Nationally, nurse anesthetists have been administering anesthesia to patients for 150 years... Nationally, nurse anesthetists have been administering anesthesia to patients for 150 years, long before it was a physician specialty. Traditional training took place in hospital-based or military programs that ranged in length from a few months to a few years. Surgeons were, and remain to be, strong supporters of CRNA practice abilities and rights. In 1912, Dr. George Crile, general surgeon and founder of The Cleveland Clinic Foundation, was targeted by Ohio physicians through the Ohio State Medical Board and the Attorney General because of his support for nurse anesthetists. Crile, and his Lakeside Hospital, was threatened with the withdrawal of hospital appropriation funding and physician payments because he supported the training and use of nurse anesthetists. After a 5-year protracted battle, Crile and his Lakeside Hospital emerged victorious in their support of nurse anesthetists. Agatha Hodgins, his chief nurse anesthetist since 1908, became the founder of the National Association of Nurse Anesthetists, the predecessor of the American Association of Nurse Anesthetists (AANA). During this time, other sanctions and lawsuits took place against those who used or educated nurse anesthetists in Kentucky, California, New York, and Pennsylvania (Bankert, 1989).

Challenges Associated with Autonomous CRNA Practice

Outcomes data supports the safety and cost-effectiveness of the delivery of anesthesia care by CRNAs. CRNAs have had their ability to practice independently challenged. During the last decade, nurse anesthetists’ skills have been publicly brought into question by physicians who have attempted to block efforts aimed at independent CRNA practice. Efforts include pressuring state governors from opting out of the federal Medicare Part A physician supervision requirement for facility reimbursement of CRNA services, particularly when there is no state law or regulation requiring nurse anesthetists to be supervised by a physician. In a press release targeting members of Congress, anesthesiologists declared, “seniors will die” if CRNAs are not supervised by anesthesiologists (ASA, 2000), despite the fact that no state mandates CRNA supervision by an anesthesiologist. The anesthesiologist lobbyists stated the reason for the supervision stems from lack of sufficient (medical school) training (ASA, 2000). However, some small successes have worked towards the favor of the CRNAs, and to date, seventeen state governors have opted out of this unnecessary federal requirement in order to provide flexible staffing models that work for the delivery of safe anesthesia services in their respective states (AANA, 2013a).

More recently, insurers have sought to deny CRNA reimbursement for chronic pain management services based on private corporate analysis that nurse anesthesia education and training is inadequate for them to be paid for those services. Fortunately, the Centers for Medicare & Medicaid Services (CMS) ruled in November 2013 that Medicare administrators should reimburse CRNAs for chronic pain management services as long as they are within the CRNA scope of practice for the state in which the services are rendered (AANA, 2013c)

...increasing the number of CRNAs, and permitting them to practice in the most efficient delivery models, will be a key to containing costs while maintaining quality care. Outcomes data supports the safety and cost-effectiveness of the delivery of anesthesia care by CRNAs.  After analysis of seven years of Medicare data, Dulisse and Cromwell (2010) found the change in CMS policy allowing states to opt out of the physician supervision requirement for CRNA reimbursement was not associated with increased risk to patients. Other research suggests that CRNAS are less costly to train than anesthesiologists and have the potential for providing anesthesia care efficiently and competently (Hogan, Seifert, Moore & Simonson, 2010). Anesthesiologists and CRNAs can perform the same set of anesthesia services, including relatively rare and difficult procedures such as open-heart surgeries and organ transplantations, pediatric procedures, and others. CRNAs are generally salaried employees; however, compensation lags behind anesthesiologists. As the demand for health care continues to grow, increasing the number of CRNAs, and permitting them to practice in the most efficient delivery models, will be a key to containing costs while maintaining quality care (Hogan et. al, 2010)

Challenges in the CRNA Educational Milieu

Reimbursement

Nurse anesthesia educational programs in universities often share clinical education sites with physician anesthesia training programs in anesthesiologist-managed facilities. CRNA students often find that they are removed from assigned cases to be replaced Nurse anesthesia educational programs in universities often share clinical education sites with physician anesthesia training programs... by physician residents for difficult cases or cases that require invasive line placement or regional anesthesia. As a result, in order for CRNA students to be adequately trained, program administrators must rotate students to multiple sites, sometimes at significant geographical distances and at significant cost to the program and the student (personal communications, M. Frankin, February 10, 2013). The driving force behind this issue is that hospitals receive significant financial compensation from Medicare for each physician resident they train, yet they receive no federal funding for APRN student training (Nonnemaker, 2010). This creates a disincentive for hospitals to accept CRNA students since physician trainees can generate income for a facility.

Furthermore, Medicare rules on reimbursement for anesthesiologists teaching student CRNAs are not equitable with teaching physician anesthesia residents. When an anesthesiologist teaches two physician residents, the anesthesiologist receives 100% of the allowed reimbursement for both cases. When an anesthesiologist teaches two student registered nurse anesthetists, the anesthesiologist receives only 50% of the allowed reimbursement for both cases (CMS, 2009). Obviously, when seeking greater reimbursement, the anesthesiologist will choose to teach physician residents rather than student CRNAs in the high acuity, Medicare patient cases.

Changing Educational Mandates

Many programs have since integrated practice doctorate programs and there are currently 20 COA-accredited nurse anesthesia programs... In 2005, the American Association of Colleges of Nursing (AACN) released a position statement mandating that all APRN programs would need to confer practice doctorates by 2015 (AACN). Since some nurse anesthesia educational programs do not reside in colleges of nursing, the requirement could not be imposed on all CRNA educational programs using the proposed timeline. The accrediting body of nurse anesthesia programs, the Council on Accreditation of Nurse Anesthesia Educational Programs (COA), supported, and refined, the decision by mandating that all students admitted to programs after 2022 would be required to receive a practice doctorate upon graduation (Hawkins & Nezat, 2009). Many programs have since integrated practice doctorate programs and there are currently 20 COA-accredited nurse anesthesia programs where students are admitted with a BSN and graduate approximately 3 years later with a Doctor of Nursing Practice (DNP) or Doctor of Nurse Anesthesia Practice, (DNAP) (F. Gerbasi, personal communication, October 1, 2013).

Implementing the practice doctorate mandate has created some challenges for nurse anesthesia educators and students. Implementing the practice doctorate mandate has created some challenges for nurse anesthesia educators and students. CRNA programs are extremely rigorous and have always required full time student enrollment. Rare is the student who can successfully attend a CRNA program and continue to work outside of the program. Even rarer is the student whom can complete this education without acquiring at least some loan debt. With the new doctoral requirement, students who were previously required to attend a nurse anesthesia program for 28 months without any income, are now required to spend 30 -36 months obtaining their education without income. This change in CRNA educational requirements has created a barrier to practice to some extent. For registered nurses interested in becoming a CRNA who do not have the financial resources to independently support themselves for 3 years, graduating with over $100,000 in debt sometimes becomes the definitive barrier to their becoming nurse anesthetists (Roche, 2013).

Faculty issues

Whether discussing students in practice doctorate educational programs or those obtaining a master’s degree, one issue that cannot be overlooked is the need for adequate, qualified anesthesia faculty. Attracting and retaining enthusiastic and experienced educators can be difficult. In all areas of nursing, but especially in nurse anesthesia, the financial compensation afforded educators is less than the compensation they can receive in clinical practice (National Council of State Boards of Nursing, 2008). Lower compensation and extensive student loan debt may economically prohibit a career as a nurse anesthesia educator. Current faculty can become overworked, overstressed, and frustrated; many become burned-out and return to clinical practice (NCSBN, 2008). Lack of capable faculty can further become a factor in admission rates, student oversight, didactic rigor and eventual certification pass rates (NCSBN, 2008).

The Challenges of Professional Practice

CRNA Scope of Practice

Challenges related to other disciplines’ recognition of the CRNA scope of practice create barriers to practice. Many state statutes prevent CRNAs from practicing to the full extent of their education and training. The CRNA’s ability to provide chronic pain management services has been legislatively challenged by organized medicine in Iowa, California, Illinois, and Oklahoma (AANAb, 2013). Additionally, the American Society of Anesthesiologists (ASA) and other medical societies campaigned to 46 members of the U.S. House of Representatives to write the Veterans Health Administration (VHA) expressing concern about the agency’s plan to recognize CRNAs and other APRNs as full practice providers (AANAb, 2013). CRNAs must leave the operating room suites and assume leadership positions on hospital boards and committees to enlighten hospital administrators of their contribution to the healthcare system. Continued research aimed at outcomes data related to CRNA effectiveness and quality is necessary to aid the successful reduction of such barriers to practice.

Following Recommendation 1 in the Institute of Medicine of the National Academies’ Report, The Future of Nursing Leading Change, Advancing Health (2010) may promote the cost-effective delivery of quality anesthesia services that are more accessible, especially in rural and other medically underserved areas of the United States. For example, amending the requirements for hospital participation in the Medicare program will ensure APRNs are eligible for clinical privileges and membership on medical staff. A plan of action to reform scope of practice regulations to follow the NCSBN Model Nursing Practice Act and Model Nursing Administrative Rules (Article XVIII, Chapter 18) may help to reduce barriers for CRNAs to provide services they are educated to perform (NCSBN, 2008).

Reimbursement

Fair reimbursement for CRNA services poses another challenge for nurse anesthetists. Legislation passed by Congress in 1986 Fair reimbursement for CRNA services poses another challenge for nurse anesthetists. granted CRNAs direct reimbursement rights under the Medicare program (Garde, 1996). However, barriers still exist for nurse anesthetists in regards to Medicare reimbursement. CRNAs are required to work under physician supervision for reimbursement of Medicare Part A (facility fees) unless the state governor opts out of this requirement (Federal Register, 2001). The requirement is more restrictive than the majority of state laws or regulations and shifts what could be a quality and access decision for a state into a challenge between professional disciplines. 

Challenges also exist for CRNAs with insurance company policies for non-physician provider reimbursement by third-party payers. Provider nondiscrimination provisions that promote patient safety, competition, and choice in healthcare were included in The Patient Protection and Affordable Care Act of 2010 (PPACA). The federal Provider Nondiscrimination law, which was scheduled to take effect on January 1, 2014, prohibits health plans from discriminating against entire classes of qualified licensed healthcare professionals, such as CRNAs, solely on the basis of their licensure. Under this provision, health plans retain latitude to address provider network sufficiency and quality for the availability of healthcare benefits to their enrollees (AANA, 2013). APRNs have advocated for this provision and joined in protection of this law. APRNs must remain unified to ensure implementation to the legislative intent.

Summary

Barriers to CRNA and APRN practice are complicated and multi-factorial. Barriers to CRNA and APRN practice are complicated and multi-factorial. Strategies for educating others on the long history of safe care given by APRNs may ameliorate these barriers. Advocating for CRNAs, and obtaining support from, federal and state governments, insurers, healthcare professionals, and consumers may help to advance autonomous CRNA practice. Interdisciplinary education and respect for roles that providers have in delivering seamless healthcare to patients may assist CRNAs to practice according to the scope of their education and licensure. Nurses are the largest group of healthcare professionals in our country and can be instrumental change agents in reshaping the system of healthcare delivery.

Authors

Debra P. Malina, CRNA, DNSc, MBA, ARNP
Email: dmalina@barry.edu

Dr. Malina is an Assistant Professor and Assistant Program Director of Clinical Education for the Barry University Anesthesiology Programs in Hollywood, FL. She is responsible for coordinating simulation activities for nurse anesthesiology residents in the program as well. She continues to work as an anesthesia consultant and clinically as a locum tenens CRNA for an all-CRNA practice. Dr. Malina received her Master’s Degree in Anesthesiology from Barry, an MBA from Madison University in Gulfport, MS, and her DNSc from the University of Tennessee in Knoxville, TN. The focuses of her research interests are voluntary reporting mechanisms, human factors, effective communication techniques, evidence-based practice, and improved patient safety. She serves as a reviewer for the Journal of Peri-Anesthesia Nursing. Dr. Malina was President of the AANA in 2011-2012. She is currently the Secretary of the Nursing Organizations Alliance, a coalition of nursing organizations united to create a strong voice for all nurses. Dr. Malina also co-chairs the Florida Association of Nurse Anesthetists Government Relations Committee.

Janice J. Izlar, CRNA, DNAP
Email: janiceizlar@gmail.com

Dr. Izlar is currently a clinical nurse anesthetist and the administrator of anesthesia services for the Georgia Institute for Plastic Surgery in Savannah, Georgia and immediate past president of the American Association of Nurse Anesthetists (AANA). A CRNA for more than three decades, Dr. Izlar received her doctorate in nurse anesthesia practice from Virginia Commonwealth University in Richmond, VA. She earned a Master of Science in Nursing from Columbia University in New York, NY. As a member of the Georgia Association of Nurse Anesthetists, Dr. Izlar has served her state association on multiple committees and Board of Directors positions, including President. Nationally, she has served as AANA President-elect, Vice President, and Director Region 2.  Additionally, she has also served on numerous AANA committees, AANA Foundation Board of Trustees, Chair of the Advanced Practice Registered Nurse Committee advising the Georgia Board of Nursing and the Joint Commission’s Professional Technical Advisory Committee for Ambulatory Care.

American Association of Nurse Anesthetists. (2013a). Federal supervision rule/opt-out information. Retrieved from www.aana.com/advocacy/stategovernmentaffairs/Pages/Federal-Supervision-Rule-Opt-Out-Information.aspx.

Center for Medicare and Medicaid Services, Medicare Physician Fee Schedule for 2013, November 1, 2012. Retrieved fromwww.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files-Items/RVU13AR.html

© 2014 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2014