Letter to the Hon. Denis McDonough, Secretary of Veteran Affairs - Underwood Urges Veterans Health Administration to Permanently Expand Full Practice Authority to Certified Registered Nurse Anesthetists at Va Facilities
Dear Secretary McDonough:
I write to encourage the Veterans Health Administration (VHA) to permanently expand full practice authority within the scope of their license to Certified Registered Nurse Anesthetists (CRNAs) providing anesthesia services to patients with Department of Veterans Affairs (VA) health care benefits. Consistent with the Department of Veterans Affairs' December 14, 2016 final rule titled "Advanced Practice Registered Nurses" (81 FR 90198), I urge VA to make this rule applicable in every state.
CRNAs are Advanced Practice Registered Nurses (APRNs) who administer more than 49 million anesthetics to patients each year in the United States. CRNAs provide every aspect of the delivery of anesthesia services in addition to acute, chronic, and interventional pain management services. CRNAs have provided these services where they are most desperately needed: historically, CRNAs have been the predominant providers of anesthesia care in the smallest and most remote hospitals in the United States. CRNAs also tend to serve lower-income populations as compared to anesthesiologists.
The most comprehensive review of the effects of granting full practice authority to CRNAs, published in Health Affairs, found no evidence that removing oversight requirements for CRNAs resulted in increased inpatient deaths or complications. The high quality of care that CRNAs can be trusted to provide is reflected in our military, where TRICARE allows CRNAs to practice independent of physician referral and supervision.
The Department's 2016 rule granted full practice authority to all APRNs except CRNAs. However, the rule specifically stated that that the initial exclusion of CRNAs "did not stem from CRNAs' inability to practice to the full extent of their professional competence."
Instead, the rule stated that the exclusion of CRNAs stemmed "from VA's lack of access problems in the area of anesthesiology." In the midst of the COVID-19 pandemic, access problems have clearly emerged, as evidenced by the "Health Care Professional Practice in VA" directive that Dr. Richard Stone issued on April 21, 2020 (VHA Directive 1899) and by a regulatory shift from the Centers for Medicare and Medicaid Services (CMS) to waive supervisory requirements to "free up physicians from the supervisory requirement and expand the capacity of both CRNAs and physicians."
As the United States continues its response and recovery efforts related to COVID-19, it is imperative that we have as many providers practicing to the full extent of their education and training as possible to ensure the highest level of access to care for our veterans. The April 2020 VHA directive providing a temporary expansion of full practice authority was an important first step, but the need for anesthesia services from CRNAs will extend beyond the current public health emergency. Therefore, I encourage VA to revisit the 2016 rule and permanently grant full practice authority to CRNAs in VA facilities in every state. This change is critical to expanding access to important anesthesia services that our nation's veterans will need during COVID-19 and beyond.