Discussions surrounding the nation's ongoing anesthesia provider shortage have centered on California in recent months, particularly after the state's Department of Health sent a letter in September to state hospitals clarifying guidance surrounding the use of certified registered nurse anesthetists in acute care.
The letter is just one event in a series of regulatory developments in the state as healthcare officials attempt to address the factors behind California's anesthesia shortage.
As the shortage continues, the history and current conversation surrounding anesthesia care in California may offer insights for other states on a similar trajectory.
Reasons behind the shortage
While the situation in California is driven by many of the same factors driving the anesthesia shortage in other states — including a sharp decline in reimbursement rates and the inadequate number of anesthesia residency slots –– California has its own specific challenges, too.
"California is the most populous state with over 40 million residents, and the demand for procedures requiring anesthesia has been increasing dramatically," Antonio Hernandez Conte, MD, former president of the California Society of Anesthesiologists, told Becker's. "An aging population everywhere, but specifically in California, represents a massive demographic shift."
ASA President Ronald Harter, MD, also told Becker's that the 51,492 active anesthesiologists and thousands more CRNAs and anesthesiologist assistants in the U.S. workforce is still being outpaced by the uptick in non-operating room anesthesia sites.
"The rise in NORA sites is a reflection of improved technology resulting in more complex procedures that allow for treatment of patients with higher acuity and more complex medical conditions," Dr. Harter said. "This combination has resulted in the need for anesthesia care rather than moderate sedation for these patients and procedures."
Additionally, of those 51,492 active anesthesiologists, 56.9% are 55 or older, putting further pressure on need for increased residency slots in order to meet or outpace the current rate of physicians exiting the industry.
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. While these declines are not specific to California, their impacts are.
"California has a high cost of living, which means a large portion of the anesthesiology residents and fellows trained in California are choosing to leave the state," Dr. Hernandez Conte said. "They are graduating with high levels of student loan debt, high cost of living and lower compensation options in California, and many are choosing to move to a lower-cost state."
The supply of CRNAs faces some similar issues, as nursing programs deal with serious budget cuts. In 2022 to 2023, four-year universities turned down more than 65,000 qualified applications for nursing programs due to "insufficient clinical placement sites, faculty, preceptors and classroom space, as well as budget cuts," according to the American Association of Colleges of Nursing.
According to the California Association of Nurse Anesthesiology, the supply side of the anesthesia shortage equation in the state is also partially driven by "provider redundancy challenges." This is related to staffing models that rely on physician supervision, which they argue contributes directly to the shortage, rather than "efficiency driven models where CRNAs and physician anesthesiologists collaborate yet remain independent.”
What are the restrictions around CRNA use in California?
In 2009, California opted out of a Medicare regulation requiring physician supervision of CRNAs, according to the Journal of Nursing Regulation. The CSA and the California Medical Association filed a lawsuit against then-Gov. Arnold Schwarzenegger, alleging that the opt-out violated state law. A court ultimately ruled in favor of the governor's decision, which was held up on appeal, allowing CRNAs to practice without the supervision of a physician under state law.
CANA contends that the opt-out improved care in rural and underserved areas and "allowed hospitals and other facilities to provide more cost-effective care," according to a statement shared with Becker's.
Since then, individual health systems in California have been able to choose how to structure their own anesthesia care models and whether to rely on physician supervision or allow CRNAs to work more independently.
This became the center of discussion in the CDPH's letter released Sept. 6, after two hospitals in Modesto, Calif., were cited for compliance issues connected to CRNAs. The letter clarified that "[in] California, a CRNA administering anesthesia services is not required to be under the supervision of the operating practitioner or of an anesthesiologist, however they may only provide services within their scope of practice."
It specifically cited the Nursing Practice Act in the ruling of California Society of Anesthesiologists vs. Supreme Court in 2012, which states "CRNAs have legal authority to administer anesthesia after a physician orders a course of treatment that includes anesthesia."
The letter also clarified that:
- Use of CRNAs must be approved by hospital administration and must be at the discretion of a physician.
- Contracted CRNAs are subject to the bylaws of hospitals where they are administering anesthesia.
- The general scope of practice for CRNAs is defined by the Nursing Practice Act and regulated by California Board of Registered Nursing.
Further regulations imposed on CRNA use or utilized in systems' staffing models reflect the decision-making of individual hospitals or health systems.
What comes next?
Advocates for CRNAs argue for both removing the barriers that prevent them from practicing more independently while maintaining collaborative care structures with physician anesthesiologists that maximize efficiency.
AANA President Janet Setnor, MSN, CRNA, said that federal programs such as Medicare and the Veterans Health Administration too often place "unnecessary barriers to care between patients and providers, such as CRNAs," in a statement shared with Becker's.
"Removing these burdensome barriers will allow both CRNAs and physician anesthesiologists to provide direct patient care, increasing the utilization of the current workforce and making it more efficient and cost effective," she said. She noted that federal legislation, such as the Improving Care and Access to Nurses Act, as well as numerous state policies, seek to remove these barriers.
CANA doubled down on this idea of supporting a collaborative, yet "independent," work flow between physicians and CRNAs.
While CRNAs may practice with a degree of indepdence under California law, CSA contends that physician involvement is still vital in the strucuture of anesthesia care teams.
"Expanding access to care should not be done by eliminating physician involvement in anesthesia care," said Dr. Hernandez Conte. "Instead, the physician-led anesthesia care team model is the optimal way to use different team players with different levels of training, and responsibly deploy those providers in the right roles."
Anesthesiologist groups voice support for Medicare reimbursement reform, strategic utilization of AI and addressing burnout to retain physicians within the profession.
Both anesthesiologist and CRNA advocacy groups overwhelmingly support increasing the flow of practitioners into the anesthesia by urging the federal government to support increased capacity in medical education and anesthesia training programs.
"At the national level, we support efforts to improve Title VIII funding and resources for all aspects of nursing workforce demand, including education, practice, recruitment and retention," said CANA's statement. "In California, specifically, we’re excited for UC Davis’ new doctoral nurse anesthesia program to open, which will become the sixth DNP-NA program in the state."
Both ASA and CSA support the licensure of certified anesthesiologist assistants in California to expand anesthesia coverage.
"These providers are part of the anesthesia care team who can also work under the supervision of anesthesiologists [and] they can help increase access and coverage while ensuring patient safety with physician involvement," Dr. Hernandez Conte said. "California law must be updated to allow CAA licensure in this state."