Educational and Clinical Barriers for CRNAs

Certified registered nurse anesthetists (CRNAs) ensure access to anesthesia and pain management services, particularly in rural and underserved communities. A 2007 Government Accountability Office study revealed that CRNAs predominate where more Medicare patients reside (1). However, of the recognized advanced practice registered nursing (ARPN) specialties, CRNAs have historically experienced the most resistance from outside entities regarding their assigned dutues. Currently, there are quite a few educational and clinical barriers that exist for CRNAs attempting to expand their role in the healthcare system.

During the last decade, nurse anesthetists’ skills have been brought into question by physicians who have attempted to block efforts aimed at autonomous CRNA practice. In particular, physicians have pressured state governors from opting out of the federal Medicare Part A physician supervision requirement for facility reimbursement of CRNA services. Anesthesiologists have argued that CRNAs need anesthesiologist supervision, due to lack of sufficient (medical school) training (2). 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. In spite of this, 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 (2).

There are also a few challenges associated with the educational milieu of CRNAs. Nurse anesthesia educational programs in universities often share clinical education sites with physician anesthesia training programs in anesthesiologist-managed facilities. However, physician residents are often favored over CRNA students at these training sites. This is mostly due to the fact that hospitals receive significant financial compensation from Medicare for each physician resident they train, yet receive no federal funding for APRN student training (3). This creates an incentive for hospitals to accept physician trainees over CRNAs, as the former can generate significantly more income. Changing educational mandates are also a challenge facing CRNAs. In 2009, the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) mandated that all students admitted to CRNA programs after 2022 would be required to receive a practice doctorate upon graduation (2). 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. 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 (2). Additionally, attracting and retaining educators in the field of nurse anesthesia can be difficult, as nurses generally earn more in clinical practice than in academia (2).

Furthermore, the CRNA’s ability to provide chronic pain management services has been legislatively challenged by organized medicine in Iowa, California, Illinois, and Oklahoma. 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. Continued research aimed at outcomes data related to CRNA effectiveness and quality would be needed to potentially facilitate the reduction of such barriers to practice (2). Fair reimbursement for CRNA services poses another challenge for nurse anesthetists. For example, 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 (4).

In summary, the barriers to CRNA and APRN practice are complicated and involve many different financial, educational, and clinical factors. Advocating for CRNAs, and obtaining support from federal and state governments, insurers, healthcare professionals, and consumers may help to advance autonomous CRNA practice. Additionally, expanding the role of CRNAs and other APRNs could potentially decrease costs and expedite treatment by eliminating the need for physician sign-off.

References

1. Brassard, A. (2019). Removing Barriers to Advanced Practice Registered Nurse Care: Hospital Privileges.
2. Malina, D., Izlar, J. (2014). Education and practice barriers for Certified Registered Nurse Anesthetists. Online J Issues Nurs (19).
3. Nonnemaker, L. (2010).Graduate medical education and medicare: Understanding the issues. Insight on the Issues (42).
4. Center for Medicare and Medicaid Services, 66 Fed Reg 219. 42 CFR Part 416, 482, and 485, Hospital Conditions of Participation Anesthesia Services. November 13, 2001.