Center for the Future of Health Professions Feb. 2024 digest
Posted: February 14, 2024
Welcome to the February 2024 op-ed column of the Center for the Future of the Health Professions Digest! We are committed to delivering trustworthy information and research on the healthcare workforce, assisting policymakers and health system stakeholders to plan for a sustainable future. This month, we will review certified registered nurse anesthetists (CRNAs). CRNAs provide anesthesia services for patients across the lifespan at all acuity levels undergoing surgical and diagnostic procedures of varying complexity and have done so for more than 150 years. They provide much-needed healthcare services in this country.
We are pleased to introduce Michael J. Kremer, PhD, CRNA, CHSE, FNAP, FAAN, a professor and interim chair of the Adult Health and Gerontological Nursing Department in the Rush University College of Nursing. He practiced clinically as a CRNA for 35 years in tertiary medical centers in Seattle and Chicago, community hospitals, surgery centers, and office-based practices.
Dr. Kremer completed undergraduate degrees in psychology, nursing, and nurse anesthesia; a master of science degree in nursing leadership; a PhD in nursing science; and postdoctoral studies in psychoneuroimmunology. He has served as a didactic and clinical nurse anesthesia educator and a nurse anesthesia program director at Rush and Rosalind Franklin University. In addition, he was the Rush Center for Clinical Skills and Simulation co-director for 17 years.
Dr. Kremer has held elected and appointed local, state, and national positions. He has served as an on-site reviewer and board member for the Council on Accreditation of Nurse Anesthesia Educational Programs. Dr. Kremer is a peer evaluator for the Higher Learning Commission. He has provided poster and platform presentations at local, regional, national, and international conferences and has authored multiple journal articles and textbook chapters. Dr. Kremer is a fellow in the American Academy of Nursing, the National Academies of Practice, and the Institute of Medicine – Chicago. He is also a Certified Healthcare Simulation Educator (CHSE).
We invite you to share your thoughts on this month’s digest.
Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA
Professor and Director
The Center for the Future of the Health Professions
A.T. Still University
Certified registered nurse anesthetists: Past, present, and future
Certified registered nurse anesthetists (CRNAs) provide anesthesia services for patients across the lifespan at all acuity levels undergoing surgical and diagnostic procedures of varying complexity.
Nurse anesthetists in the United States have provided anesthesia care for over 150 years. Catherine Lawrence was a nurse who administered anesthesia in combat zones during the American Civil War. Agatha Hodgins, founder of the American Association of Nurse Anesthetists (AANA), pioneered techniques in trauma anesthesia care during World War I. Nurse anesthetists were the primary providers of anesthesia care to wounded soldiers on the front lines of these wars and subsequent armed conflicts.1,2 By historical and legal precedents, anesthesia is the practice of nursing provided by CRNAs and is the practice of medicine when provided by physicians.3
The first national certification examination for nurse anesthetists was administered in 1945. By 1952, AANA implemented an accreditation process for nurse anesthesia programs in the U.S. The CRNA credential was developed in 1956. Nurse anesthesia was the first nursing specialty to require continuing education in 1978.4 CRNAs have had direct reimbursement rights under Medicare Part B since 1986.2 In 2001, the Centers for Medicare and Medicaid Services (CMS) altered the federal physician supervision rule for nurse anesthetists, permitting state governors to opt out of this facility reimbursement requirement. Analysis of Medicare data found no evidence that opting out of the physician oversight requirement increased anesthesia morbidity or mortality.4 To date, 24 states and Guam have exercised this opt-out.5
The National Board for Certification and Recertification of Nurse Anesthetists (NBCRNA) reports there are more than 59,000 CRNAs in the U.S.6 AANA member survey data shows that 50,259 CRNAs are members of this organization.7 The gender mix of CRNAs is 47% male and 53% female. Most CRNAs are hospital employees (41%), work for anesthesia groups (25%), or are independent contractors(18%).
Alternatively, a few serve in the military or Veterans Administration (3%). CRNAs have full practice authority in every branch of the military. They are the primary anesthesia providers for deployed U.S. military personnel in all settings, including navy ships and aircraft evacuation teams worldwide. CRNAs are entrepreneurs who own or partner in anesthesia groups and provide anesthesia independently in office-based surgical settings.7
Most CRNAs (87%) are clinical practitioners. CRNAs also serve as clinical administrators (3.6%), business owners/partners (3.3%), nurse anesthesia program administrators (2.1%), and teaching faculty (2.3%).7 In 2023, 8,369 students were enrolled in 133 accredited nurse anesthesia programs, with an additional 15 programs in development.8
There are four CRNA/physician anesthesiologist anesthesia delivery models commonly used in the U.S.: CRNA-only, physician anesthesiologist supervision of CRNAs, physician anesthesiologist direction of CRNAs, and physician anesthesiologist-only. Despite the variety of anesthesia delivery models, CRNAs are not required by deferral or state laws, except in New Jersey, to be supervised, directed by, or even work with a physician anesthesiologist.5
Healthcare systems and facilities have addressed rising costs and flat or declining reimbursement for surgical and diagnostic services, resulting in increased demand for CRNAs, who are paid significantly less than anesthesiologists for many of the same services. In 2023, the mean compensation for CRNAs was $235,000, while the average anesthesiologist salary was $427,800. Since outcomes data are positive for CRNAs, this enhances their participation in emerging quality/value-based reimbursement mechanisms.10
The cost-effectiveness and quality of care provided by CRNAs bode well for the profession’s future. CRNAs provide anesthesia services in hospital operating rooms, labor and delivery suites, and numerous ancillary areas, including cardiac catheterization laboratories, endoscopy suites, and interventional radiology settings. CRNAs may be the sole anesthesia providers in rural and medically underserved areas and downrange military settings. Anesthesia in ambulatory surgery centers and office-based practices may be provided by a CRNA working collaboratively with a surgeon, dentist, or podiatrist.11
The U.S. Bureau of Labor Statistics projects 194,500 average annual openings for registered nurses between 2020 and 2030, with employment expected to grow by 9%. In 2020, the median age of RNs was 52 years, with more than 20% stating their intent to retire from nursing over the next five years.12 This nursing workforce shortage could decrease the supply of eligible applicants for nurse anesthesia programs.
A shortage of anesthesia providers is impacting hospitals, healthcare systems, and patients. An increasing disparity between the number of anesthesia providers and available practice opportunities contributes to this shortage. Other factors related to the attrition of current anesthesia providers include anticipated retirements and burnout. Currently, 31% of CRNAs and 56% of the 42,264 physician anesthesiologists in the U.S. are 55 or older. Almost 30% of currently practicing physician anesthesiologists plan to leave practice by 2033, resulting in a shortage of 12,500 physicians. The demand for qualified anesthesia providers will increase when CRNAs and physician anesthesiologists retire. Burnout is another factor that may contribute to retirements, with 47% of physician anesthesiologists and 56% of CRNAs reporting burnout. CRNA attrition has significant implications for rural counties, where CRNAs represent over 80% of anesthesia providers.13
CRNA employment is forecasted to grow by 11.8% between 2021 and 2031. Since surgical services comprise about 60% of a facility’s revenue, maintaining staffing for surgeons, anesthesia providers, and OR staff is critical. Some healthcare organizations utilize interim directors and locum tenens to fill key roles and supplement existing staff. AI-based technology has been deployed to improve OR utilization, reduce costs, and expand efficiencies. Providing a supportive and flexible work environment can be an effective retention strategy for anesthesia providers. Measures including flexible scheduling, professional development opportunities, and mentorship programs can help organizations surmount the anesthesia provider shortage.13
Based on current and projected demand, CRNAs will continue to be valued and highly recruited healthcare team members. In addition to the salary and autonomy associated with the CRNA role, job satisfaction is high: 95% of CRNAs report that they are satisfied or very satisfied with their career choice.7
References
- American Association of Nurse Anesthesiology, 2023. About us: available at: https://www.aana.com/about-us/who-we-are., accessed 1/21/2024
- Bankert M. 1989. Watchful care – A history of America’s nurse anesthetists. New York, NY: Continuum.
- Blumenreich G. 1990. Is the administration of anesthesia the practice of medicine? AANA J, 85(4): 261-269.
- Dulisse B,, Cromwell J. 2010. No harm found when nurse anesthetists work without supervision by physicians. Health Affairs, 29(8); 1469-1475.
- American Association of Nurse Anesthesiology. 2023. Fact sheet concerning state opt-outs and November 13, 2001 CMS rule. Rosemont, IL: AANA.
- National Board for Certification and Recertification of Nurse Anesthetists. 2023. Promoting patient safety by enhancing provider quality: About the NBCRNA. Available at: About Us | NBCRNA, accessed 1/21/2024.
- American Association of Nurse Anesthesiology. 2023 Member Survey Data. Rosemont, IL: AANA.
- Gerbasi F. 2023. Program Directors’ Update. Issue 94: 1.
- American Association of Nurse Anesthesiology, 2023. Quality reimbursement. Available at: https://www.aana.com/advocacy/quality-reimbursement, accessed 1/21/2024.
- Merritt Hawkins. 2019. CRNA supply, demand and recruiting trends. Available at: www.merritthawkins.com/uploadedFiles?Merritt_Hawkins_CRNA_Whitepaper_2019.pdf, accessed 1/21/2024.
- Liao C, Quraishi J, Jordan L. Geographical imbalance of anesthesia providers and its impact on the uninsured and vulnerable populations. Nursing Economics. 105;33(5): 263-270.
- American Nurses Association. Nurses in the workforce. 2023. Available at: https://www.nursingworld.org/practice-policy/workforce/, accessed 1/22/2024.
- Medicus Healthcare Solutions. The anesthesia provider shortage. 2023. Available at: https://medicushcs.com/resources/the-anesthesia-provider-shortage