As a profession, nurse anesthesia is at a tipping point. While recent federal legislation and changes to the U.S. Medicare program have expanded opportunities for certified registered nurse anesthetists (CRNAs) to provide care to more patients and receive reimbursement for their services, many states still restrict their scope of practice and limit their pay. A special section in the current issue of Clinical Scholars Review, the journal of advanced practice nursing published by Columbia Nursing, explores how the Affordable Care Act (ACA) empowers CRNAs to help make anesthesia services more accessible to patients, while also highlighting laws in New York and other states that may impede the expanded access to care envisioned by ACA.
The broad goals of the ACA are to extend health insurance to millions of uninsured Americans and to improve the accessibility, quality, and cost-effectiveness of care. With respect to anesthesia and pain management, the ACA takes some steps in the right direction, but still falls short of fully achieving these goals, argues Janice Izlar, CNRA, DNAP, MS '06, immediate past president of the American Association of Nurse Anesthetists, in her essay in the journal, "Health Care Challenges to the Certified Registered Nurse Anesthetist as an Advanced Practice Registered Nurse."
Starting in January 2014, the ACA put a stop to health plans' practice of excluding qualified licensed health care providers, such as CRNAs, from insurance networks solely on the basis of their licensure. But the ACA left untouched a Medicare reimbursement policy that lets states opt out of regulations permitting CRNAs to administer anesthesia without physician supervision. In many states, including New York, this has pitted anesthesiologists against CRNAs in legislative fights over scope of practice. "Health care facilities should have the flexibility to choose practice arrangements that best meet their needs without enduring a political battle that has nothing to do with patient safety and could limit access to care," Izlar says. "Unfortunately, the ACA doesn't address this issue."
Another federal policy that limits opportunities of CRNAs has to do with funding for clinical education, Izlar says. While Medicare pays hospitals extra money for training medical residents, no such funds are provided for advanced practice nurses to do clinical rotations. Here, the ACA offers a glimmer of hope, ushering in a $200 million federal pilot project to provide funding for graduate nurse education at five institutions around the country. "For hospitals right now, it's much more beneficial to train anesthesiologists because they get the graduate education funding," Izlar says. "While this has put all advanced practice nurses at a disadvantage, it has been a particular hardship for CRNAs."
In her essay, "The Tipping Point in Health Care: Using the Full Scope of Practice of Certified Registered Nurse Anesthetists as Advanced Practice Registered Nurses," Maribeth Leigh Massie, CRNA, PhD, MS '98, a program director for the University of New England Nurse Anesthesia Program, argues that models of care delivery need to change to achieve the high-quality, cost-effective anesthesia care envisioned by the ACA. Instead of the current vertical integration, with physicians positioned at the top, we need to look at organizing anesthesia services in a more horizontal, collaborative reporting structure, Massie says. "We currently have this arcane model of medical direction that even anesthesiologists have found unsustainable," she argues. "A collaborative team or CRNA-only model would improve access to care by using all providers at their highest level while decreasing the costly and duplicative requirements of the medical direction model."
In New York State, however, this model of care may not currently be possible. Laura Ardizzone '10 DNP, '04 MS, chief nurse anesthetist at Memorial Sloan Kettering Cancer Center in New York City, explores the roadblocks created by state laws in her essay, "Navigating the Uncertainty That Lies Ahead: Certified Registered Nurse Anesthetists and the Patient Protection and Affordable Care Act." In New York, for example, the state doesn't recognize advanced practice nursing licenses, making it impossible for CRNAs to receive payment from the state-administered Medicaid program. This barrier to practice at the state level is an unnecessary roadblock to providing care to patients newly insured under the ACA, Ardizzone argues.
"As more people gain coverage under ACA, there are going to be a lot more people needing surgery and needing anesthesia," Ardizzone says. "Instead of just saying we need to spend taxpayer dollars to educate another 6,000 medical residents in anesthesia, why can't we use the CRNAs we have already trained and start letting them practice to the fullest scope of their potential."
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