Lawmakers in Tennessee recently revived a bill that would allow certified anesthesiologist assistants to practice in the state in an effort to address the ongoing anesthesia provider shortage.
The bill would allow CAAs to practice in the state, where they currently need additional state approval. There are currently 21 states that allow CAAs to practice without state approval and at a similar level of independence to CRNAs, but all CAAs must still practice under the direction of a physician.
The bill has brought Tennessee into the center of the conversation around strategies for addressing the shortage and how to best regulate anesthesia care team structures to expand care coverage while maintaining patient safety and saving healthcare costs.
The factors behind Tennessee's anesthesia shortage
"Many factors play into this demand, such as an aging patient population, growth in the number of non-surgical procedures requiring anesthesia, an increase in the number of outpatient surgery centers and a decrease in post-COVID medical providers," Kelli Ray, a certified anesthesiologist assistant and president of the Tennessee Academy of Anesthesiologist Assistants, told Becker's.
She also said that many of the open positions for certified registered nurse anesthetists, who are also a crucial part of anesthesia care teams, are often filled by traveling CRNA providers from out of state, which can be expensive.
The Tennessee Society of Anesthesiologists echoed these sentiments, and said that every metro area in the state is facing a shortage of anesthesia professionals, with CRNA vacancy rates in some practices exceeding 20%.
Cuts to reimbursements for anesthesia have also put a strain on the supply side of the provider equation in Tennessee and across the country. CMS anesthesia reimbursements have also declined 8.2% from 2019 to 2024 — from $22.27 per unit to $20.44, according to a May blog post by VMG Health.
Anesthesiologist, anesthesiologist assistant and CRNA organizations in the state all pointed to the shortage of residency slots in anesthesia as being a primary factor in the shortage. In 2024, 1,695 anesthesiology residency positions were available nationwide, and around 44% of medical students seeking an anesthesiology residency did not match.
Proposed strategies and solutions
"Many steps could help to alleviate this shortage of anesthesia professionals in Tennessee, including increasing the number of anesthesiologist residency training positions, expansion of rural pass-through to include anesthesiologists, and increasing the number of student nurse anesthetist positions in Tennessee nursing schools with a focus on retaining those students to work as CRNAs in our state after graduation," said Ronald Harter, MD, president of the American Society of Anesthesiologists, in a statement shared with Becker's.
ASA and TSA also expressed support for a Tennessee bill that would provide licensure to CAAs in the state's last legislative session in statements shared with Becker's.
Others have expressed concern that because CAAs must still practice under an anesthesiologist, the bill would not do enough to adequately expand coverage in rural areas.
In a report published by WKRN, Chris Hulin, DNP, CRNA, the president of the Middle Tennessee School of Anesthesia, which trains CRNAs, said that CAA use would "lock in" an expensive care model.
"They can do no patient care without a physician anesthesiologist being present in a ratio of 1 to 4, so every time you have a patient encounter, you're paying two people,” Mr. Hulin said.
But others argue that allowing state certification of CAAs would still make a significant difference in the availability of anesthesia providers, as anesthesia is in high demand for an increasing number of procedures, not just surgeries.
"There are 3,800 certified anesthesiologist assistants currently practicing in 20 states across the country. Many of these CAAs are originally from Tennessee, have family in Tennessee, or would love to live and work in Tennessee," said Ms. Ray of TAAA. "We are highly skilled anesthesia providers with the desire to care for patients in Tennessee, just like we do in the nearby states of Georgia, Florida, Alabama, North Carolina and South Carolina."
"We are asking for Tennessee lawmakers to give hospitals the option to work with both types of advanced practice anesthesia providers as well, just as they do for other medical specialities," she continued. She also supports adding an accredited CAA school in Tennessee to immediately address the shortage.