When private insurers began cutting QZ reimbursements to 85%, they framed it as “alignment” and “standardization.” Strip away the euphemisms and you find an old story: a margin-play that offloads risk and cost onto hospitals, ambulatory surgery centers, and the patients who can least absorb it. Cigna moved first in 2023, followed by Anthem in 2024; UnitedHealthcare is rolling them out next month. Others will certainly follow.
This is not the harmless tweak to a billing modifier that these insurers have sold. Rather, it is a targeted devaluation of the most widely distributed anesthesia workforce in America. Certified Registered Nurse Anesthetists (CRNAs) handle millions of cases safely every year. Across the US, CRNAs represent more than 80% of anesthesia providers in rural counties, and in four out of five of these counties, no other anesthesia providers are availablei. CRNAs are the only reason surgeries, labor and delivery, trauma stabilization, and colorectal cancer screenings are available in many communities nationwide.
What happens when QZ drops to 85%
Insurers are strangling the system at a time when rural health centers and Ambulatory Surgery Centers need more support to expand CRNA workforce to keep cases flowing and communities healthy. Inviting payor policy into care delivery decisions is never in the patient’s interest.
Rural hospitals and Critical Access Hospitals (CAHs)
In these hospitals, QZ cases are frequently the backbone of anesthesia coverage. They already operate on razor-thin margins. A 15% reimbursement cut to QZ cases forces ugly choices which may include restricted OR hours or limited obstetrics coverage overnight, resulting in sending patients to distant facilities or delayed or cancelled procedures. Add this to the ongoing rural hospital closure crisisii, and you have a predictable access disaster.
Ambulatory Surgery Centers (ASCs)
ASCs that rely on CRNAs to keep routine procedures affordable either drop low-margin cases, exit certain payor contracts, or pass costs along to patients. Trade publications warn the UnitedHealthcare cut could directly disrupt ASC staffing modelsiii.
Patients
Patients will suffer from treatment delays and excessive travel which increases health risk. When local ORs go dark, people drive hours for routine cancer screening such as colonoscopies and for urgent and emergent care like C-sections or hip fractures, or they wait. The impediment to accessing care lands hardest on rural, low-income, and elderly patientsiv.
The quality myth and other deflections. Again
Insurers have implied that reducing QZ payments is about “quality” or “APRN peer equity.” Others in the healthcare space have echoed those sentiments uncritically. The evidence simply does not support this. The fact that CRNAs are demonstrably safe and effective isn’t new. Numerous studies and reports over the past decade and a half have shown conclusively that CRNA-provided care is statistically indistinguishable from that of other providers in terms of quality, safety, and other outcomesv.
The peer equity justification is a transparent deflection. CRNA-provided services cannot reasonably be compared to those of other APRNs. CRNAs are specifically educated and trained to be independent anesthesia experts, providing the same care, using the same pharmaceuticals, under the same standards of care, to the same patients and producing the same outcomes as other independent anesthesia providers. In this regard, it is about the degree of the care provided and not the degree of the care provider. Patients can expect and receive the same level of care regardless of the degree of their anesthesia provider.
Why this looks a lot like illegal discrimination under the Health Services Act
Section 2706(a) of Public Health Service Act (codified at 42 U.S.C. §300gg-5) says health plans “shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.” That language exists for a reason: to stop plans from sidelining whole classes of licensed providers for non-clinical reasons.
Providing an appropriate enforcement mechanism has never been done, despite the language in the HSA and subsequent attempts by Congress through section 108 of the No Surprises Act as part of the bipartisan Consolidated Appropriations Act of 2021. In fact, this issue has been in listening session and rule-making agenda purgatory since its inception a decade and a half ago.
In 2024, the American Association of Nurse Anesthesiology (AANA) filed a petition for a writ of mandamus in federal court to compel then HHS Secretary Xavier Becerra to finally enforce the provider non-discrimination provision of the HSA. While AANA’s petition was dismissed in August, that matter is not settled and a notice of appeal has been filed.
In spite of the plain language of the law, federal agencies have failed to complete the necessary action providing compliance mechanisms for this provision. Insurers have taken this inaction as an invitation to abuse the nondiscrimination directive of the law.
So where do QZ cuts fit?
When an insurer pays 85% solely because the anesthesia was delivered by a CRNA (even when 100% of the service was rendered, the service is covered by the insurer, deemed medically necessary, and within the CRNA’s scope of practice) that constitutes discrimination “with respect to participation…or coverage” based on licensure alone. Plans might argue “rates” are exempt. If rate design is used as a blunt instrument to deter use of specific licensed providers for the same covered service, we have crossed from actuarial nuance into functional exclusion. This is the very behavior that the law was meant to deter.
Follow the money, follow the harm
Insurers are protecting their margins and everyone else pays. As a society, we have allowed ourselves to become numb to the perpetual commoditization of health. That numbness is a feature, not a bug. The AANA has called out these cuts as discriminatory and harmful to access. News and legal outlets have documented the payor moves in real time. Private coverage underpayments are now a leading factor in rural hospital instability. This makes the QZ cut far more than just a CRNA issue. It’s a community survival issue.
Bottom line
Cutting QZ to 85% is not an innocent, neutral policy calibration. These cuts are a naked money grab by corporations who are already posting record profits. Worse for the country, they undermine proven and safe anesthesia delivery in precisely the communities with the thinnest safety nets. Trading safe and effective care for shareholder value is abhorrent.
If administrators, legislators, and state regulators do not use the tools at hand to act, we should not be surprised when ORs go dark and patients pay with time, money, and, too often, their health.
i (Martsolf GR, 2019)
ii (Chatterjee, 2022; American Hospital Association, 2022; National Rural Health Association, 2025; Rupasingha, Cho,
& United States. Department of Agriculture. Economic Research Service, 2025)
iii (Holly, 2025)
iv (Liao CJ, 2015)
v (Jogan PF, 2010) (Dulisse B, 2010) (Lewis SR, 2014)
