Anesthesiologist Assistants as Physician Extenders: An Option Whose Time Has Come?
SUMMARY
Anesthesiologist assistants (AAs) are highly trained professionals who work solely in the anesthesia care team environment under the supervision of a physician anesthesiologist. With the looming anesthesiologist shortage due to an aging population and increased demand for surgical services, the addition of AAs to the care team might be worthy of consideration in some practice situations. AAs are currently licensed to practice in a handful of states. The following overview is intended as an update on this emerging opportunity. Please note that reimbursement policies vary by locality and payment for AA services may not be the same as for CRNAs. ABC clients interested in understanding how the employment of AAs might impact their practice are encouraged to contact their account managers for more a detailed assessment.
The use of physician extenders has become commonplace in medicine and anesthesia is no exception. More than 75 percent of all anesthetics are administered by CRNAs. Do AAs offer a viable alternative? Our perception is that most anesthesiologists still know relatively little about this profession, which is understandable given the current state of AA involvement across the country. Only anesthesiologists in Ohio and Georgia have much experience working with AAs.
We thought it would be useful to provide some background on this clinical option and put the key issues in perspective.
Who are AAs and what do they do?
According to the American Academy of Anesthesiologist Assistants (AAAA), AAs are highly skilled health professionals who work exclusively in an anesthesia care team environment under the direction of licensed anesthesiologists to implement anesthesia care plans. Currently, there are approximately 1,700 certified AAs in the United States.
To become certified, AAs must have a premedical background and a bachelor's degree, and must complete a comprehensive graduate program and receive extensive training in the delivery and maintenance of anesthesia care and advanced patient monitoring techniques. AAs and CRNAs are both defined as "non-physician anesthetists" and have identical standing within the Centers for Medicare and Medicaid Services' (CMS's) section of the Code of Federal Regulations, but their educational requirements differ. (A fact sheet with additional information is available here.) Commercial payers also make no distinction between the two types of anesthetists with regard to payments for services provided under an anesthesiologist's medical direction.
AA education programs must be affiliated with a university that has a medical school and academic anesthesiology faculty. These programs must have at least one board certified anesthesiologist as a director. Training includes classroom time as well as a minimum of 2,000 hours of hands-on clinical experience. AAs who pass the examination for certification administer anesthesia under the supervision of a physician anesthesiologist.
There are currently 12 AA education programs in the United States, all of which offer master's degrees. The vast majority (approximately 97 percent) of currently practicing AAs have a master's degree. According to the AAAA, the responsibilities of an AA mirror those of CRNAs and include all the standard aspects of anesthesia care. The key difference is that AAs cannot practice independently. The scope of practice for an AA may vary depending on local practice, the medically directing anesthesiologist, the hospital's clinical protocol, the state board of medicine and state regulations.
Anesthesiologists may delegate additional responsibilities to an AA, based on their qualifications and demonstrated skills, such as responding to life-threatening situations with the cardiopulmonary resuscitation team.
An AA may not practice outside of anesthesia or without anesthesiologist supervision. In addition, an AA may not practice as a physician's assistant (PA) unless they have also completed a PA education program and passed the certification exam.
Similarly, a PA may not practice as an AA unless they have completed an accredited program and passed the National Commission for the Certification of Anesthesiologist Assistants (NCCAA) exam. A dual-credentialed PA must practice as an anesthetist only as a physician extender and cannot provide anesthesia care under the direction of a physician of any other specialty other than an anesthesiologist.
Currently, AAs are able to work in 15 jurisdictions and Guam by licensure and in two states (Michigan and Texas) by physician delegation (Click here for a map). AAs are authorized to work at all Veterans Affairs hospitals using the TRICARE insurance program. Licensure for AAs is achieved through state law or by approval of the individual state board of medicine. The ability to practice by physician delegation is achieved through the state board of medicine or through statutes included in the state's medical practice act. Delegating authority ultimately holds the physician responsible for the patient in all states.
High Demand—With Roadblocks
Certified AAs are currently in high demand, especially in states with licensure, according to Jeremy Betts, director of state affairs for the AAAA, who responded by email to a request for information. "In states where AAs have been licensed for more than five years, AAs and other anesthetists work nearly interchangeably within the physician-led anesthesia care team to meet the needs of growing anesthesia practices," he says.
This demand is not surprising, considering the findings of a 2010 Rand Corporation analysis of anesthesia workforce data that predicts a significant shortage of anesthesiologists by 2020 as the result of the rapid aging of the baby boom population. According to a 2012 article in ASA Monitor by Jay R. Mesrobian, MD, and Howard Odom, MD, "demand for advanced practice providers, including both AAs and CRNAs, also is increasing. CRNA training programs by themselves, however, cannot fill this need . . . It makes sense for a practice to consider another type of anesthesia provider, AAs, in order to ensure an adequate worker supply in the coming years."
Many anesthesiologists believe the specialty would benefit from incorporating AAs into a care team model by giving practices the ability "to clearly define your role as anesthesiologists, set expectations related to your future practice, and strengthen the relationship with your organization by contributing to a mutually successful enterprise," Drs. Mesrobian and Odom state.
The American Society of Anesthesiologists (ASA) supports AA practice authorization in all states and supports the inclusion of AAs in the anesthesia care team (click here for positions and policy, including the ASA Statement on the Anesthesia Care Team).
The fact that AA licensure requires state-by-state approval continues to provide a barrier for anesthesia groups interested in adding AAs to their teams, according to Mr. Betts. "The largest impediment to AA practice is the number of states that do not allow for more than one type of anesthetist," says Mr. Betts, noting that state anesthesiology societies and AAAA are working to address this issue. The Illinois Society of Anesthesiologists, for example, has introduced a bill (HB2975) that would provide for AA licensure.
In an article published by the California Society of Anesthesiologists (a state that does not have AA licensure), anesthesiologist Linda Hertzberg, MD, observes that "in hindsight, it might have been easier if the AA profession had been launched as a subspecialty under the broader umbrella of PAs, who already can be licensed in all 50 states. Physician anesthesiologists specialize in anesthesia, but practice in every state under a general license as physicians. Since AAs are defined as a separate profession, however, each individual state must approve AA licensure (or another means of authority) in order for them to practice."
Are AAs as physician extenders in anesthesia practices the wave of the future? That remains to be seen. However, as anesthesia groups grapple with competition, regulatory compliance and the many other demands of contemporary practice, AAs are an option worth knowing more about.
For more information, see Integrating Anesthesiologist Assistants into Your Practice: What You Need to Know, available on the ASA website.
For those who may be interested in understanding the potential of AAs in their practice, ABC will be happy to prepare a detailed analysis. Clients simply need to reach out to their account manager.
With best wishes,
Tony Mira
President and CEO