As the shortage of physician anesthesiologists across the U.S. becomes more severe, certified-registered nurse anesthetists have emerged as an essential pillar in perioperative care teams.
Some ASCs and other surgical facilities have come to depend heavily on CRNAs. CRNAs deliver more than 80% of anesthesia services in rural counties, administering over 50 million anesthetics each year, according to the American Association of Nurse Anesthesiology.
Staffing gaps persist, with facilities reporting anesthesia shortages rose from 35% in 2020 to 78% by late 2022, and nearly 22% of anesthesia providers are projected to leave the workforce by 2033.
CRNAs are also not immune from reimbursement challenges. In October 2025, UnitedHealthcare cut reimbursement for QZ-billed CRNA services by 15% in select states and eliminated payments tied to several add-on and qualifying-circumstance codes. Because QZ billing reflects CRNA services delivered without physician medical direction, the reduction directly lowers compensation for independent CRNAs and may eliminate pay for higher-acuity cases entirely.
Terry Schreiber, a self-employed CRNA in St. Augustine, Fla., recently joined Becker’s to share his thoughts on why ASCs will continue to shift toward more CRNA-dependent models and what trends may emerge next in the anesthesia workforce.
Editor’s note: This response has been lightly edited for clarity and length:
Question: What trends do you think will define anesthesia management at ASCs in the future? Where does the pendulum swing next?
Mr. Schreiber: Hopefully, the trend of low-acuity ASCs, eye centers, and [gastroenterology] endoscopy centers moving towards CRNA-only models and away from anesthesia care team (ACT) models will accelerate. Faced with increasing reimbursement pressures and anesthesia subsidy pressures for contracted anesthesia management providers, ASCs are waking up to the realization that by employing CRNAs directly, they can turn anesthesia delivery into an actual profit center for the ASC. In the current environment, the ACT model where MD anesthesiologists are medically directing or supervising CRNAs adds no value or efficiency to the process. In fact, in low-acuity centers it can actually be a drag on case volume and efficiency and therefore profit if the contracted providers are actually following [Tax Equity and Fiscal Responsibility Act] requirements. Regarding the TEFRA requirement — Medicare and the Office of Inspector General are starting to ramp up audits on anesthesia providers who employ “cloned anesthesia attestations” on anesthesia records so I think it’s important that ASCs understand the rules governing their contracted anesthesia providers to determine if they are in compliance.
For ASCs that are concerned about the 15% penalty that Cigna and UHC are imposing on unsupervised CRNAs, the impact is nominal considering average percentages of payer mixes, particularly in ASCs dedicated primarily to ophthalmology, endoscopy, and orthopedics. Even with the current penalty in place, low-acuity ASCs who employ CRNAs are still way ahead of the curve compared to ACT model ASCs in terms of profitability. These penalties are already being seriously challenged and time will tell if they are eventually rolled back.
Another recent trend I’m seeing is private equity-backed anesthesia management groups promising ASCs uninterrupted ACT coverage with no subsidies. In these situations, the private equity company is willing to absorb the added cost of the MD anesthesiologist in order to gain market share and improve valuation in the hopes of selling the anesthesia management company at a higher multiple in the future. ASCs should be prepared for requests for higher cash reserves or subsidies once they’ve entered into these agreements.
As to “Where does the pendulum swing next?” I believe, as previously mentioned, that the CRNA model will accelerate and proliferate when ASCs realize that a new profit center can be created by employing CRNAs directly, even when considering the current 15% penalty.
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