In some states, ASCs are ending contracts with physician anesthesia groups and hiring groups made up only of certified registered nurse anesthetists to balance costs. Some anesthesia leaders say rising case acuity makes the move riskier than it used to be.
“California is an opt-out state,” Megan Friedman, DO, chair and medical director of Los Angeles-based Pacific Coast Anesthesia, said June 11 at Becker’s Spine, Orthopedic and Pain Management-Driven ASC Conference in Chicago. “We’re seeing a lot of independent CRNA groups that are CRNA only, and a lot of, particularly ASCs, in an attempt to save money, are terminating their contract with their physician groups and going with CRNA groups.”
California is one of 27 states that have opted out of the federal Medicare requirement that a physician supervise CRNAs. It opted out in 2009. Vermont and Ohio became the 26th and 27th states in July 2026, according to the American Association of Nurse Anesthesiology, and Washington, D.C., followed in September. Utah and Wyoming have partial opt-outs.
An opt-out removes only the federal supervision condition and does not expand a CRNA’s scope beyond state law. Facilities can still require physician oversight on their own. The American Society of Anesthesiologists said states that use terms such as collaboration, coordination, delegation or direction still expect physician involvement, and very few states permit a nurse-only model.
“‘Opt-out’ does not mean physician supervision has been removed and a nurse-only model of anesthesia care has been adopted,” ASA President Patrick Giam, MD, wrote in a piece shared with Becker’s.
The switch in practice
Some centers didn’t choose the switch. Proliance Surgeons’ ENT ASCs in the Seattle area moved to a CRNA group in late 2024 after their physician anesthesia group couldn’t staff the centers consistently and didn’t renew its contract. Other physician groups had asked for both billing rights and daily stipends.
“I think it was more that we were forced into a decision,” administrator Dan Zahumensky told Becker’s in 2025. About nine months in, the centers hadn’t moved any cases to the hospital over provider or patient concerns, he said.
Several ASCs in Springdale, Ark., have also shifted to CRNA-only models to hold down costs.
The Modesto precedent
Dr. Friedman pointed to a case in Modesto, Calif. In 2024, a California Department of Public Health survey cited Stanislaus Surgical Hospital in Modesto for several issues, including using CRNAs in place of anesthesiologists. Doctors Medical Center, also in Modesto, received an immediate jeopardy citation as well. The immediate jeopardy citation came from CMS, and it was specifically for using CRNAs to sedate and monitor surgical patients.
The California Association of Nurse Anesthesiology sued the California Department of Public Health and the Office of Administrative Law on Oct. 1 in San Francisco County Superior Court. The suit alleges that state regulations improperly bar CRNAs from serving on hospital medical staff, in conflict with state law that lets medical staff include licensed practitioners deemed competent in their fields. The association also contends that the department exceeded its authority by restricting decisions that belong to each hospital’s medical staff. The association said the Modesto enforcement at the two hospitals led to the cancellation of nearly 1,000 procedures.
Medicare’s conditions of participation don’t require an anesthesiologist. In states that haven’t opted out, a CRNA working in an ASC must be supervised by the operating physician. In a hospital, the CRNA can be supervised by the operating practitioner or by an anesthesiologist “who is immediately available if needed.” New York hasn’t opted out, so at ASCs there the operating surgeon can be the supervising physician.
When its anesthesiology group left about two years ago, the Ambulatory Surgery Center of Niagara in Niagara Falls, N.Y., had to adopt new supervision policies, retrain its clinical staff and rebuild its surgical schedule. The move changed the surgeons’ role most of all. Under the old model, anesthesiologists ran anesthesia. Without one on site, the center’s surgeons now supervise the CRNAs.
“It was a big change for our surgeons,” administrator Kimberly Fullone told Becker’s. Ms. Fullone added that the surgeons weren’t trained in anesthesiology and didn’t want that responsibility at first.
Acuity is the risk
Dr. Friedman framed the issue as matching a group’s experience to the cases coming in. As higher-acuity patients move into ASCs, a CRNA group “that was doing just fine” may face more difficult cases.
That shift is speeding up. In its 2026 outpatient and ASC payment final rule, CMS finalized a three-year phaseout of the inpatient-only list. It also added 560 codes to the ASC covered procedures list, including electrophysiology studies, ablations, percutaneous coronary intervention and posterior lumbar interbody fusion.
“Centers need to make sure that whoever they’re partnering with, anesthesia group-wise, they can cover these high-acuity cases,” Dr. Friedman said. “You need to think about who is coming to the center and what is their skill set and what is their experience.”
Her own group requires every anesthesiologist to be able to work in both hospitals and ASCs, even subspecialists such as cardiac anesthesiologists who spend most of their time in the hospital.
CRNA advocates dispute that care differs by provider type.
“There have been numerous studies showing that nurse anesthetists’ outcomes are the same as physician anesthesiologists,” Melissa Croad, CRNA, government relations director of the Massachusetts Association of Nurse Anesthetists, told Becker’s in 2025. Ms. Croad pointed to rural states such as Nebraska and Montana, where CRNAs deliver most anesthesia care. “The best study is the status quo,” she said.
The cost pressure behind the switch
Anesthesia is getting more expensive for ASCs no matter who provides it. The share of ASCs expecting to pay anesthesia stipends rose from 28% in 2024 to 44% in 2025, according to VMG Health’s survey of ASC leaders.
The CRNA discount is also shrinking. CRNA pay grew 59% from 2019 to 2026, about twice the 29% growth for anesthesiologists. Anesthesiologists still average $565,071 in total compensation, compared with $290,002 for CRNAs, according to Marit Health.
At the same conference, David Mackey, MD, a professor of anesthesiology at MD Anderson Cancer Center in Houston, said CRNA salaries are approaching “almost unsustainable levels” even as new training programs open, and warned of a “bubble.”
Certified anesthesiologist assistants don’t offer much relief on cost, said Mira Yaache, administrator of the anesthesiology and critical care medicine department at Johns Hopkins Bayview Medical Center in Baltimore. “The salaries are very comparable for a CAA and a CRNA,” she said.
Some operators are skipping groups altogether, employing anesthesia providers directly. Remedy Surgery Center CEO Sean Gipson bought his own anesthesia group after hospital stipends climbed past what his center could match.
The CRNA view
Brett Maxfield, CRNA, president and CEO of Idaho Falls, Idaho-based Maxfield Healthcare Solutions, said every state he has practiced in during a 20-plus-year career allowed independent CRNA practice.
“I’ve never had direct supervision through that entire time,” he said. “The expansion is not new.”
Independent CRNA practice also frees anesthesiologists who would otherwise spend their time supervising to go back to patient care, he said. He cited New Jersey, which let CRNAs practice independently during the pandemic with “no detrimental effect,” he said.
Mr. Maxfield also said payment pressure lands on facilities, not providers. Commercial payers are “targeting provider-specific things,” but CRNA salaries stay the same regardless of what a facility collects. “That’s hurting the facilities, that’s not hurting the anesthesia providers,” he said.
Commercial payers have been cutting pay for independent CRNA services. In October 2025, UnitedHealthcare began paying 85% of the allowable amount on claims billed with the QZ modifier.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
