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Submitted by Edward Gentry – BSN, MSN, CRNA (Graduate of UTC Nurse Anesthesia and UTC Nursing) –
Certified Registered Nurse Anesthetists (CRNAs) are here in TN and almost exclusively provide direct anesthesia care to patients undergoing anesthesia for surgery and other procedures with and often without the presence of a physician, medical doctor anesthesiologist (MDA). This is a proven safe practice that is standard throughout the United States.
Tennessee conservatives should understand that there is a move within the state legislature that aims to introduce an additional anesthesia provider to the state of TN. This is claimed to be available and cost effective. That provider is an Anesthesiologist’s Assistant (AA). In other states, AAs monitor patients undergoing anesthesia while being supervised by MDAs. AAs cannot practice separately from MDAs. AAs are not equivalent to CRNAs in education or experience. AAs are not trained to have the same capabilities as CRNAs. AAs cannot currently and have never been allowed to practice in TN. There are likely no AAs currently living or voting in TN.
There is a claim that AAs will decrease healthcare costs. This is absolutely not accurate. The reality is that current AA starting salaries in other states are not less than CRNAs in TN. AAs also require twice as many MDAs to supervise them; therefore, the long-term cost will increase due to having to pay more MDAs to supervise at their own substantially increased rate.
SB 0453 intends to allow licensure of AAs in the state of TN. This bill, SB0453, is sponsored by Sen. Dr. Richard Briggs of Knoxville. It is co-sponsored by Sen. Adam Lowe of Bradley, McMinn and Meigs Counties, and Sen. Todd Gardenhire of Bledsoe, Hamilton, Marion, and Sequatchie Counties. Bo Watson of Hamilton County previously sponsored the bill in 2023. It was deferred to 2024 and then passed off to Dr. Richard Briggs. SB 0453 passed a committee vote (7-2) on February 21, 2024. That puts TN closer to having a provider that is less trained and experienced than the CRNA providers that are already here in TN.
The companion house bill is HB 1146 and is sponsored by Representative Greg Vital of Collegedale and north Hamilton County. There are several hospital systems on record in support of this bill. The greatest impetus behind the support and lobby of this bill is the Tennessee Association of Anesthesiologists (TSA) and several of its members.
Tennessee already has a wealth of highly skilled and qualified anesthesia providers. CRNAs practice in every hospital in TN and additionally in ambulatory surgery centers and office-based practices throughout the state. CRNAs are the sole anesthesia providers in almost all rural hospitals nationwide and in TN. Nurse Anesthetists have been in practice in the US for more than 150 years. CRNA certification started in 1945. The TN Association of Nurse Anesthetists website has a wealth of additional information about CRNAs.
In 2022, the Bureau of Labor Statistics reported 46,540 CRNAs in practice nationwide and 1,760 CRNAs in TN. This is down from 2,280 reported in 2017.
The population of TN is growing. TN needs to keep more CRNAs. Tennessee already has seven CRNA training programs turning out well over 180 new CRNAs every year. Tennessee is only surpassed by Pennsylvania in training the most CRNAs per year. All seven schools in TN are listed and detailed here; Additional information about CRNAs can be found with the AANA and the NBCRNA websites.
All CRNAs have training and a background in intensive care nursing practice. CRNAs progress to have further extensive education and training in anesthesia practice. Every CRNA has a minimum of a bachelor’s degree and licensure in nursing prior to starting CRNA school. Every CRNA has at least two years of experience as a critical care nurse, which is required for application to CRNA school. Most CRNAs in practice have a master’s degree that entailed at least 27 months of specialized anesthesia training on top of the degree and background of critical care nursing. Current education requirements have increased to a 36-to-38-month doctorate program to become a CRNA.
Major advantages that CRNAs have over MDAs and AAs include the years of ICU nursing experience. Unless a MDA or AA has been a nurse prior to medical school, he or she has never been responsible for the immediate hands-on care of a critical patient. CRNAs have experience in minute-to-minute monitoring of a patient in critical condition. CRNAs have experience in the administration of real patient contact and care that becomes essential to providing a high-quality anesthetic in the operating room. The curriculum of the MDA program at the University of TN is a four-year residency that consists of a three-year curriculum of learning and practice of training in anesthesia. MDAs claim that medical school is superior to nursing school and real-life critical care nursing experience. In direct comparison to anesthesia specific education, there is not much difference in the amount of training between CRNAs and MDAs. AAs receive less education and training than both aforementioned professionals.
AAs have training that is equivalent to physician assistants (PAs) but specific to anesthesia practice. AAs were created as a profession in the 1960s by anesthesiologists at Emory University. The intention is quoted from Emory University School of Medicine, “Responsibility and immediate care of the patient must remain within the province of the anesthesiologist; consequently, personnel could not work independently but only under the immediate direction of an anesthesiologist. An advantage in manpower for the anesthesiologist would result, as he could provide attention to several patients with the proper employment of the anesthesia team, described above.”
According to the University of Georgia Pre-AA Quick Facts, the question of the differences between CRNAs and AAs is answered. “AAs must work directly under an anesthesiologist while CRNAs can work under the operating surgeon, dentist, other non-anesthesiologist physicians, and can sometimes work independently. To pursue a career as an AA, you must complete an undergraduate degree with the appropriate science pre-requisites and then apply to an AA graduate program. To become a CRNA, you must first purse a BSN, gain clinical experience as an RN, and then enter a CRNA program.”
This model was intended to allow one MDA to supervise AAs while not always being in the operating room during surgery. Most states allow two AAs to be supervised by one MDA. Florida allows up to four AAs to be supervised by one MDA. When CRNAs practice with MDAs, four CRNAs can be supervised by one MDA. Independent CRNAs in TN practice with surgeons and other physicians that satisfy the state requirement for physician supervision. Twenty-eight states and Washington DC, along with Guam and the entire military and VA system allow full unsupervised practice authority for CRNAs. TN needs full practice authority for CRNAs
In contrast to CRNAs and MDAs, AAs have a substantial difference in education and training. There is no requirement for nursing school. There is no requirement for critical care nursing experience. There is no requirement for medical school. Most AAs have a bachelor’s degree in a science, but there are no specific requirements for a certain major. There can be a background in anything including having work experience in healthcare, but it is not necessary. I recently heard first-hand of an AA in a nearby state that was previously employed as a carnival ride operator prior to AA school and another was a glass-blower.
Would you want you or your family member or your own patient to be in the OR with an AA who is reliant for minute-to-minute decisions on the MDA who is tied up with another AA down the hall or observing the monitor from the doctor’s lounge while possibly browsing the internet? The purpose and goal are for the MDA to not be required to provide direct anesthesia care to any single patient. The intention and purpose of an AA is to show up and do what they are told and directed to do by the MDA.
To give a clear understanding of the financial landscape of the situation, current salary ranges are listed for TN in comparison to Georgia where AAs are licensed along with CRNAs and MDAs. Below are the current ranges of W-2 salary offerings listed publicly on Gaswork.com on February 26, 2024.
TN has 36 Listings for full-time Anesthesiologists within the salary range:
$475,000-$650,000/yr. Max Listing $1,200,000/yr.
TN has 74 listings for Full-time CRNAs within the salary range:
$140,000 $270,000/yr. Max Listing $350,000/yr.
GA has 84 Listings for full-time Anesthesiologists within the salary range:
$400,000-$750,000/yr. Max Listing $1,200,000/yr.
GA has 189 listings for Full-time CRNAs within the salary range:
$160,000-$380,000/yr.
GA has 47 listings for Full-time AAs within the salary range:
$140,000-$270,000
As previously stated, CRNAs can practice independently of MDAs, therefore some of the higher listings for CRNAs in GA may be in rural areas and procedure centers that cannot and will not incur the cost of an MDA. On analysis of these salary listings, the presence of AAs in TN may push CRNA salaries higher.
Almost every MDA listing is in the model of supervising CRNAs and AAs in other states. MDAs routinely only function as supervisors and rarely touch a patient beyond consultation and occasional procedures. MDAs submit billing for up to four cases concurrently if they are supervising CRNAs. The CRNA is the person directly providing anesthesia to the patient having surgery or a procedure. Patients, almost exclusively, are unaware of this model and are often surprised when they see a bill for an MDA, and a CRNA that they do not remember. This is especially true, when the MDA has referred to the CRNA as, “one of my nurses” or just an anesthesia nurse.
Many CRNAs leave TN because the job market in TN has been managed by MDAs and has persisted in keeping salaries as low as possible. This is particularly true in the Nashville area as well as Chattanooga and Knoxville. This situation is perfectly illustrated by the current situation of the anesthesia department at Park Ridge Hospital in Chattanooga which is managed by the MDAs of North American Anesthesia Partners (NAPA). The group was formerly American Anesthesiology which sold out to Mednax several years ago before being acquired by NAPA. Park Ridge Hospital is being staffed extensively by contract locum providers because the group valued its business with CHI Memorial Hospital more than Park Ridge. There are multiple CRNAs who have left the NAPA group or refuse to join because of below market salary offerings. NAPA has recently lost contracts in the Knoxville area as well as Memorial Hospital in Chattanooga due to poor management and staffing. The other large anesthesia group in town is still independent but frequently has CRNA openings because their salary package is kept as low as possible despite recent increases. Increasing CRNA compensation will immediately lead to filled positions.
The legislators have been presented with an argument that Tennessee needs AAs to meet the increased need for anesthesia providers. The anesthesiologists and the TSA that presented this argument want to increase the demand for supervising MDAs. They do not want to stay in an operating room individually and directly provide anesthesia to the patient who thinks he or she is getting anesthesia from the MDA. MDAs want to supervise more providers. They are claiming a need. They claim that adding AAs will alleviate a deficit in providers. This is a false argument. By adding AAs, more MDAs are required at a distinctly higher cost as noted above.
The better option would be to remove the supervision requirement of CRNAs in the state of Tennessee and empower the MDAs to resume the practice of first-hand administration of anesthesia. For every four CRNAs, you could free up a MDA to provide quality anesthesia to a fifth patient on their own. This is a strategy to immediately increase providers in TN.
We do not need AAs in TN. We need MDAs to return to directly providing anesthesia alongside independent CRNAs with full-practice authority. This will alleviate the provider shortage and reduce costs.
