April 2, 2015
The Honorable Susan Bonilla
California State Senate
State Capitol, Room 4074
Sacramento, California 95814
RE: AB 890 (Ridley-Thomas) – Oppose
Dear Assemblymember Bonilla:
On behalf of the California Association of Nurse Anesthetists (CANA) representing over 2200
Certified Registered Nurse Anesthetists (CRNAs) licensed in the state of California, and the
California Nurses Association (CNA) representing over 85,000 members, we write in opposition
to AB 890 (Ridley Thomas).
AB 890 aims to create a new class of anesthesia provider in California called anesthesiologist
assistants (AAs). California currently has the systems in place to educate, license and regulate
two established and proven anesthesia providers – anesthesiologists and certified registered nurse
anesthetists (CRNAs). CRNAs practice autonomously in 82% of California counties that
provide surgery, obstetric and trauma stabilization services. In addition, seven counties in
California receive 100% of their professional anesthesia services solely by nurse anesthetists.
CRNAs are educated to exercise independent judgment and practice autonomously. The role of
the Anesthesiologist Assistant is to “assist” an anesthesiologist. AAs are not educated to serve as
physician assistants (PAs). There are clear limitations concerning where AAs may assist in the
administration of anesthetics and under what conditions. Unlike CRNAs, AAs are not trained to
exercise independent judgment, thus AAs are not qualified to administer anesthesia as
autonomous providers. For this key reason, AAs fail to increase access to anesthesia services,
especially in rural and medically underserved areas and within all branches of the armed forces
and Veterans Affairs healthcare system — all of which are currently served by autonomously
practicing nurse anesthetists. AAs similarly do not increase access to obstetric pain
management services because AAs are not uniformly trained to administer regional anesthetics
such as spinals and epidurals, and because the presence of an anesthesiologist is mandatory for
their functioning 100% of the time. Research indicates that anesthesiologists find it difficult to
comply with Medicare Medical Direction requirements, and that even at a supervision ratio of 1:2,
lapses occurred on 35% of days.1 Regardless of the wording of state law, all facilities that bill
Medicare (all hospitals) must comply with the Medicare Medical Direction Regulations for all
patients in the facility, and not just for Medicare covered patients. That means that the direction
and supervision referred to in Section 3553 would need to consist of the Medicare Medical
Direction Regulations if the facility wants to be certified for Medicare reimbursement.
The AA credential has been used since 1971; however, there are only about 1,800 AAs in the
entire U.S. today that are licensed in just 13 states and the District of Columbia. Per the Centers
of Medicare & Medicaid Services (CMS), AAs must be medically directed by an anesthesiologist
who is immediately available in the operating room suite. Several states restrict AAs to medical
direction only by board-certified anesthesiologists, and AAs are expressly forbidden by law in
one state. The medically directing anesthesiologist must fulfill all the mandatory Medicare
medical direction requirements to comply with Part B regulations in order to qualify to receive
additional reimbursement. However, as long as the supervising anesthesiologist is in the
operative suite, the AA could administer anesthesia without the presence of the anesthesiologist
in the operating room. It is important to note that states which do utilize AAs typically have
language which requires enhanced supervision of these personnel.
Training plays a large factor in the limited role that AAs play. AAs are not required to have any
prior healthcare education or experience before they begin their AA educational program; thus,
their pre-anesthesia clinical experience must be incorporated into their AA training program. In
comparison, Certified Registered Nurse Anesthetists (CRNAs) are required to hold a
baccalaureate degree in nursing or a related science specialty, must be licensed as a Registered
Nurse (RN), and must have acute care experience prior to admission to a nurse anesthetist
educational program. CRNAs currently obtain a masters or doctoral degree upon program
completion; by the year 2021, 100% of nurse anesthesia educational programs in the U.S. will
award doctoral degrees for entry into practice.
Medical direction and supervision by anesthesiologists has been proven to be the most expensive
method of providing anesthesia services. In areas of California where nurse anesthetists practice
autonomously, facilities realize greatly reduced cost of services with no compromise in quality,
safety or outcomes. The autonomous nurse anesthesia practice model provides significant
benefits for Californians, healthcare facilities and the state. Indeed, nurse anesthesia services are
especially important now that the Covered California health benefits exchange is completely
underway. It is well documented by independent research that the added expense of medically
directed anesthesiology services produces no added benefit for patient outcomes, healthcare
facilities or communities, and that efficacy of anesthesia delivery and outcomes are equivalent
when anesthesia administered by CRNAs and anesthesiologists.2, 3, 4, 5, 6
AB 890 does not require an AA to have a California license, and does not set up any agency
oversight of AA functions. In addition, AB 890 does not authorize an AA to administer
medications or anesthetic agents, and does not authorize essential anesthesia functions, such
as intubation.
For all these reasons, we oppose AB 890 and respectfully request your NO vote when the bill is
heard in the Assembly Business and Professions Committee.
Sincerely,
cc:
References
1. Epstein, R & Dexter, F (2012), Influence of Supervision Ratios by Anesthesiologists on First-case Starts
2.
and Critical Portions of Anesthetics, Anesthesiology 116, pp 683-691.
Dulisse, B & Cromwell, J (2010), No Harm Found When Nurse Anesthetists Work Without Supervision by
Physicians, Health Affairs 29(8): 1469-1475.\
3. Needleman, J & Minnick, A (2009), Anesthesia Provider Model, Hospital Resources, and Maternal
Outcomes, Health Services Research 44 (2p1): 464-482
4. Hogan, P, Furst Seifert, R, Moore, C & Simonson, B (2010), Cost Effectiveness Analysis of Anesthesia Providers,
5.
6.
Nursing Economics 28 (3): 159-169
Lewis Sr, N, Smith, A, & Alderson, P (2014), Physician Anaesthetists versus Non-physician Providers of
Anaesthesia for Surgical Patients, Cochrane Collaboration (7), Wiley, pp 1-80.
Pine, Michael, MD, Hold, K, & You-Bel, Lou (2003), Surgical Mortality and Type of Anesthesia Provider,
AANA Journal 71(2), pp 109-116.