Anesthesia providers are grappling with a variety of legislative and policy-related issues that hold implications for patient access, provider compensation and practice staffing.
Here are four recent policy concerns at the center of conversations within the industry:
UnitedHealthcare’s recent policy update
On July 1, UnitedHealthcare issued a policy update that will no longer include certain physical status considerations in its anesthesia reimbursement calculations.
The policy update specifies that reimbursement calculations for anesthesia services will no longer include physical status modifiers P3, P4 and P5. These indicate a patient’s level of disease, with P3 denoting patients with severe systemic disease and P5 denoting a “moribund patient who is not expected to survive without the operation,” according to the American Society of Anesthesiologists. UHC will also no longer include additional units for several CPT codes, such as those correlated with hypothermia, hypotension and emergency cases. ASA urged UHC to reverse these policy changes in a statement shared with Becker’s.
“Insurers disregarding the needs of medically complex patients flies in the face of basic health care, in which a physician assesses a patient’s symptoms and conditions and creates a plan to treat the patient based on that assessment. One size definitely does not fit all,” said ASA President Donald Arnold, MD, in the statement. “It’s shameful that insurers are padding their profits at the expense of payments for those providing important care to complicated patients, as well as patients receiving care in difficult clinical circumstances.”
Udaya Padakandla, MD, an anesthesiologist at Baylor Scott & White Health in Dallas and immediate past president of the Texas Society of Anesthesiologists, told Becker’s that UHC is not the first payer to make this sort of adjustment to physical status modifiers.
“HealthCare Services Corp. and Aetna/CVS were the first. The stated reason is cost containment. The real reason, of course, is the appeasement of their investor/shareholder base in the face of significant recent downturn in UHC’s Wall Street earnings amid rumors of [a Department of Justice] investigation of their Medicare Advantage plans among many other things,” he said. “This is deeply detrimental to all physicians in general and anesthesiologists in particular. Anesthesiologists are being squeezed financially from all directions, including payers, CMS and Affordable Care Act-imposed moratoria on physician ownership of healthcare facilities.”
The policy update also slashed reimbursements for anesthesia services administered by certified registered nurse anesthetists. The update will cut anesthesia reimbursements to CRNAs by 15%, effective Oct. 1.
“It benefits the insurance companies and their bottom line — who it doesn’t benefit are the patients,” Janet Setnor, MSN, CRNA, president of the American Association of Nurse Anesthesiology, told Becker’s.
“Hospitals and ASCs are going to have to absorb the higher cost for dealing with possible staffing shortages, which we’re already facing with anesthesia,” said Ms Setnor. “It’s extremely concerning, and this is discriminatory toward independent CRNAs. Independent CRNAs are the ones who are mainly providing care in rural hospitals, underserved and critical access areas. This could result in longer travel time for patients, canceled procedures, surgical delays … there’s a bunch of things this could negatively affect.”
In September 2024, the AANA filed a petition for a writ of mandamus in an Ohio federal court, asking the court and the secretary of HHS to enforce this nondiscrimination provision against payers in the case of CRNA reimbursement cuts.
Scope of practice
The debate around CRNA autonomy remains contentious, escalated by an ongoing shortage of anesthesia providers and high demand for anesthesia services.
A white paper from Medicus Healthcare Solutions found that 75% of CRNAs reported practicing without physician oversight, as of 2023. Additionally, CRNAs now account for over 80% of anesthesia providers in rural counties and administer more than 50 million anesthetics annually in the U.S., according to the report.
“These demands are driving a transition toward CRNA-led and CRNA-only models, which align more closely with the clinical and financial objective of these facilities,” Jeff Tieder, MSN, CRNA, clinical assistant professor in the nurse anesthesia program at the University of Tennessee in Chattanooga told Becker’s. “The growing pressure to contain costs while maintaining safety is elevating the visibility and necessity of CRNAs. With the physician anesthesia shortage looming and reimbursement models shifting, CRNAs will continue to be at the forefront of innovative and sustainable anesthesia delivery.”
Mr. Tieder also pointed to evolving anesthetic techniques that support same-day discharges and minimize complications. He cited the growing use of opioid-sparing or opioid-free protocols, increased regional anesthesia and fast-track recovery strategies as examples of changes enabling efficient ASC care.
While CRNA advocates point to safety, efficiency and expanding access, critics continue to argue that physician-led models offer higher standards of care.
“There is a significant push this year at the federal level and in several states for passing laws to permit practice of clinical care by non-physician professions without any oversight or involvement from physicians,” Dr. Padakandla said. “Proponents for this legislation tend to focus on legal and financial aspects of the healthcare marketplace to justify their course of action. They consistently miss the overwhelming concern physicians emphasize, which has to do with safety for patients.”
Melissa Croad, CRNA, government relations director for the Massachusetts Association of Nurse Anesthetists, challenged the basis of these safety concerns.
“There have been numerous studies showing that nurse anesthetists’ outcomes are the same as physician anesthesiologists,” she told Becker’s. “It’s already happening — CRNAs are already working independently. If we were unsafe and killing people, we would know it. My response to that would be, ‘Where are we stuffing the bodies?’… The best study is the status quo. Especially in rural areas like Nebraska and Montana, they are receiving care from about 99% CRNAs. It is hard for me to qualify where [ASA] is coming from with safety concerns when this type of care is happening all day, every day.”
No Surprises Act
“Ever since the passage of NSA and its enactment into law, network carriers have done their best to rewrite the regulations behind the backs of legislators. That led to four different lawsuits from the Texas Medical Association,” Dr. Padakandla said. “With the exception of [the] ghost rates component, TMA won all the four lawsuits. A majority of independent dispute resolution arbitration awards have been in favor of physicians. However, carriers have largely not been compliant with these awards. It turns out there are no penalties for carriers for non-compliance, but there are, for physicians!”
In May, Elevance Health, parent company of Blue Cross Blue Shield of Georgia, filed a lawsuit against billing company HaloMD and two physician groups accusing them of exploiting the federal arbitration system established under the No Surprises Act.
‘Chronic’ underpayment by CMS
While CMS’ recently released proposal for the 2026 payment rule included a boost for physicians, Dr. Padakandla said that these payments are still far lower than what is needed and that current formulas for determining payment are inadequate.
“Starting around 1991-1992, CMS introduced a formula for payments provided under Part B using a system called [resource-based relative value system]. Payments under this system have consistently undervalued payments to physicians because they are not based on the actual costs involved in healthcare but constrained by the funds available in the Medicare Trust Fund.”
He added that this formula has led to anesthesia reimbursements that are about a third of the levels of other physician specialties.
“This came to be known as the 33% problem. At the current payment levels, this has transformed more into a 25% payment problem. The problems related to anesthesia payment in the current market will not get any better until this fundamental problem is fixed,” he said. “This is where we need the anesthesiology advocacy forces to focus on and to sit with the lawmakers and lobby strongly and effectively for more equitable anesthesiology related payments by both CMS and by private insurers.”
