October 12, 2017
The Hon. David Shulkin
Office of the Secretary of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Re: Full Practice Authority for CRNAs in the Veterans Health Administration
Dear Secretary Shulkin,
The American Association of Nurse Anesthetists (AANA) is appalled at the recent story1 highlighting the lack of access to anesthesia services at Veterans Health Administration (VHA) facilities and the ensuing delays for critical surgeries for our veterans. The VHA was specifically warned about staffing issues in the Independent Assessment of the VHA, which reported that current VHA workforce capacity may not be sufficient to provide care to veterans.2 Despite clear evidence that the VHA workforce was lacking, and despite the fact that the U.S. Department of Veterans Affairs was given a solution in the form of offering full practice authority to Certified Registered Nurse Anesthetists (CRNAs), the department blatantly ignored both when it came to its final rule on December 14, 2016. In choosing to exclude CRNAs from the other forms of Advanced Practice Registered Nurses (APRNs) while granting full practice authority, the rule stated, “VA’s position to not include the CRNAs in this final rule does not stem from the CRNAs’ inability to practice to the full extent of their professional competence, but rather from VA’s lack of access problems in the area of anesthesiology.”3 Given the many delays and cancelations of procedures specifically due to a lack of anesthesia services, it is clear the VHA was incorrect in its assessment of the need to grant CRNAs full practice authority in the VHA system, choosing to place politics above the needs of our veterans.
The AANA is the professional association for Certified Registered Nurse Anesthetists and student registered nurse anesthetists (SRNAs). AANA membership includes more than 50,000 CRNAs and SRNAs, representing over 90 percent of the nurse anesthetists in the United States. CRNAs are advanced practice registered nurses (APRNs) who personally administer approximately 43 million anesthetics to patients each year in the United States. Nurse anesthetists have provided anesthesia in the United States for 150 years, and high-quality, cost-effective CRNA services are in high demand.
The story by KDVR news in Denver, a facility that has reportedly been operating with one of the most inefficient anesthesia delivery models with a 1:2 supervision ratio, demonstrates how VHA’s blatant disregard for the recommendations of both the Commission on Care’s Final Report4 and the VHA Independent Assessment5, both of which advised providing full practice authority to CRNAs as way to improve access to quality care in the VHA system. Additionally, in their final rule, the VHA stated of their decision to exclude CRNAs, “comment is requested on whether there are access issues or other unconsidered circumstances that might warrant their inclusion in a future rulemaking.” It is clear that access issue exists to warrant revisiting this prejudicial and detrimental decision. We continue to stand by the call for granting CRNAs full practice authority with renewed urgency given the unacceptable situation our veterans face.
Concerns over anesthesia delays in VHA facilities stem from the underutilization of CRNAs who are not allowed to practice to the full scope of their education, experience, and licensure, as well as anesthesiologists who spend more time supervising CRNAs than actually providing hands-on patient care, even though the VA does not require CRNAs to be supervised by anesthesiologists or by any other physicians. Additionally, no state or federal laws require CRNAs to be supervised by anesthesiologists. CRNA supervision leads to increased costs and reduced access to timely care, but does not lead to better healthcare outcomes as confirmed by scientific research data time and time again. Observations within the VHA find CRNAs are commonly supervised by anesthesiologists at 1:1 and 1:2 ratios not generally found in the commercial healthcare delivery marketplace, and which do not correlate with improved outcomes.6
We believe that our veterans deserve better, and that it is well past time to follow the litany of recommendations to grant CRNAs full practice authority in the VHA. This incident is simply the latest fallout from an unwarranted decision that needs to be revisited with all due speed. Should you have any questions regarding these matters, please feel free to contact the AANA Senior Director of Federal Government Affairs, Ralph Kohl, at 202.484.8400, firstname.lastname@example.org.
Bruce A. Weiner, DNP, MSNA, CRNA
1 Rob Low, “VA Surgeries postponed because there aren’t enough anesthesiologists” Fox31 Denver. October 11, 2017. http://kdvr.com/2017/10/11/va-surgeries-postponed-because-there-arent-enough-anesthesiologists/
2 RAND Health, “Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans” 2015. https://www.rand.org/content/dam/rand/pubs/research_reports/RR1100/RR1165z2/RAND_RR1165z2.pdf
4 Commission on Care, “Final Report of the Commission on Care” June 30, 2016 https://s3.amazonaws.com/sitesusa/wp-content/uploads/sites/912/2016/07/Commission-on-Care_Final-Report_063016_FOR-WEB.pdf
5 RAND Health, “Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans” 2015 https://www.rand.org/content/dam/rand/pubs/research_reports/RR1100/RR1165z2/RAND_RR1165z2.pdf
6 Dulisse, op cit., http://content.healthaffairs.org/content/29/8/1469.full.pdf and Negrusa op cit., http://journals.lww.com/lww-medicalcare/Abstract/2016/10000/Scope_of_Practice_Laws_and_Anesthesia.4.aspx