JDSUPRA.COM
The California Department of Public Health’s (CDPH) September 6, 2024, All Facilities Letter (AFL) reaffirms the independent practice authority of Certified Registered Nurse Anesthetists (CRNAs). Despite this reaffirmation, misinterpretations of nurse anesthesiology scope of practice continue to disrupt anesthesia services in general acute care hospitals throughout California.
JDSUPRA.COM
The California Department of Public Health’s (CDPH) September 6, 2024, All Facilities Letter (AFL) reaffirms the independent practice authority of Certified Registered Nurse Anesthetists (CRNAs). Despite this reaffirmation, misinterpretations of nurse anesthesiology scope of practice continue to disrupt anesthesia services in general acute care hospitals throughout California.
(December 6, 2024)—Assemblymember Heath Flora (R-Ripon) today issued the following statement in response to revised guidance by the Centers for Medicare & Medicaid Services (CMS) for surveyors and health care providers regarding immediate jeopardy:
“On behalf of my constituents, I commend CMS’ decision to revise their immediate jeopardy (IJ) guidelines. By introducing more precise and evidence-based criteria, health care facilities in California can address safety concerns without undue overreach. The revisions promote fairness and accountability in regulatory oversight, and should help reduce the risk of arbitrary enforcement that can destabilize health care facilities and jeopardize access to care.
(December 6, 2024)—Assemblymember Heath Flora (R-Ripon) today issued the following statement in response to revised guidance by the Centers for Medicare & Medicaid Services (CMS) for surveyors and health care providers regarding immediate jeopardy:
“On behalf of my constituents, I commend CMS’ decision to revise their immediate jeopardy (IJ) guidelines. By introducing more precise and evidence-based criteria, health care facilities in California can address safety concerns without undue overreach. The revisions promote fairness and accountability in regulatory oversight, and should help reduce the risk of arbitrary enforcement that can destabilize health care facilities and jeopardize access to care.
CAPITOLWEEKLY.NET
OPINION – Certified Registered Nurse Anesthetists (CRNAs) play an indispensable role in California’s health care system, particularly for underserved and rural communities where anesthesia access is critical, yet limited. For decades, California CRNAs have independently provided safe, cost-effective, and patient-centered anesthesia care—a policy reinforced by state statute and upheld by court rulings and regulatory guidance.
California’s independent, collaborative anesthesia model allows physician anesthesiologists and CRNAs to function in an identical capacity in the surgery suite.
CAPITOLWEEKLY.NET
OPINION – Certified Registered Nurse Anesthetists (CRNAs) play an indispensable role in California’s health care system, particularly for underserved and rural communities where anesthesia access is critical, yet limited. For decades, California CRNAs have independently provided safe, cost-effective, and patient-centered anesthesia care—a policy reinforced by state statute and upheld by court rulings and regulatory guidance.
California’s independent, collaborative anesthesia model allows physician anesthesiologists and CRNAs to function in an identical capacity in the surgery suite.
(SACRAMENTO, CA) – Recent surveys overseen by the California Department of Public Health (CDPH) have prompted significant concerns from Certified Registered Nurse Anesthetists (CRNAs), legislators, and health care advocates across the state. Reports indicate that a surveyor contracted by CDPH misrepresented state and federal laws regarding CRNA practice, causing significant disruptions in anesthesia services, especially in underserved regions.
“The CDPH’s lack of oversight of their surveyors reflects a troubling disregard for established CRNA practices and patient care standards in California. It is critical for the Department to address these biased surveys and prevent further harm to the public,” said Sandra Bordi, DNP, CRNA, FAANA, President, California Association of Nurse Anesthesiology (CANA).
The improper survey activities in question pressured hospitals to reduce scope of CRNA practice and, in the case of one hospital, led to the unnecessary cancellation, delay, and/or transfer of more than 1,000 surgeries, majority of which affected Medi-Cal and Medicare beneficiaries. While the California Board of Registered Nursing (BRN) is the only state agency with governance over CRNA scope of practice, the Centers for Medicare and Medicaid Services (CMS), California Health and Human Services Agency (CalHHS), and CDPH have failed to adequately respond to requests for clarification and have ignored repeated requests for an investigation into the survey process.
“Documents received from a Public Records Act (PRA) request of the CDPH made clear that CRNAs were terminated or replaced by physician anesthesiologists without warning or opportunity to be heard at Stanislaus Surgical Hospital. Based on these documents, CRNAs had actually been absent from the hospital for approximately six months when the final inspection report in July 2024 resulted in the hospital’s termination of Medicare enrollment. It’s therefore incorrect to state that the hospital closed as a result of the care provided by CRNAs,” said Katherine A. Bowles, Director, Fennemore.
In California, CRNAs have been allowed to practice independently, without physician supervision, since the 1980s, a policy reinforced by the California Court of Appeal in 2012 and supported by the Nursing Practice Act and Business and Professions Code 2725. Despite these laws and regulations, including a September 6, 2024, All Facilities Letter, hospitals and facilities continue to remain confused due to CDPH’s apparent regulatory capture by physician anesthesiologists, as well as a lack of urgency by California government agencies to correct the narrative.
“After reviewing documents received from the PRA request, we, unfortunately, are confident that the CDPH surveys were not only misinformed but also resulted in significant and unnecessary disruptions for health care facilities and their patients. California statute, and supporting regulations, clearly support CRNAs’ independent practice – actions contradicting these facts are detrimental to anesthesia care in the state,” concluded Bordi.
The current situation in California highlights a broader effort by special interests to target and discredit CRNAs and other advanced practice providers. CDPH’s actions seemingly align with a campaign to revert California to a physician supervision model, which threatens to reduce the number of qualified providers and puts even more strain on the state’s severe health care workforce shortage.
CRNAs play a crucial role in ensuring affordable health care across California, especially in underserved and rural areas. It is imperative that CMS, CalHHS, CDPH, and the BRN promptly address these issues to prevent further disruptions and to maintain the strength and accessibility of California’s health care system. Immediate corrective action is necessary to support CRNAs in continuing to deliver essential services and to uphold the integrity of our health care infrastructure.
About CANA
The California Association of Nurse Anesthesiology (CANA) represents CRNAs across the state. Since 1931, CANA has provided leadership, advocacy, and education to advance patient safety and support the nurse anesthesia profession. Learn more at www.canainc.org.
(SACRAMENTO, CA) – Recent surveys overseen by the California Department of Public Health (CDPH) have prompted significant concerns from Certified Registered Nurse Anesthetists (CRNAs), legislators, and health care advocates across the state. Reports indicate that a surveyor contracted by CDPH misrepresented state and federal laws regarding CRNA practice, causing significant disruptions in anesthesia services, especially in underserved regions.
“The CDPH’s lack of oversight of their surveyors reflects a troubling disregard for established CRNA practices and patient care standards in California. It is critical for the Department to address these biased surveys and prevent further harm to the public,” said Sandra Bordi, DNP, CRNA, FAANA, President, California Association of Nurse Anesthesiology (CANA).
The improper survey activities in question pressured hospitals to reduce scope of CRNA practice and, in the case of one hospital, led to the unnecessary cancellation, delay, and/or transfer of more than 1,000 surgeries, majority of which affected Medi-Cal and Medicare beneficiaries. While the California Board of Registered Nursing (BRN) is the only state agency with governance over CRNA scope of practice, the Centers for Medicare and Medicaid Services (CMS), California Health and Human Services Agency (CalHHS), and CDPH have failed to adequately respond to requests for clarification and have ignored repeated requests for an investigation into the survey process.
“Documents received from a Public Records Act (PRA) request of the CDPH made clear that CRNAs were terminated or replaced by physician anesthesiologists without warning or opportunity to be heard at Stanislaus Surgical Hospital. Based on these documents, CRNAs had actually been absent from the hospital for approximately six months when the final inspection report in July 2024 resulted in the hospital’s termination of Medicare enrollment. It’s therefore incorrect to state that the hospital closed as a result of the care provided by CRNAs,” said Katherine A. Bowles, Director, Fennemore.
In California, CRNAs have been allowed to practice independently, without physician supervision, since the 1980s, a policy reinforced by the California Court of Appeal in 2012 and supported by the Nursing Practice Act and Business and Professions Code 2725. Despite these laws and regulations, including a September 6, 2024, All Facilities Letter, hospitals and facilities continue to remain confused due to CDPH’s apparent regulatory capture by physician anesthesiologists, as well as a lack of urgency by California government agencies to correct the narrative.
“After reviewing documents received from the PRA request, we, unfortunately, are confident that the CDPH surveys were not only misinformed but also resulted in significant and unnecessary disruptions for health care facilities and their patients. California statute, and supporting regulations, clearly support CRNAs’ independent practice – actions contradicting these facts are detrimental to anesthesia care in the state,” concluded Bordi.
The current situation in California highlights a broader effort by special interests to target and discredit CRNAs and other advanced practice providers. CDPH’s actions seemingly align with a campaign to revert California to a physician supervision model, which threatens to reduce the number of qualified providers and puts even more strain on the state’s severe health care workforce shortage.
CRNAs play a crucial role in ensuring affordable health care across California, especially in underserved and rural areas. It is imperative that CMS, CalHHS, CDPH, and the BRN promptly address these issues to prevent further disruptions and to maintain the strength and accessibility of California’s health care system. Immediate corrective action is necessary to support CRNAs in continuing to deliver essential services and to uphold the integrity of our health care infrastructure.
About CANA
The California Association of Nurse Anesthesiology (CANA) represents CRNAs across the state. Since 1931, CANA has provided leadership, advocacy, and education to advance patient safety and support the nurse anesthesia profession. Learn more at www.canainc.org.
(Sacramento, CA)—California Association of Nurse Anesthesiology (CANA) President Sandra Bordi, DNP, CRNA, FAANA today issued the following statement regarding CRNAs’ independent practice authority in California:
“The California Association of Nurse Anesthesiology commends the California Department of Public Health (CDPH) for maintaining the precedent set forth by California Society of Anesthesiologists v. Superior Court and Business & Professions Code Section 2725 in their All Facilities Letter released on September 6, 2024.
“The AFL clarifies, among other matters, that CRNAs do not require physician supervision in California and that the Nursing Practice Act gives CRNAs legal authority to provide all direct and indirect patient services related to anesthesia care.
“Unfortunately, despite the AFL’s clarifications of existing state and federal law and regulations, false statements about CRNAs’ scope continue to decimate care in underserved regions of the state. Therefore, we are immediately calling on the California Board of Registered Nursing and the CDPH to better protect the public by providing clear guidance to hospitals about CRNAs’ independent authority. This guidance must include the fact that once a provider schedules a treatment regimen that includes anesthesia, both physician anesthesiologists and CRNAs are allowed to independently administer anesthesia care and services in the same way, as well as the fact that the 2012 court decision makes it clear that an ‘order’ does not imply ‘supervision’ or ‘direction.’
“Of note, anesthesia services are not limited to medication administration alone. These services are delivered during the perianesthesia time period, which includes pre-operative, intra-operative, and post-operative care. Anesthesia also encompasses services performed outside of the perioperative setting of an acute care facility, including, but not limited to, offices, clinics, and outpatient surgery settings. An order or directive entered on the chart or medical record of a patient registered in the hospital is authorization for the CRNA to select the type of anesthesia for the patient, to abort or modify the type of anesthesia for the patient during the course of care, and to select and administer medications related to the anesthesia services provided.
“For decades, CRNAs have routinely and regularly provided safe, effective, and cost-efficient anesthesia care in California. CANA and our legislative champions are committed to protecting patient access to timely and high-quality anesthesia services, whether the services are led by a CRNA or in collaboration with a physician anesthesiologist. We request the BRN and CDPH immediately follow suit by providing clear guidance regarding CRNAs’ independent authority in California.”
About California Association of Nurse Anesthesiology (CANA)
CANA is the definitive source of leadership, advocacy, and education for certified registered nurse anesthetists (CRNAs) in California. Since 1931, CANA has worked to advance patient safety, foster access to the highest quality anesthesia, and support the nurse anesthesia profession in California. Learn more by visiting www.canainc.org.
(Sacramento, CA)—California Association of Nurse Anesthesiology (CANA) President Sandra Bordi, DNP, CRNA, FAANA today issued the following statement regarding CRNAs’ independent practice authority in California:
“The California Association of Nurse Anesthesiology commends the California Department of Public Health (CDPH) for maintaining the precedent set forth by California Society of Anesthesiologists v. Superior Court and Business & Professions Code Section 2725 in their All Facilities Letter released on September 6, 2024.
“The AFL clarifies, among other matters, that CRNAs do not require physician supervision in California and that the Nursing Practice Act gives CRNAs legal authority to provide all direct and indirect patient services related to anesthesia care.
“Unfortunately, despite the AFL’s clarifications of existing state and federal law and regulations, false statements about CRNAs’ scope continue to decimate care in underserved regions of the state. Therefore, we are immediately calling on the California Board of Registered Nursing and the CDPH to better protect the public by providing clear guidance to hospitals about CRNAs’ independent authority. This guidance must include the fact that once a provider schedules a treatment regimen that includes anesthesia, both physician anesthesiologists and CRNAs are allowed to independently administer anesthesia care and services in the same way, as well as the fact that the 2012 court decision makes it clear that an ‘order’ does not imply ‘supervision’ or ‘direction.’
“Of note, anesthesia services are not limited to medication administration alone. These services are delivered during the perianesthesia time period, which includes pre-operative, intra-operative, and post-operative care. Anesthesia also encompasses services performed outside of the perioperative setting of an acute care facility, including, but not limited to, offices, clinics, and outpatient surgery settings. An order or directive entered on the chart or medical record of a patient registered in the hospital is authorization for the CRNA to select the type of anesthesia for the patient, to abort or modify the type of anesthesia for the patient during the course of care, and to select and administer medications related to the anesthesia services provided.
“For decades, CRNAs have routinely and regularly provided safe, effective, and cost-efficient anesthesia care in California. CANA and our legislative champions are committed to protecting patient access to timely and high-quality anesthesia services, whether the services are led by a CRNA or in collaboration with a physician anesthesiologist. We request the BRN and CDPH immediately follow suit by providing clear guidance regarding CRNAs’ independent authority in California.”
About California Association of Nurse Anesthesiology (CANA)
CANA is the definitive source of leadership, advocacy, and education for certified registered nurse anesthetists (CRNAs) in California. Since 1931, CANA has worked to advance patient safety, foster access to the highest quality anesthesia, and support the nurse anesthesia profession in California. Learn more by visiting www.canainc.org.
The shortage of anesthesia providers has plagued healthcare across the country, driven by ongoing issues on the supply and demand ends of the spectrum.
As a result, many healthcare facilities — particularly in rural communities — have turned to clinical staffing models that rely more heavily on certified nurse anesthetists for their anesthesia coverage.
However, Anthem Blue Cross Blue Shield will reduce QZ services performed by CRNAs to 85% of the physician fee schedule starting Nov. 1.
This sparked criticism from the American Association of Nurse Anesthesiology, which specifically mentioned the effect of this new policy on rural communities.
The shortage of anesthesia providers has plagued healthcare across the country, driven by ongoing issues on the supply and demand ends of the spectrum.
As a result, many healthcare facilities — particularly in rural communities — have turned to clinical staffing models that rely more heavily on certified nurse anesthetists for their anesthesia coverage.
However, Anthem Blue Cross Blue Shield will reduce QZ services performed by CRNAs to 85% of the physician fee schedule starting Nov. 1.
This sparked criticism from the American Association of Nurse Anesthesiology, which specifically mentioned the effect of this new policy on rural communities.
California state law has allowed certified registered nurse anesthetists to practice independently since the 1980s. In 2009, then-Gov. Arnold Schwarzenegger codified their ability to bill Medi-Cal as licensed independent providers to ensure all Californians had access to high-quality anesthesia care no matter a patient’s zip code.
California state law has allowed certified registered nurse anesthetists to practice independently since the 1980s. In 2009, then-Gov. Arnold Schwarzenegger codified their ability to bill Medi-Cal as licensed independent providers to ensure all Californians had access to high-quality anesthesia care no matter a patient’s zip code.
CANA has issued this action alert to legislators about protecting access to quality anesthesia care for all Californians and to share accurate information about CRNA qualifications, education, and practice in our state.