRNAs delivers value?

5. What do plans pay for?

6. Fee-for-service (Base + time) x ($CF) = anesthesia fee
(Relative value) x ($CF) = physician fee
Pays for a thing
Does not necessarily pay for
Quality
The right thing
Care coordination
Optimal efficiency

7. Medicare & CRNAs Part A: Hospital insurance Part B: Physician services
Conditions of participation
Pass-through program
Part B: Physician services
Anesthesia payment
Teaching rules
Reimbursement for other services
Parts C & D: Managed care, prescription drugs

8. Part A for CRNAs Conditions of participation & of coverage
Anesthesia services
ASC surgical services
Reasonable cost passthrough
Certain qualifying rural and critical access hospitals
<800 cases or less
CRNA services as a hospital service, no Part B

9. Part B for CRNAs Anesthesia payment Payment for other services
Medical direction
Pain care
Teaching rules
Payment for other services

10. Most common anesthesia services
QZ, CRNA nonmedically directed QX, CRNA medically directed by an anesthesiologist QK, anesthesiologist medically directing 2, 3 or 4 concurrent CRNA cases AA, personally performed by an anesthesiologist

11. New England Assy of Nurse Anesthetists: Federal Issues & Advocacy
Supervision
It is a Medicare requirement, a portion of a regulation, 42 CFR §482.52(a)(4)
Anesthesia must be administered only by … (4) A certified registered nurse anesthetist (CRNA), as defined in (b) of this chapter, who, unless exempted in accordance with paragraph (c)of this section, is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed ….

12. In the Day
1997: Proposed to be repealed 1/2001: Repealed in a final rule 2/2001: Suspended 11/2001: Finalized as an opt-out process 11/2001 to today: 17 states have opted out

14. What is required to opt out?
Letter from Governor to CMS making the request
Governor has consulted with boards of nursing and of medicine
Opt-out is consistent with state laws
Opt-out is in the interest of the people of the state
Effective upon receipt at CMS

15. Who opposes the opt-out?

16. What happens when you do opt-out
The California Society of Anesthesiologists (CSA) and the California Medical Association (CMA) sued Governor Schwarzenegger: February The Colorado Society of Anesthesiologists (CSA) and the Colorado Medical Society (CMS) sued Governor Ritter: September 28, 2010

17. A national opt-out?
Would eliminate supervision in those states that could opt out but have not Does not eliminate supervision in states with requirements No reversal of opt-out Not “no” but not “now”

19. Supervision vs Medical Direction

20. What are the TEFRA rules?
Performs a pre-anesthetic examination and evaluation;
Prescribes the anesthesia plan;
Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence;
Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthetist;
Monitors the course of anesthesia administration at frequent intervals;
Remains physically present and available for immediate diagnosis and treatment of emergencies; and
Provides indicated-post-anesthesia care.
MCM Ch 12 Sec 50G
MCM Ch 12 Sec 50G

21. TEFRA medical direction rules
Anesthesiologist performs all seven tasks in each of up to four concurrent cases provided by a CRNA Fee split 50/50 between CRNA and medically directing anesthesiologist A payment model not a standard of care Encourages higher-cost anesthesia delivery without demonstrated quality improvement

22. Medical Direction Undermined
[DO NOT READ THIS BRACKETED STATEMENT. THESE SLIDES WERE PREPARED BY AANA FGA AND COMMS, 3/14-15, 2012, for the use of American Association of Nurse Anesthetists members making presentations.]
As you may have read from President Malina’s message the other day, lapses in anesthesiologist supervision of CRNAs are common even when an anesthesiologist is medically directing as few as two CRNAs, according to an important new study published in the March issue of the journal Anesthesiology. The study, titled “Influence of Supervision Ratios by Anesthesiologists on First-case Starts and Critical Portions of Anesthetics,” looks at over 15,000 anesthesia records in one leading U.S. hospital and raises critical issues about propriety and compliance in the most common and costly model of anesthesia delivery at a time when quality and cost-effectiveness are white-hot healthcare issues at every level.
Anesthesiology 2012; 116:

23. Of the anesthetics you personally administer, how often is an anesthesiologist involved in the following activities?
Anesthesiologists are present with full-time CRNAs most commonly for pre-anesthetic assessment and emergencies. Anesthesiologists are least often present for emergence from anesthesia.
Yet, is patient safety at issue here? No. The AANA has long held that medical direction ratios have nothing to do with quality of care, and everything to do with reimbursement systems—inefficient, unsustainable systems that make healthcare cost too much and divert millions upon millions of scarce healthcare dollars from real patient needs. Recent landmark studies on anesthesia safety and cost-effectiveness published in the journals Health Affairs and Nursing Economic$ have confirmed the safety and cost-effectiveness of CRNAs, and the Institute of Medicine in The Future of Nursing emphasizes APRN safety in arguing for nurses to practice to their full scope.
AANA 2011 member survey, unpublished.
2011-2
0809

24. Anesthesiologist Supervision Often Lapses
Now, this study in Anesthesiology confirms anesthesiologist supervision of CRNAs is more honored in the breach than in the observance. This graph is drawn directly from the study itself.
Anesthesiology 2012; 116:

25. Medical Direction vs Supervision
Supervision, generally
By an anesthesiologist
By operating practitioner, or by an anesthesiologist who is immediately available if needed
Seven services required in order to claim medical direction reimbursement (50% of a fee, up to 4 concurrent cases (TEFRA rules)
Required as a condition of participation for your hospital, or a condition of coverage in your CAH or ASC
Opt-out does not apply
Opt-out does apply; 17 states have opted-out

26. Anesthesiologist Assistants
Overview of AA Practice
ASA support of AAs
AA education, practice under state law or delegation
Distinctions between AAs and CRNAs
Current legislative battles
Moving on to AAs
Today, I’m going to give you an overview of AAs.
-Overview of AA practice.
-ASA support of expanding AAs as an anesthesia provider.
-AA education, practice under state law or physician delegation.
-Distinctions between AAs and CRNAs.
-Current legislative battles.

27. Anesthesiologist Assistants
Approximately 1,800 AAs have been produced in the U.S. since the 1970s
10 current AA educational programs
Explicit recognition in more states.
14 states and DC (includes states that authorize PA/AA practice)
-The American Academy of Anesthesiologist Assistants or Quad A is the national association for AAs. According to the AAAA, the AA is an allied health professional, specializing in anesthesia, who works under the direction of an anesthesiologist in the anesthesia care team environment .
-AAs have been practicing since the early 1970s, so approximately 40 years or so.
-The AA develops and implements an anesthesia care plan in an assistant capacity. One of the huge distinctions between AAs and CRNAs is that AAs must work under the close supervision of an anesthesiologist. AAs may not work under the direction of other physicians or healthcare professionals.
-There are approximately 1800 AAs currently practicing. At this point, they would be viewed as a fringe anesthesia provider based on these numbers, but they are a long-term threat.
-Right now, 14 states and the District of Columbia explicitly authorize AA practice through either a licensure or certification process. This includes states that authorize PA/AA practice, and I will explain that more shortly. In all of these states, AAs must work under the direction or supervision of an anesthesiologist.

28. Anesthesiologist Assistants
AANA has not taken an official position on AAs.
SGA works closely with state associations on addressing AA issues.
ASA has supported AAs after years of neutrality.
The ASA sponsors the CAAHEP Accreditation Review Committee on Education for the Anesthesiologist Assistant (ARC-AA).
-The AANA has not taken an official position on AAs, but the SGA division works closely with state associations on addressing AA issues and the state association’s strategy on AA bills.
-ASA has increasingly shown support for AA efforts, particularly in the last 10 years or so.
-In October 2000, ASA formally passed a resolution to endorse AA efforts to obtain licensure and reimbursement for AAs practicing under the onsite medical direction of an anesthesiologist.
-ASA endorses efforts to educate, train and allow for the practice of AAs in states where anesthesiologists want AAs.
-ASA has established a standing Committee on AA Education and Practice to deal with all issues related to the AA profession. Members of this committee include anesthesiologists and AAs.
-The Commission on Accreditation of Allied Health Education Programs, or CAAHEP, is the organization that accredits AA programs, similar to the AANA affiliate, the Council on Accreditation. In 2005, ASA became a sponsor of the CAAHEP’s Accreditation Review Committee on Education for the Anesthesiologist Assistants. This committee makes recommendations to CAAHEP about program accreditation decisions and revisions to accreditation standards and guidelines for AA programs.
-ASA also supports advocacy efforts by state component societies to pass AA practice legislation.

29. AA Education Admission criteria CAAHEP standards
Baccalaureate degree in the arts or sciences from an accredited institution.
CAAHEP standards
No minimum hours for core courses
Limited scope of training
Masters degree
-Now, I wanted to touch on a few key areas of distinction between AAs and CRNAs. In the interest of time, I’m going to focus on the areas listed on the next two slides, but there are many more differences than those noted.
-For admission to an AA program, you need a baccalaureate degree. No nursing, medical, anesthesia or healthcare education, experience, licensure, or certification is required.
-For comparison, nurse anesthesia programs require 4 years of professional nursing education; a baccalaureate; an RN license and at least one year of acute care experience as a professional registered nurse
-For AA programs, no minimum number of anesthesia cases are required, and guidelines recommend 600 anesthesia cases.
-For nurse anesthesia programs, COA standards require that students administer a minimum of 550 anesthesia cases for a wide variety of procedures. Based on transcript data for students completing their programs in 2013, it shows the average number of anesthetics administered was 853.
- There is no minimum hours for core courses in AA programs, and the scope of training is significantly limited compared to CRNA programs – they are trained to be an assistant and to be closely supervised, they are not trained to be an autonomous provider.
-AA students graduate from programs with a Master’s degree, and the AAAA does not endorse an entry-level doctoral degree for Anesthesiologist Assistants.

30. AA Practice Scope of Practice Practice Setting Salary Safety Record
Coverage by health plans
-As I mentioned previously, AAs must work under the close supervision of an anesthesiologist, unlike CRNAs who are educated and trained to work with or without anesthesiologist or physician supervision and to exercise independent judgment.
-AAs typically practice in urban hospital settings and can only work where anesthesiologists work. In contrast, CRNAs practice in all settings where anesthesia is delivered.
-According to the AAAA, when employed within the same department and when possessing the same job description and experience level within the anesthesia care team, AAs and nurse anesthetists are compensated with identical salary and benefit packages.
-When it comes to patient safety, while numerous studies have concluded that CRNAs are safe providers, there are no credible research studies on the safety record of AAs.
- AA services are covered by Medicare when they are under the direct supervision of an anesthesiologist, which CMS in 2014 defined as “medical direction.” Little information is available about commercial plan coverage of AAs

31. Anesthesiologist Assistants
Where are AAs Authorized to Practice (includes states that authorize PA/AA practice)?
Law
Regulations
Licensure
Certification
Alabama
Colorado DC
Florida*
Florida
Georgia
Indiana
Kentucky**
Kentucky
Missouri
-The states that explicitly recognize AA practice typically do this through the medical practice act or board of medicine regulations, and in these states, AAs are formally licensed or certified by the state.
13 states and the District of Columbia have adopted laws or regulations that explicitly authorize AA practice: The states are Alabama, Colorado, Florida, Georgia, Indiana, Missouri, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Vermont, and Wisconsin.

32. Anesthesiologist Assistants
Where are AAs Authorized to Practice (cont’d)?
Law
Regulations
Licensure
Certification
New Mexico
North Carolina
Ohio
Oklahoma
South Carolina
Vermont
Wisconsin
-2 states authorize certified PAs to administer and regional anesthesia if they have also graduated from an AA program: Florida and Kentucky.
-So, if you look at all the states that explicitly recognize AA or PA/AA practice, 14 states and the District of Columbia have adopted laws or regulations explicitly authorizing this practice.

33. Anesthesiologist Assistants
AA Legal Authority to Practice Under Physician Delegation
AA Practice Prohibition
Laws: Louisiana
-In some states, it is possible that AAs do not need explicit authority to practice in a state because they may practice through physician delegation laws and rules. These provisions would not explicitly identify AAs as authorized anesthesia providers but could potentially apply to AAs and implicitly authorize their practice.
-These delegation provisions may give physicians broad power to delegate medical acts to unlicensed or unregulated individuals, or in other cases, these provisions may grant more narrow delegation authority to physicians.
-According to the AAAA, AAs practice through delegation in 2 states: Michigan and Texas. Previously, AAAA included New Hampshire and West Virginia as delegation states, but it has changed its position on these two states.
-The legality of practice under physician delegation may be questionable.
-In terms of prohibitions of AA practice, Louisiana is the only state that has specifically prohibited AA practice, and this is through statute.

34. - Locations of AA programs
For those of you that like pictures versus charts, this slide gives you a pictorial – the states that are red are where AAs are explicitly recognized, the states in purple are the delegation states, and Louisiana is in green because AAs are prohibited. The yellow triangles represent the AA programs.

35. 2011 2012 2013 2014 Nevada – failed Colorado – passed with amendments
California – carried over
California - failed
New Mexico - failed
Kentucky - failed
Indiana – passed Senate and House, vetoed by governor
Indiana - passed
Texas - failed
New York – failed
Utah - failed
Wisconsin – passed with amendments
Michigan – carried over
Michigan - TBD
New Mexico – 2 bills, one failed, one passed (negotiated)
Nevada – rule withdrawn
New York – carried over
New York - TBD
Oregon - failed
-This slide summarizes the AA activity we’ve seen in the last 4 years.
-You can see that we have seen some increase in activity in the last couple of years.
-I wanted to point out Nevada because the proposal in that state was a new tactic. This year, the board of medicine proposed to amend their physician delegation rules to explicitly allow anesthesiologists to delegate anesthesia to AAs.
-Currently, AAs are not recognized under Nevada statutes, though AA bills have been introduced. This was a back door approach that was being taken in Nevada, since they had not been able to successfully pass an AA bill.  
-This rule has been withdrawn. A bill draft request for an AA licensing bill has been pre-filed for the 2015 legislative session.

36. Coverage of AA Services
Medicare recognizes AAs
AANA secured CMS statement that it pays AA claims only when they are medically directed by an anesthesiologist
VHA recognizes AAs
Low ranking as GS-9
CRNA services provide maximum flexibility

37. AA Resources
Tool Kit
AA Fact Sheet
CRNA-AA Comparison Table
SGA Staff

40. Questions about AAs AANA Division of State Government Affairs
(847)

41. We’ve learned about Reimbursement and CRNA services value and markets
Supervision, medical direction and opt-out processes
Anesthesiologist assistants

42. Thank You from Your AANA FGA
Frank Purcell, Senior Director Federal Gov’t Affairs Kate Fry, Associate Director Political Affairs Emily Forrest, Assistant Director Federal Government Affairs Romy Gelb-Zimmer, Associate Director Federal Regulatory and Payment Policy Randi Gold, Associate Director Federal Regulatory and Payment Policy Ralph Kohl, Associate Director Federal Government Affairs Octavia Thompson, Administrative Assistant
AANA Division of Federal Government Affairs
25 Massachusetts Ave., Suite 550
Washington, DC
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