July 25, 2016

Introduction

Few are unfamiliar with the general state of veterans and healthcare in our country. According to statistics recently released by the VA, an average of 20 veterans died from suicide in 2014.¹ Further, there is a backlog of nearly 500,000 veterans waiting 30 days or longer to receive care at VA facilities across the U.S. This is higher than the numbers from one year ago when reports were released that showed veterans dying while waiting for care as a result of the backlog.² In an effort to combat these problems—seen, in part, as a result of a shortage of physicians—the VA issued a Proposed Rule, Advanced Practice Registered Nurses (APRN), aimed at allowing APRNs to practice within their full authority (Proposed Rule).

Proposed Rule

The VA’s goal in issuing the Proposed Rule is to “increase veteran access to needed VA health care…as well as decrease the amount of time veterans spend waiting for patient appointments.”³ The VA’s method in achieving this goal is to increase the number of healthcare providers available to treat veterans within its existing framework by allowing APRNs to practice to the full extent of their education, training, and certification without the clinical oversight of a physician. For purposes of the Proposed Rule, APRNs have been divided into four categories: certified nurse practitioners, certified registered nurse anesthetists (CRNAs), clinical nurse specialists, and certified nurse-midwives.⁴ Although many states have certain restrictions on what services an APRN can provide without physician supervision, the VA seeks to preempt state law in the VA hospital setting.⁵ Services rendered at non-VA hospitals would continue to be subject to State law restrictions on an APRN’s scope of practice.⁶

Anesthesia Impact

Under the Proposed Rule, CRNAs have the full practice authority to: (a) plan and initiate anesthetic techniques (general, regional, local) and sedation; (b) provide post-anesthesia evaluation and discharge; (c) order and evaluate diagnostic tests; (d) request consultations; (e) perform point-of-care testing; and (f) respond to emergency situations for airway management.⁷ Although the services enumerated in the Proposed Rule do not impact the current services rendered by CRNAs, the VA is continuing to evaluate whether CRNAs should be permitted full practice authority when providing anesthetics in VA hospitals.⁸

Not surprisingly, members of many physician organizations, including the American Medical Association and the American Society of Anesthesiologists (ASA) voiced strong opposition to the plan, saying it could make it more difficult to ensure the level of care needed for veterans. According to an ASA press release, “… the policy removes anesthesiologists from surgery and replaces them with nurses, lowering the standard of care and jeopardizing Veterans’ lives.”⁹

The ASA argues the rule abandons a proven model of care where anesthesiologists and nurse anesthetists work together as a team to provide Veterans with high quality and safe anesthesia.¹⁰ The model helps ensure patients have access to an anesthesiologist if an emergency or complication occurs.¹¹ Furthermore, the ASA emphasizes the training that anesthesiologists have undergone as compared to an APRN. The AMA also takes the same general position.

According to the ASA’s website, it has dedicated a number of resources to making its position known and enumerates its efforts below:

To date, ASA has engaged over 90 Members of the U.S. House of Representatives and U.S. Senate, prominent national Veteran organizations and other Veteran health stakeholders in raising concerns about the safety of eliminating physician involvement in Veterans’ anesthesia care. This unprecedented effort has led to VA’s decision to closely examine the appropriateness of the nurse-only model of anesthesia care and to formally seek public input into the decision.¹²

On the other hand, and as expected, the American Nurses Association (ANA) offered support for the proposal, saying it would allow the VA to more effectively meet the healthcare needs of the nation by removing barriers that prevent APRNs from providing a full range of services to veterans. The ANA takes the position that the Proposed Rule is not solely to address a physician shortage at the VA. It has been years in the making when the VA began making changes to the Nursing Handbook in 2009. The ANA states the proposal reflects those changes.

The President of the American Association of Nurse Anesthetists (AANA), Juan Quintana, DNP, MHS, CRNA, a nine-year veteran of the Air Force Reserve, stated, “[i]mproving the VHA’s ability to provide better, faster care to our veterans doesn’t necessarily require increasing budgets or staff … One solution has been there all along, and is as simple as removing bureaucratic barriers to APRNs’ ability to be credentialed and practice to the full extent of their education, training, and certification.”

The VA hopes, if implemented, the Proposed Rule would help to increase veteran access to needed healthcare, especially in medically underserved areas as well as decrease the amount of time veterans spend waiting for an appointment, something that has garnered much media attention in recent years. However, for physicians and nurses, the fate of the Proposed Rule could be foreshadowing actions the Federal or State governments could take in the future. After all, VA hospitals within each state would be prime case studies for regulators to evaluate when determining whether to expand APRNs’ scopes of practice. As such, it is of utmost importance for all members of the anesthesia industry to be aware of this issue and be prepared for additional rulemaking specifically affecting anesthesia to come down the pike.

With best wishes,

Tony Mira
President and CEO

1. http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2801
2. http://www.cnn.com/2015/10/20/politics/veterans-delays-va-hospitals/
3. Proposed Rule, Pp. 33155.
4. Proposed Rule, Pp. 33156 (38 CFR § 17.415(a)(1)).
5. Proposed Rule, Pp. 33155 (38 CFR § 17.415(e)).
6. According to CMS’s website, 17 states have chosen to opt-out of the physician supervision requirement of CRNAs. Those states are: California, Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, South Dakota, Wisconsin, Montana, Colorado and Kentucky.
7. Proposed Rule, Pp. 33157 (38 CFR § 17.415(c)(ii)).
8. Proposed Rule, Pp. 33159.
9. http://www.asahq.org/about-asa/newsroom/news-releases/2016/05/physician-anesthesiologists-oppose-va-policy
10. http://www.asahq.org/about-asa/newsroom/news-releases/2016/05/physician-anesthesiologists-oppose-va-policy
11. http://www.asahq.org/about-asa/newsroom/news-releases/2016/05/physician-anesthesiologists-oppose-va-policy
12. https://www.asahq.org/advocacy/fda-and-washington-alerts/washington-alerts/2016/05/federal-independent-nurse-practice-proposal-released-by-va
13. http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2793
14. http://www.rnaction.org/site/DocServer/ToolKit_for_States_VA_Proposed_Rule_Talking_Points.pdf page 2
15. http://www.aana.com/newsandjournal/News/Pages/052616-Military-Veterans-and-CRNAs-Applaud-VHA-Plan-to-Improve-Vets-Access-to-Timely-Quality-Healthcare.aspx
16. http://www.npr.org/sections/health-shots/2016/05/16/477814218/attempted-fix-for-va-health-delays-creates-new-bureaucracy