Anesthesia Staffing Models and Geographic Prevalence Post-Medicare CRNA/Physician Exemption Policy

By Coomer, Nicole M.; Mills, Amy et al. | Nursing Economics, March/April 2019 | Go to article overview

Anesthesia Staffing Models and Geographic Prevalence Post-Medicare CRNA/Physician Exemption Policy


Coomer, Nicole M., Mills, Amy, Beadles, Christopher, Gillen, Emily, Chew, Rob, Quraishi, Jihan A., Nursing Economics


Three common anesthesia staffing models for surgical cases in the United States include services delivered by (a)anesthesiologists alone, (b)certified registered nurse anesthetists (CRNAs) alone, and (c)anesthesiologist/CRNA teams (Matsusaki & Sakai, 2011). Before 2001, the Centers for Medicare & Medicaid Services (CMS) conditions of participation required CRNAs to be supervised by a physician (an operating physician or an immediately available anesthesiologist). In 1997, CMS started the process to change the conditions of Medicare participation for CRNAs by proposing an exemption for CRNAs from the physician supervision requirement (Jacobson, 2001; Medicare and Medicaid Programs, 2001). The final rule in 2001 cited a lack of scientific evidence supporting the CRNA physician supervision requirement and gave states the option to request an exemption from the physician supervision requirement (Jacobson, 2001; Medicare and Medicaid Programs, 2001). The exemption requires the governor to consult with the state board of medicine, nursing, and other experts and to submit a written request for exemption in the form of a letter to CMS stating the exemption is in the best interest of the state's citizens.

Two studies of the opt-out policy, examining opt-out states, have not demonstrated a substantial impact of the provision on access to anesthesia services. Sun, Dexter, Miller, and Baker (2017) analyzed Medicare utilization data and found that most optout states exhibited smaller growth in anesthesia utilization compared with non-opt-out states. Further, in the same study, opt-out status was found to be associated with little or no increase in access to anesthesia services. Schneider, Ohsfeldt, Li, Miller, and Scheibling (2017) concluded that opt-out status did not appear to increase access to anesthesia services.

Recent work by Quraishi, Jordan, and Hoyem (2017) included a 15-year trend analysis of Medicare data that found the rate of CRNAs billing for anesthesia services without anesthesiologist medical direction has been increasing, while the rate of anesthesiologists providing anesthesia services alone has been decreasing. Still, there has been a persistent unequal distribution of anesthesia providers across the United States. Particularly, CRNAs tend to be concentrated in rural areas where they are often essential to providing anesthesia services for general surgery and obstetrical care (Daugherty, Fonseca, Kumar, & Michaud, 2011; Doty et al., 2008; Fallacaro & Ruiz-Law, 2004; Greenwood & Biddle, 2015; Kozhimannil et al., 2015; Liao, Quraishi, & Jordan, 2015).

Implementation of the Medicare CRNA physician supervision opt-out provision in 2001 provides opportunity to explore whether this policy has influenced anesthesia staffing models in U.S. hospitals and ambulatory surgery centers (ASCs). Currently, 17 states have exercised the opt-out provision (Schneider et al., 2017). Although studies have found using CRNAs is a cost-effective approach to delivering anesthesia, few have investigated the impact of the opt-out policy on the prevalence of predominantly CRNA models in different surgical facilities and hospitals (Henrichs et al., 2009; Hogan, Seifert, Moore, & Simonson, 2010).

In this work, researchers classified facilities into three anesthesia staffing models based on the anesthesia modifier codes billed on anesthesiology claims for surgeries performed at the facility: predominantly anesthesiologist, predominantly CRNA, or team. Facilities were classified as ASCs or hospitals; hospitals were further classified as large or small by urban/rural location and bed size. The prevalence of these facilities was assessed by location, facility type and size, and state opt-out status. Predominantly CRNA staffing models did not appear to be more common in opt-out states, yet they were more prevalent in rural areas than urban areas. Further, few facilities in rural areas used predominantly anesthesiologist staffing models regardless of a state's opt-out status. …

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