TxANA Supports Full Practice Authority - SB 1859 & HB 3794

4/9/2025

The Texas Association of Nurse Anesthetists (TxANA) proudly supports Senate Bill 1859, filed by Senator Mayes Middleton, and House Bill 3794, filed by Representative Drew Darby. These bills seek to grant Certified Registered Nurse Anesthetists (CRNAs) full practice authority (FPA) in Texas. With the demand for anesthesia services on the rise, TxANA advocates for removing barriers that limit CRNAs from practicing to the full extent of their education and training.

"CRNAs are highly trained anesthesia professionals who safely provide care in various healthcare settings, particularly in rural and underserved communities," said Wendy Odell, DNP, CRNA, President of TxANA. "By removing outdated requirements, Texas can enhance patient access to anesthesia care, reduce healthcare costs, and improve provider efficiency without compromising patient safety."

Currently, Texas regulations require physician delegation for CRNAs. Anesthesia services can be delegated to a CRNA by a non-anesthesiologist physician, a physician anesthesiologist, or a dentist anesthesiologist. Oftentimes, the delegating physician has minimal to no training in the administration of anesthesia. These outdated regulations create unnecessary administrative burdens, increase healthcare costs, and lead to healthcare system inefficiencies. Physician delegation does not necessarily contribute to better patient outcomes. Furthermore, extensive evidence demonstrates the safety and efficacy of independent CRNA care.

Texas is facing a critical anesthesia provider shortage. FPA for CRNAs would address the growing demand for anesthesia services. In rural areas, CRNAs are often the sole anesthesia providers. Numerous facilities in Texas currently use a model where CRNAs are the sole anesthesia provider for surgical patients. Removing restrictive legislation and allowing CRNAs to practice to the full extent of their education and training streamlines healthcare delivery and reduces financial burdens on hospital systems, thus supporting the State's evolving healthcare needs.

TxANA is committed to supporting policy changes that empower CRNAs to serve their communities without unnecessary restrictions. The association urges Texas lawmakers to take action in support of FPA. Doing so will strengthen the State's healthcare system and ensure every Texan can access timely, high-quality, cost-effective anesthesia care.

Urge your legislator to support SB 1859/HB 3794 here.

8 Comments

Scott O'Brien

4/9/2025 02:59:14 pm

I fully support this bill. As an army veteran and army trained CRNA, I feel as though if the U.S. military trusts us as independent providers, that should be good enough for its citizens that we defend.

Mike M.

4/9/2025 03:07:17 pm

The Fallacy of CRNA "Supervision"
February 25, 2019
Michael MacKinnon
Bending the cost curve! #BeFirst #BendTheCostCurve
The Backstory

In order to understand the American Society of Anesthesiologists (A$A)
FIGHT to require supervision of nurse anesthesiologists (CRNA) and opposition to states opting out one has to first understand the evolution of the process.

In 1997 what was then known as the health care financing administration (HCFA) but now known as the centers for medicare and medicaid services proposed a rule in the federal register (Department of Health and Human Services, 1997).

That rule included REMOVING the physician supervision requirement for nurse anesthetist and deferring the decision to the states.

This would have effectively eliminated the “physician supervision” requirement that in anesthesia cases involving medicare patients nurse anesthetist must be supervised in order for hospitals to be reimbursed for the non-anesthesia portion of the patient's care.

This would then leave the decision up to individual states and hospitals to choose the anesthesia model they wanted as opposed to having a blanket requirement imposed by the federal government.

This was to be the final rule.

It is important to note that for CRNAs themselves to be reimbursed,
medicare does NOT require any physician supervision.

HCFA did not just randomly come up with this initial decision.

During the creation of this rule and extensive literature review and research review was part of the due diligence.

In the decision to remove this supervision language HCFA states that they:
"found NO compelling scientific evidence that an across-the-board federal physician supervision requirement for CRNA's leads to better outcomes".

However, to the detriment of access to cost effective
anesthesia care across the nation and a blow to limited government, the final rule was AMENDED with significant work by the
A$A lobby team.

The final rule was published in November 2001 and RETAINED the medicare mandate on physician supervision of CRNA's while establishing an OPT OUT process for state governors.

Although HCFA and the evidence in the original final rule clearly identified that there was NO benefit to the supervision language, the A$A was successful in their lobby efforts (Department of Health and Human Services, 2001).

Supervision ≠ (does NOT equal) Patient Safety

The prime argument utilized by the A$A was then and continues to be now that it is "too risky to administer anesthesia without the supervision of a physician".

Although there is no requirement for a physician anesthesiologist to be the individual who supervises a CRNA the A$A states that "there is only one other medical professional in the operating room with the education and training to perform these services: the SURGEON”.(American Society of Anesthesiologists, 2019).

Essentially, they suggest that the SURGEON will be there to save the day AND the CRNA if something happens to the patient during anesthesia.

There are three major problems with this argument:

1) Removing Supervision Does Not Remove the Surgeon: Regardless if the word supervision is removed from the Medicare requirements for hospitals to bill for non-anesthesia services the surgeon is not actually removed from the operating room during anesthesia. Therefore, in the event of any emergency the "team" would work in concert for the best interest of the patient.

2) No Evidence the Supervision Requirement has Value: even in 2001 HCFA clearly stated there was no value or evidence for the requirement for supervision. Since 2001 multiple studies have continued to validate that CRNA's provide high quality cost-effective services with outcomes equivalent to our physician anesthesiologist colleagues (Dulisse & Cromwell, 2010; Negrusa, Hogan, Warner, Schroeder, & Pang, 2016; Beissel, 2016; Lewis, Nicholson, Smith, & Alderson, 2014; Simonson, Ahern, & Hendryx, 2007; Needleman & Minnick, 2009).

3) Surgeons have LIMITED Anesthesia Training: Surgeons get extensive training in surgery and surgical management of their patients as they are the experts in their surgical specialty. However, surgeons do NOT get in-depth extensive training in anesthesia, anesthesia delivery, complications or rare anesthetic emergencies which could impact a patient's outcome. If surgeons DID have sufficient training to provide or supervise anesthesia it would indicate that the medical specialty is unnecessary.

Evidence by Proclamation ≠ Evidence

The ASAs argument rests on the idea that surgeons due to their training, need to supervise CRNA's in order to keep patients safe throughout the anesthetic and surgical process.

For this assertion to be true one would assume that surgeons would have at a minimum, the same level of training as a CRNA does in anesthesia,
but that is NOT the case.

As of this writing there is NO
official requirement during surgical residency for ANY anesthesia r

4/9/2025 03:09:42 pm

As of this writing there is NO
official requirement during surgical residency for ANY anesthesia related training though some residencies do require between one and three WEEKS in the operating room learning basic airway management.

The surgical council on resident education (SCORE) is a noncommercial consortium formed in 2006 by the principal organizations involved in United States surgical education (http://www.surgicalcore.org/).

SCORE defines the specialty of general surgery and provides greater assurances that residents are receiving sufficient training in all areas.

They focus primarily on the five years of progressive education training that constitute general surgery residency in the United States, but these requirements are common among all surgical specialties.

The following organizations are members of SCORE and are intricately involved in the development of these requirements: American Board of Surgery, American College of Surgeons, American Surgical Association, Association of Program Directors in Surgery, Association for Surgical Education, Residency Review Committee for Surgery of the Accreditation Council of Graduate Medical Education and the Society of American Gastrointestinal and Endoscopic Surgeons.

SCORE and its member organizations define what is important during the educational process of a surgical resident related to patient care, medical knowledge, professionalism, interpersonal and communication skills.

So, it stands to reason that SCORE are the experts we should look to when investigating the level of anesthesia education required during surgical residencies.

In reviewing the SCORE curriculum outline for 2018-2019 out of 60 items in the medical knowledge category, there are only NINE anesthesia items representing just 15% of the category.

Out of all 623 items in all 8 categories anesthesia represents only 1.44% of covered knowledge.

Although it is without question that surgeons are the experts in surgery and highly capable physicians, it is clear they do NOT get significant training in anesthesia (Surgical Council on Resident Education, 2019).

Another important organization involved in the assessment of general surgery residency training is the American Board of Surgery (ABS) who developed and administers the american board of surgery in training examination (ABSITE).

The exam is designed to measure the progress attained by residents in their knowledge of applied science and management of clinical problems related to surgery.

Per the ABS website the ABSITE is aligned and based on the SCORE criteria and has a primary focus on clinical management.

In fact, they indicate that approximately 80% of the questions will address clinical management topics.

Per the American Board of Surgery content outline for this exam anesthesia represents
1%
of the total content (The American Board of Surgery, 2019).

In addition, the final qualifying examination for general surgeons only includes anesthesia under miscellaneous topics as one of six indicators with a total value of 5% of the exam making it at best, 0.83% of the exam (The American Board of Surgery, 2019).

This clearly indicates that the focus is NOT on anesthesia nor is it a significant portion of the content surgical residents and are expected to know, nor should it be.

Surgeons are busy performing lifesaving surgery they should not have to worry about anesthesia delivery as well.

It is predictable that our detractors would suggest this data indicates only physician anesthesiologists should be "supervising" CRNAs to meet the medicare part A conditions of participation.

However, such an assumption would run counter to 150 years of evidence showing that CRNAs provide high quality, cost effective and equivalent care.

Just like CRNAs, physician anesthesiologists are highly trained healthcare professionals and the evidence consistently shows that outcomes, M&M (mortality and morbidity)and patient satisfaction are the SAME with or without physician anesthesiologist involvement (Dulisse & Cromwell, 2010; Negrusa, Hogan, Warner, Schroeder, & Pang, 2016; Beissel, 2016; Lewis, Nicholson, Smith, & Alderson, 2014; Simonson, Ahern, & Hendryx, 2007; Needleman & Minnick, 2009).

Additionally, any discussion
about value added services from physician anesthesiologist’s supervision should take into account medical malpractice premiums.

Medical malpractice actuaries who have NO interest in the politics of anesthesia, set premiums based on risk stratification and ensure that the premium charged for such insurance will enable the company to cover potential claims, other expenses and generate a profit.

When there is increased risk, premiums logically increase and vice versa.

However, CRNA premiums are the SAME regardless if they work with a physician anesthesiologist or in teams with surgeons indicating that actuaries do not assess a value to their presence in terms of lower premium costs for CRNAs working wi

4/9/2025 03:11:21 pm

However, CRNA premiums are the SAME regardless if they work with a physician anesthesiologist or in teams with surgeons indicating that actuaries do not assess a value to their presence in terms of lower premium costs for CRNAs working with them or higher costs for CRNAs working only with surgeons.

Additionally, surgeons who work in teams with CRNAs and hospitals who use this model do NOT generally pay higher fees or carry an additional insurance rider to do so.

This indicates there is NO additional risk to either related to CRNA/Surgeon model.

This evidence combined with the risk of closure of thousands of hospitals across the country using CRNA/Surgeon teams today, not only invalidate such a position in terms of value or safety added,
but would devastate access to care and making it untenable nationally.

In conclusion, when taking into account the ABS and SCORE data it would be an impossible reach to suggest that surgeons are educated and trained to the same degree as CRNAs in the specialty of anesthesia, let alone trained to ‘supervise’ them.

The A$A promoted requirement for CRNA supervision is unnecessary, without evidence or justification and is clearly politically motivated.
💰💰💰💰💰💰💰💰💰💰💰💰

Surgeons are the experts in surgery, CRNAs are experts in anesthesia and both work in a team to take care of patients.

References
The American Board of Surgery. (2019). The American Board of Surgery. Retrieved from GENERAL SURGERY: CONTENT OUTLINE FOR THE ABS IN-TRAINING EXAMINATION: http://www.absurgery.org/xfer/GS-ITE.pdf
The American Board of Surgery. (2019). The American Board of Surgery. Retrieved from GENERAL SURGERY: CONTENT OUTLINE FOR THE QUALIFYING EXAMINATION: http://www.absurgery.org/xfer/GS-QE.pdf
American Society of Anesthesiologists. (2019). Opt Outs. Retrieved from ASAHQ: https://www.asahq.org/advocacy-and-asapac/get-talking-points/state-issues/opt-outs
Beissel, D. (2016, November/December). Complication rates for fluoroscopic guided interlaminar lumbar epidural steroid injections performed by certified registered nurse Anesthetists in diverse practice settings. Journal for Healthcare Quality, 38(6). http://dx.doi.org/https://doi.org/10.1111/jhq.12093
Department of Health and Human Services. (1997). Medicare and Medicaid Programs; Hospital Conditions of Participation; Provider Agreements and Supplier Approval. Federal Register, 62(244), pp. 66726-66763.
Department of Health and Human Services. (2001). Medicare and Medicaid Programs; Hospital Conditions of Participation; Provider Agreements and Supplier Approval. Federal Register, 66(219), pp. 56762-56769
Dulisse, B., & Cromwell, J. (2010, August). No harm found when nurse anesthetists work without supervision by physicians. Health Affairs, 29, 1469-1475. http://dx.doi.org/https://doi.org/10.1377/hlthaff.2008.0966
Lewis, S., Nicholson, A., Smith, A., & Alderson, P. (2014, July 11). Physician anaesthetists versus non‐physician providers of anaesthesia for surgical patients. Cochrane Database of Systematic Reviews. http://dx.doi.org/https://doi.org//10.1002/14651858.CD010357.pub2
Needleman, J., & Minnick, A. F. (2009, March 12). Anesthesia provider model, hospital resources, and maternal outcomes. Health Services Research, 44(2p1), 464-482. http://dx.doi.org/https://doi.org/10.1111/j.1475-6773.2008.00919.x
Negrusa, B., Hogan, P., Warner, J., Schroeder, C., & Pang, B. (2016, October). Scope of practice laws and anesthesia complications: No measurable impact of certified registered nurse anesthetist expanded scope of practice on anesthesia-related complications. Medical Care, 54, 913-920. http://dx.doi.org/10.1097/MLR.0000000000000554
Simonson, D. C., Ahern, M. M., & Hendryx, M. S. (2007, January-February). Anesthesia staffing and anesthetic complications during cesarean delivery: A retrospective analysis. Nursing Research, 56(1), 0-17. Retrieved from https://journals.lww.com/nursingresearchonline/Abstract/2007/01000/Anesthesia_Staffing_and_Anesthetic_Complications.2.aspx
Surgical Council on Resident Education. (2019). Surgical Council on Resident Education. Retrieved from Curriculum Outline : https://www.surgicalcore.org/public/curriculum
Published By

Michael MacKinnon
Bending the cost curve! #BeFirst #BendTheCostCurve
#anesthesia #anesthesiology #BendingTheCostCurve

Patrick Cepeda

4/10/2025 03:02:38 pm

Thanks for the great post Mike. Very informative.

Israel Coronado

4/9/2025 06:46:58 pm

As a CRNA and healthcare professional who’s been in the trenches for years, I fully support SB 1859 and HB 3794. Granting Full Practice Authority to CRNAs isn’t some radical idea but instead it’s plain old common sense, backed by decades of data, cost-efficiency studies, and real world outcomes. The current requirement for physician delegation which is often from providers with minimal or no anesthesia training is a relic of the past that serves more as a gatekeeping tool than a safeguard for patient safety.

Let’s be honest: the idea that a general surgeon with maybe one to three weeks of anesthesia exposure during residency is somehow more qualified to “supervise” a CRNA with years of dedicated anesthesia training is laughable at best, dangerous at worst. If the goal is truly patient safety, why are we pretending that a surgeon who hasn’t managed an airway in years (or ever) brings more value to the OR in reference to administration of anesthesia than a CRNA who does it daily?

Take rural Texas, for example, where CRNAs are often the only anesthesia providers for miles. Facilities are functioning smoothly and safely with CRNA-only models, and outcomes speak for themselves. Or look at the VA and military health systems, where CRNAs function independently and are trusted to care for our nation’s heroes. Apparently, if you wear a uniform, CRNA independence is fine. Take the uniform off and treat civilians and wear scrubs, suddenly we’re a liability?

There’s a mountain of peer-reviewed research, malpractice data, and economic modeling that shows CRNAs practicing independently provide equivalent (and often more cost-effective) care than supervised models. But somehow, a few well-funded lobby groups would have lawmakers believe that the sky will fall if CRNAs are allowed to practice like they already do in 20+ other states.

It’s time to retire the scare tactics and start legislating based on evidence, not turf wars. SB 1859 and HB 3794 are not just about CRNA autonomy. This is about smart, efficient, and safe healthcare for Texans.

Sospeter Opasi

4/9/2025 07:33:25 pm

I wholeheartedly support this bill being passed. As a critical nurse with three years of experience, I am currently in the process of enrolling in an anesthesia program and have witnessed firsthand the critical role of CRNAs in surgical care. During emergencies, especially at night, CRNAs are the only on-call professionals available for airway management. The past has been promising, and the future of this profession looks even brighter.

Binoj Mathew

4/11/2025 10:25:52 am

Support for SB 1589 and HB 3794: Full Practice Authority for CRNAs

I am writing to respectfully request your support for Senate Bill 1589 and House Bill 3794, which seek to grant full practice authority to Certified Registered Nurse Anesthetists (CRNAs).

As you may know, CRNAs play a crucial role in our healthcare system, providing high-quality anesthesia care across various settings, including hospitals, surgical centers, and rural clinics. Granting full practice authority to CRNAs will not only enhance patient access to safe and effective anesthesia care but also alleviate the burden on our healthcare providers, especially in underserved areas.

By supporting these bills, you will be empowering CRNAs to practice to the full extent of their education and training, ultimately improving healthcare delivery and outcomes for all patients. I urge you to consider the positive impact that full practice authority would have on our healthcare system and to lend your support to SB 1589 and HB 3794.

Thank you for your attention to this important matter. I appreciate your commitment to improving healthcare in our state and look forward to your support.

Association News

TxANA Supports Full Practice Authority - SB 1859 & HB 3794

Urge your legislator to support SB 1859/HB 3794 here.

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