Five reasons that anesthesiologist assistants limit anesthesia flexibility and profitability

There are four groups of anesthesia providers In the United States. Physician Anesthesiologists, Dental Anesthesiologist, Nurse Anesthesiologists and Anesthesiologist Assistants (AA). Dentist, Physician and Nurse Anesthesiologist work in every state of the union autonomously and have since each professions inception.

However, the newcomer AAs, require direct supervision by a Physician Anesthesiologist to practice anesthesia and are currently only licensed in 15 states; they are also not approved for practice in the US Military. Our rapidly evolving healthcare system is best served when all practitioners can provide the full scope of anesthesia services independently/autonomously, thus maintaining practice flexibility and ensuring fiscally responsibility and patient access to care. The following are 5 key reasons why AAs cannot help hospitals, other healthcare facilities and anesthesia departments meet these goals:

1) Inefficient Model: AAs must work directly under a Physician Anesthesiologist in a 1:4 or less ratio depending on state law and billing model without losing significant revenue3. The AA medical direction requirement could lead to delayed starts, fewer cases done per day and higher costs to the system due to CMS TEFRA rules3. It also eliminates AAs as part of the solution to improving access to care in medically underserved areas (such as rural America), and could cost a practice significant revenue due to AAs inability to expand access to care as needed.

2) High Risk for Medicare Fraud: AA practice must be billed as medical direction for maximum revenue generation and in order to avoid high risk for Medicare fraud. The civil fines are up to three times the amount of damages sustained by the government and an additional charge of up to $21,563 per false claim1,2. Criminal penalties may include fines, imprisonment or both. In the 2012 article entitled “Influence of supervision ratios by anesthesiologists on first-case starts and critical portions of anesthetics” in the journal Anesthesiology found that 35% of the time in a 1:2 ratio the required medical direction (TEFRA) rules were not be followed resulting in Medicare fraud which could easily be the case for medically directed AAs1. Facilities may also be at risk for Medicare fraud for not assuring appropriate medical direction of AAs, practices cannot afford this but neither can the facilities they serve.

3) Unsustainable Costs: The medical direction practice model is the most expensive and least efficient due to the requirement of one physician anesthesiologist for every four AAs/Nurse Anesthesiologists. While Nurse Anesthesiologists can work autonomously, thereby expanding services in greater ratios or on their own, AAs generally only work in a maximum 4:1 model. This additional cost of service requires large subsidies from the facility to maintain high cost anesthesia services. Such subsidies are a significant line item expense not sustainable by facilities already under significant downward economic pressure in an uncertain healthcare environment. These additional costs coupled with the high probability of Medicare fraud puts anesthesia practices and facilities at risk.

4) AAs fail to meet demand: The operating room is a dynamic environment with constantly shifting needs. It is not uncommon to have emergency cases and add-ons requiring opening additional ORs and therefore anesthesia providers. While Physician Anesthesiologist and Nurse Anesthesiologists can work autonomously to meet these needs AAs cannot as they are limited by the number of Physician Anesthesiologist available to cover them. This can result in delayed cases, decreased efficiency and lack of flexibility to meet operating room demand and/or increased costs for additional Physician Anesthesiologist to medically direct and non-revenue generating extra bodies waiting for cases. All of which are bad for facility and practice bottom lines.

5) Not Full Service: New graduate AAs have only 2000-3000 hours of experience compared to ~9000 for CRNAs and require no previous clinical experience prior to AA school4,5. This leaves a large gap in clinical capability, skill, experience and clinical acumen entering their programs. By comparison, Nurse Anesthesiologists earn a bachelor’s degree in nursing and attain an average of 2.5 years of critical care experience before entering a nurse anesthesia educational program. Thus, AAs require significant guidance and close direction during the administration of anesthesia and cannot work autonomously.

Today, anesthesia practices and facilities must be more cost conscious than ever. With increasing anesthesia needs, stagnant revenue and facilities seeking to reduce or eliminate anesthesia subsidies from the bottom line, all practices will be required to do more with less. To meet this demand in a cost-effective way it is imperative that practices use practitioners who can provide the full scope of anesthesia services independently/autonomously, limit fraud risk, be highly flexible and increase access. The use of AAs simply does not achieve these goals.

1. Epstein, R. H., & Dexter, F. (2012). Influence of supervision ratios by anesthesiologists on first-case starts and critical portions of anesthetics. Anesthesiology: The Journal of the American Society of Anesthesiologists, 116(3), 683-691.

2. Department of Justice. (2016). The False Claims Act: A Primer. Retrieved from

3. Centers for Medicare Services. (2017). Chapter 12 - Physicians/Nonphysician Practitioners. Retrieved from

4. Nova Southeastern University. (2018). Master of Science in Anesthesia (AA). Retrieved from

5. American Association of Nurse Anesthetists. (2017). AANA Position on Anesthesiologist Assistants. Retrieved from

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

© Copyright ASC COMMUNICATIONS 2021. Interested in LINKING to or REPRINTING this content? View our policies by clicking here.


Featured Webinars

Featured Whitepapers