BILL ANALYSIS Ó
AB 890
Page 1
Date of Hearing: April 28, 2015
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Susan Bonilla, Chair
AB 890
(Ridley-Thomas) - As Amended April 20, 2015
SUBJECT: Anesthesiologist assistants.
SUMMARY: Enacts the Anesthesiologist Assistant Practice Act,
which would make it unlawful for any person to hold themselves
out to be an anesthesiologist assistant (AA) unless they meet
specified requirements, and requires an AA to work under the
supervision of an anesthesiologist.
EXISTING LAW:
1)Establishes the Medical Malpractice Act and provides for the
licensure of physicians and surgeons, including
anesthesiologist physicians, under the Medical Board of
California within the Department of Consumer Affairs (DCA).
(Business and Professions Code (BPC) § 2000 et seq.)
2)Provides for the licensure and regulation of Nurse
Anesthetists (NAs) under the Board of Registered Nursing (BRN)
within the DCA. ( BPC § 2825)
3)Defines "nurse anesthetist" as a person who is a registered
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nurse, licensed by the BRN and who has met standards for
certification from the BRN. (BPC § 2826)
4)Specifies that the utilization of a NA to provide anesthesia
services in an acute care facility shall be approved by the
acute care facility and at the discretion of the physician,
dentist or podiatrist. (BPC § 2827)
5)Indicates that a NA must abide by the bylaws of the facility,
may be required to provide evidence of liability insurance,
and shall be responsible for his or her own professional
conduct. (BPC § 2828)
THIS BILL:
6)Defines "Anesthesiologist" as a physician and surgeon who has
successfully completed a training program in anesthesiology
accredited by the Accreditation Council for Graduate Medical
Education (ACGME) or the American Osteopathic Association or
equivalent organizations.
7)Defines "Anesthesiologist assistant" as a person who meets the
following:
a) Has graduated from an anesthesiologist assistant program
recognized by the Commission on Accreditation of Allied
Health Education Programs or by its successor agency; and,
b) Holds an active certification by the National Commission
on Certification for Anesthesiologist Assistants.
8)Specifies that is an unfair business practice for any person
to use the title "anesthesiologist assistant" or any other
term, including, but not limited to, "certified," "licensed,"
"registered," or "AA," that implies or suggest that the person
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is certified as an AA, if the person does not meet the
aforementioned requirements to be called an AA.
9)Indicates that an anesthesiologist assistant shall work under
the supervision of an anesthesiologist, and requires the
supervising anesthesiologist to:
a) Be physically present on the premises and immediately
available if needed to the AA when medical services are
being rendered; and,
b) Oversee the activities of, and accept responsibility
for, the medical services being rendered by the AA.
10)Specifies that an anesthesiologist assistant under the
supervision of an anesthesiologist may deliver medical
services including, but not limited to, developing and
implementing an anesthesia care plan for a patient.
FISCAL EFFECT: Unknown. This bill is keyed fiscal by the
Legislative Counsel.
COMMENTS:
11)Purpose. This bill is sponsored by the California Society of
Anesthesiologists . According to the author, "Using properly
educated and certified anesthesiologist assistants [will] add
a new asset to the anesthesia care team without depleting an
already existing shortage of nurses. AAs will promote
efficiency by extending the reach of physician
anesthesiologists, while protecting patient safety by
operating under the physician-led, patient-centered model of
care. Overall, adding AAs as a care provider in California
will help expand capacity and improve access for patients at a
time when a growing population and aging baby boomers are
putting increased demands on the healthcare system."
12)Background. Physician anesthesiologists play a vital role in
ensuring patients are able to safely undergo surgery. They
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are responsible for determining the appropriate type of
anesthesia for procedures, providing pain control and managing
a patient's breathing. After surgery, physician
anesthesiologists provide pain management to assist the
patient in their recovery. Physician anesthesiologists lead
the Anesthesia Care Team and are often assisted by NAs or AAs.
AAs must be supervised by an anesthesiologist, and NAs may be
supervised by any physician.
AAs Compared to NAs. NAs are regulated by the BRN. There are
approximately 36,000 NAs nationwide and 1600 in California.
They are required to have a bachelors in nursing degree,
graduate from an accredited Master's or Doctoral level program
of nurse anesthesia, be licensed as a registered nurse and
possess a minimum of 1 year of nursing experience in an acute
care setting. As of 2009, NAs are allowed to practice
independently of physician supervision, but not all healthcare
facilities approve independent practice.
In 45 of the 55 California counties where NAs work, they
administer anesthesia independently. Seven California
counties do not have anesthesiologist physicians and rely
solely on NAs for anesthesia services including: 1) Colusa, 2)
Del Norte, 3) Glenn, 4) Lassen, 5) Plumas, 6) Tehama and 7)
Trinity. NAs are certified by a national certification body
and must pass a recertification exam every 10 years. They
must obtain 40 hours of continuing medical education every two
years.
There are no AAs working in California as the state has not
authorized AAs to practice except in California Veteran
Administration hospitals. It is estimated that there are
approximately 1,000 AAs nationwide. AAs are required to have
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a bachelor's degree with premedical curriculum. AAs are
certified by a national certification body and must pass a
recertification exam every six years and obtain 40 hours of
continuing medical education every two years.
The Centers for Medicare & Medicaid Services (CMS) share the
position that AAs and NAs have identical clinical capabilities
and responsibilities though education and training do differ.
The American Society of Anesthesiologists conducted a study:
ASA Statement Comparing Anesthesiologist Assistant and Nurse
Anesthetist Education and Practice and found: "More NA
education programs provide instruction in the technical
aspects of regional anesthesia. A higher percentage of AA
programs provide instruction in the placement of invasive
monitors. There is no evidence to suggest that the innate
abilities of either student type impact their suitability for
these anesthesia practices."
The ASA concluded that differences do exist between AAs and
NAs in regard to the prerequisites, curriculum, instruction in
regional anesthesia and invasive monitoring and requirements
for supervision in practice. "However, these differences are
not based on superiority of education or ability, but are
rather a product of differences in historical development and
the philosophies and motivations of those that practice within
each profession."
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Shortage of Physician Anesthesiologists - Surplus of NAs in
Some Regions. Healthcare facilities around the nation are
facing a critical shortage of anesthesiologists. According to
a nationwide survey conducted by the American Society of
Anesthesiologists, 47 percent of hospitals reported a shutdown
or reduction in operating room hours due to the shortage of
anesthesia providers.
Data from a RAND survey showed that the U.S. has a current
shortage of about 3,800 physician anesthesiologists and 1,280
NAs, representing 9.6 percent and 3.8 percent of the total
anesthesiologist and NA workforce, respectively.
Additionally, a shortage of physician anesthesiologists and a
significant surplus of NAs are projected by 2020 if current
trends continue. The study projected a shortage of about
4,500 anesthesiologists and a surplus approximately 8,000 NAs
within 10 years. If the growth in demand is assumed to be 3%,
accounting for the aging population, the shortage of physician
anesthesiologists may reach as high as 12,500 by 2020, while
the supply of nurse NAs would be at equilibrium. Shortages of
anesthesiologists were spread evenly across all regions in the
country. Shortages of NAs were more pronounced in the
Northeast, while some states in the West showed surpluses.
(data retrieved from:
http://www.physiciansweekly.com/efforts-needed-to-meet-anesthes
iologist-demand/#sthash.cmNrYMc3.dpuf)
Other States. To date, 33 states require physician
anesthesiologist supervision of AAs, and AAs work as
registered healthcare professionals in 15 states and the
District of Columbia. In the past four years, several states
have attempted to recognize or license AAs. Bills presented
to the New York, Oregon, Texas, Indiana, New Mexico and Utah
legislatures have failed. However, in 2014 and 2015, bills
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were finally passed in Indiana and Mexico, respectively, which
permitted AAs to be recognized as licensed health care
practitioners.
According to the ASA, in other states, AAs work under the direct
supervision of physician anesthesiologists to implement
anesthesia care plans. Specifically, an AA can perform the
following under physician anesthesiologist supervision:
a) Obtain a patient history;
b) Pretest and calibrate anesthesia delivery systems, and
interpret information from the systems in consultation with
the physician anesthesiologist;
c) Establish basic and advanced airway interventions;
d) Administer specified drugs;
e) Administer blood products and fluids;
f) Perform epidural anesthetic procedures;
g) Provide assistance to a cardiopulmonary resuscitation
team;
h) Participate in research and teaching activities
authorized by the physician anesthesiologist; and,
i) Supervise student anesthesiologist assistants.
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ARGUMENTS IN SUPPORT:
The California Society of Anesthesiologists (sponsor) the
Anesthesia Consultants of Fresno and the Case Western Reserve
University Anesthesia Program all similarly write in their
separate support letters, "AAs need specific statutory practice
recognition and title protection in order to establish hospital
privileges working under the direct supervision of a physician
anesthesiologist?We strongly believe AB 890 provides a unique
opportunity for California to increase healthcare access and
options to patients in a time of expanding coverage, increase
healthcare access and options to patients in a time of expanding
coverage, increase the anesthesia workforce and promote patient
safety in a patient-centered physician-led care team model."
The American Academy of Anesthesiologist Assistants writes in
their support letter, "Given the increasing number of surgical
procedures in California, concurrent with numbers across the US
(more than 40 million procedures a year), and considering the
rapidly increasing demand for anesthetic services, ACCs would
be an important addition to the California Anesthesia Care
Team."
The American Society of Anesthesiologists also supports the
bill. In their letter the note, "It is the position of ASA that
both anesthesiologist assistants and nurse anesthetists have
identical patient care responsibility and technical capabilities
- a view in harmony with their equivalent treatment under the
Medicare Program. The Proven safety of Anesthesia Care Team
approach to anesthesia with either anesthesiologist assistants
or nurse anesthetists as the non-physician anesthetists confirms
the wisdom of this view."
ARGUMENTS IN OPPOSITION:
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The California Association of Nurse Anesthetists and the
California Nurses Association write in their joint letter of
opposition, "Medical direction and supervision by
anesthesiologists has been proven to be the most expensive
method of providing anesthesia services. In areas of California
where nurse anesthetists practice autonomously, facilities
realize greatly reduced cost of services with no compromise in
quality, safety or outcomes?It is well documented by independent
research that the added expense of medically directed
anesthesiology services produces no added benefit for patient
outcomes, healthcare facilities or communities, and that
efficacy of anesthesia delivery and outcomes are equivalent when
anesthesia administered by CRNAs and anesthesiologists."
The California Association for Nurse Practitioners indicates
their opposition when they write, "California already has the
framework in place to educate, license and regulate two types of
anesthesia providers - certified registered nurse anesthetists
and anesthesiologists. Both CRNAs and anesthesiologists are
well-established, proven anesthesia providers, and both have the
training to practice autonomously and exercise independent
judgment. AAs, on the other hand, do not have the education and
training to perform anesthesia as autonomous providers.
Therefore, AAs fail to increase access to anesthesia care."
The California Nurse Midwives Association also opposes the bill
and writes, "AB 890 does not require an AA to be licensed in the
state of California and does not set up any agency oversight of
AA functions. AB 890 does not authorize an AA to administer
medications or anesthetic agents and fails to authorize
essential anesthesia functions, such as intubation. It also
does not require the seven steps of medical directions of AAs as
mandated by the Centers for Medicare & Medicaid Services."
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The California Labor Federation writes, "Generally, the purpose
of creating a less skilled health care provider classification
would be to lower health care costs and increase access to care.
However, the AA classification would drive up the cost of
health care, rather than reducing it."
The American Nurses Association California also opposes the bill
and writes, "There is no shortage of anesthesia providers in
California. We believe the AA would be an assistant to the
Anesthesiologist that would allow the Anesthesiologist to
supervise multiple rooms, providing anesthesia with an assistant
that is not as qualified as the Nurse Anesthetist or the
Anesthesiologist."
AMENDMENTS:
In order to make it clear that an AA is at all times working
under the direction and supervision of an anesthesiology
physician, the following amendments should be made:
On page 3, line 9, insert: direction and before the word
"supervision"
On page 3, line 12, strike the following: if needed
On page 3, line 17, strike the following: deliver medical
services including but not limited to
On page 3, line 17, insert: assist the supervising
anesthesiologist in before the word "developing"
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REGISTERED SUPPORT:
California Society of Anesthesiologists (sponsor)
American Academy of Anesthesiologist Assistants
American Society of Anesthesiologists
Anesthesia Consultants of Fresno
California Medical Association
Case Western Reserve University, Anesthesia Program
34 individuals
REGISTERED OPPOSITION:
American Nurses Association California
California Association of Nurse Anesthetists
California Association for Nurse Practitioners
California Labor Federation
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California Nurses Association
California Nurse Midwives Association
Over 200 nurse anesthetists
Analysis Prepared by:Le Ondra Clark Harvey, Ph.D. / B. & P. /
(916) 319-3301