VA denial of full practice authority for nurse anesthetists coming home to roost

Back in January, the Department of Veterans Affairs (VA) passed on an opportunity to improve access to anesthesia care for military veterans—a decision that’s now coming home to roost. And it’s our veterans who are once again paying the price.

On Oct. 11, Fox News Denver reported that since the beginning of August, 65 to 90 surgeries have been canceled or postponed at the Denver Veterans Affairs Medical Center. According to the Eastern Colorado Health Care System, which operates the medical center, the delays are due to “a shortage of staff, specifically anesthesiologists and Certified Registered Nurse Anesthetists.” 

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Nine months ago, the VA claimed that there was not an access to anesthesia care problem in Veterans Health Administration (VHA) facilities, despite substantial evidence to the contrary gathered through a 2015 congressionally-mandated, independent assessment of VHA facilities. The assessment confirmed that due to lack of anesthesia support, veterans routinely experience delays for health care services such as cardiovascular surgery, colonoscopies, and procedures requiring anesthesia outside of the operating room. The VA dismissed this evidence, succumbing to intense political pressure from physician anesthesiologists. As a result, the VA reversed its own proposal to grant Certified Registered Nurse Anesthetists (CRNAs) full practice authority and enable all of the VA’s CRNAs and anesthesiologists to be utilized to the full extent of their education, training and licensure. This would have ensured our veterans increased access to surgery and other procedures requiring anesthesia services.

The problems at the Denver Veterans Affairs Medical Center reflect the problems of the VHA as a whole. The solution to anesthesia-related surgical delays at the Denver facility, as at other VHA facilities dealing with similar delays, is most likely right there under the administration’s nose: Just make full use of the CRNAs and anesthesiologists who work there. At the Denver facility, there are 10 CRNAs and eight anesthesiologists. Instead of having all 18 anesthesia professionals provide hands-on anesthesia care for 18 different patients, the facility uses a costly and inefficient anesthesia delivery model where for every two CRNAs providing hands-on patient care, there is one anesthesiologist available to assist those highly qualified CRNAs if needed. The result: Only 10 veterans are receiving care instead of a possible 18. By allowing VHA anesthesia departments to waste resources in this manner, the VA perpetuates the access-to-care problem and veterans pay the price with their health. It is even more astounding when one considers that since 2000 eight different research studies have confirmed the safety and cost-effectiveness of CRNAs.

The bottom line: Denver Veterans Affairs Medical Center is wasting a lot of resources—both staff and budgetary—by using a 2:1 CRNA to anesthesiologist ratio. By having the eight anesthesiologists also sit on a stool and give anesthesia, the facility would increase its opportunity for patient care by nearly 80 percent! Instead, the facility is considering hiring three more anesthesiologists and CRNAs to “solve the problem,” which would simply mean increasing costs without meeting the need.

Likewise, the VHA also continues wasting resources, exemplified by 38 contracts with outside anesthesia providers at a cost of more than $100 million to taxpayers, clear evidence that available internal resources are not being used to full advantage. Granting CRNAs full practice authority would go a long way toward solving the VHA’s access-to-care problem—a problem the data show is only going to worsen. The VA’s own Enrollee Health Care Projection Model forecasts a “19-percent increase in demand for VA health care services nationally from FY 2014 to FY 2019, due to a projected 5.1-percent increase in enrollment and the aging of enrollees.”

CRNAs are highly-educated, advanced practice registered nurses who deliver anesthesia to patients in exactly the same ways, for the same types of complex procedures, for the same severity of patient cases and just as safely as physician anesthesiologists. CRNAs are well prepared to respond appropriately in emergency situations and already do so in combat areas for the Army, Navy, and Air Force and in Combat Support Hospitals.

By granting full practice authority to CRNAs, the VA would make full use of more than 900 CRNAs already practicing in VHA facilities, ensuring our nation’s veterans have access to essential surgical, emergency, obstetric and pain management health care services without needless delays or having to travel long distances for care. It would also align VA policy with current U.S. Department of Defense policy that does allow CRNAs to work as full practice providers in all other military service branches. The VA is the last federal health agency to restrict CRNAs from practicing to their full practice authority. If autonomous CRNA practice is appropriate for active duty military personnel, it is also appropriate for military veterans.

Utilizing the existing CRNA workforce in the VHA to its full practice authority would increase patient access to care without additional funding. The VA would continue to support the team approach to patient care, with physicians, nurses, technicians and other specialists working in concert to ensure the timeliest, highest-quality care possible for veterans. To quote former Sen. Bob Dole (R-Kan.), this “all hands on deck” approach more appropriately engages existing resources, supporting a team-centric rather than physician-centric approach, and won’t cost the VA, the federal government or U.S. citizens one additional tax dollar to support.

Our veterans shouldn’t have to wait. It is time the VA follows the lead of AMVETS, Paralyzed Veterans of America, Military Officers Association of America, Air Force Sergeants Association, AARP, numerous healthcare and other professional organizations and the nearly 100 policy makers who have expressed their support for full practice authority for CRNAs in the VA on behalf of the veterans they serve.

Bruce Weiner, DNP, MSNA, CRNA, is president of the American Association of Nurse Anesthetists, which represents more than 52,000 nurse anesthetists.