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The American Society of Anesthesiologists is an educational, research and scientific association of physicians organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient.

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January 1, 2013 Volume 77, Number 1
Incorporating Anesthesiologist Assistants Into Your Practice John H. Stephenson, M.D. Committee on Practice Management

Randall M. Clark, M.D.



At the 2011 House of Delegates in Chicago, ASA unambiguously defined its position in full support of promoting the practice of anesthesiologist assistants (AAs). By so doing, ASA secured the future of the anesthesiologist-led care team and ensured the expanding availability of safe, high-quality anesthesia care brought by AAs. Anyone who attended last year’s annual meeting probably witnessed or heard about the many important and growing contributions of AAs to anesthesiology and ASA. At the time of submission of this article, AAs practice in 18 states (including the District of Columbia) and the Veterans Affairs system (see Figure 1). AA’s mode of practice is always in the anesthesia care team led by an anesthesiologist. Their scope of practice is limited to the duties and responsibilities delegated to them by their medically-directing anesthesiologist and consistent with their facility’s medical staff bylaws and rules. AAs enjoy membership privileges in ASA and currently serve as members of 10 major ASA committees. For anyone who doubts the commitment and the allegiance of AAs to anesthesiology and ASA, look no further than the participation of AAs in your ASA Political Action Committee (PAC). AA participation rate is far above anesthesiologists in ASAPAC. The next time you see an AA wearing an ASAPAC pin, thank them for their partnership in ensuring the survival of physician-led anesthesia care and talk to them about what AAs might bring to your practice.

Anesthesiology groups are reimbursed for the care of AAs in a manner identical to that of CRNAs working under medical direction. The only substantive difference between CRNA reimbursement and AA reimbursement is that AAs must always work under the medical direction of an anesthesiologist. Centers for Medicare & Medicaid Services (CMS) regulations stipulate that an anesthesiologist may direct up to four AAs. State law may modify or further limit the CMS requirements. Your physicians must be educated on the requirements of medical direction and, as in all circumstances, you should ensure that an effective billing compliance program exists in your group or department.

If all of this has gotten you interested in incorporating AAs into your department or group, there are a few things you need to do long before you start to recruit and interview your first AA. First, ascertain whether your state is among those where AAs can practice, either by licensure or delegatory authority (DA). Licensure is accomplished by specific legislation enabling AA practice. DA is a bit different. It is a common state medical board regulatory term but can be confusing. DA involves recognition or action of the state medical board based on language in the state’s medical practice act that grants a physician the authority to delegate tasks or duties that constitute the practice of medicine to qualified individuals, so long as the physician remains ultimately responsible for the care delivered to the patient and ensures that the individual performing the tasks is qualified to do so. DA is accepted in many states and for various medical services, including anesthesia and cardiac perfusion.

If your state is neither a licensure nor a DA state and you are interested in supporting the expansion of AA practice to your state, contact the American Academy of Anesthesiologist Assistants (AAAA; website: www.anesthetist.org; email: aaaa@societyhq.com), the ASA Washington, D.C. office (j.hansen@asahq.org), and your state component society through its ASA director or state component president. These people are knowledgeable and can fill you in on the status of your state and any plans under way to make your state an AA state.

If your state is listed above, then you need only concern yourself with the issues and tasks surrounding the addition of AAs to your facility’s staff and department. The authors represent one departmental leader with “brand new” AA incorporation (RC) and one from a group with decades of experience with a blended CRNA/AA workforce (JS). To proactively address potential choke points and hurdles, start at the hospital administration, medical staff leadership and surgeon-leader level. Get all of the proper modifications incorporated into the medical staff bylaws. Usually, you can advocate for a simple replacement of the term “CRNA” with “anesthetist” everywhere it occurs in your medical staff bylaws or policies handbook. In fact, most practices utilizing AAs dispense with this distinction on a day-to-day basis and simply refer to “M.D.s and anesthetists.” If you are in a licensure state, these bylaws and policy changes should be no problem. If you are in a DA state, your component society, the AAAA, and others may have already done a thorough legal analysis of your state’s Medical Practice Act to ensure that DA is permitted. Nonetheless, your hospital may also wish to get a separate legal opinion for its own information.

Talk to your surgical colleagues, chief of staff, and “physician-friendly” administrators to educate them about what AAs are and how they can positively impact your facility’s care by facilitating, enhancing and extending the physician-led anesthesia care in your facility. Educate them about any incorrect information they may have received. AAs have an identical scope of practice to CRNAs, and most settings that use both types of providers use them interchangeably. Surprisingly, you will find that surgeons or hospital administrators will not fully understand the anesthesia care team concept. Some might think that non-physician anesthesia practitioners can completely replace anesthesiologists or that anesthetists can be put into locations without physician supervision. Alternatively, they may not understand why we exercise medical direction so closely. In their experience with PAs and NP/APNs in other roles, these decision-makers may have seen much more practice autonomy than what we consider necessary in the demanding and complex environment of the operating room. This may lead to some initial confusion on the part of these administrators and medical staff leaders. Again, be proactive and ready to explain the concept of delegatory authority to hospital leadership. Contrary to some disinformation you may encounter, DA is not a contrived concept meant to allow unqualified individuals to do things that they shouldn’t. Educate your stakeholders that DA is a widely-used extension of your ability to delegate medical acts to a qualified practitioner but that the anesthesiologist retains authority and responsibility for the care being delegated.

Before the first AAs appear, it is advisable to educate and prepare the nurses and other staff in your operating rooms for the arrival of these new practitioners. Lastly, before recruiting your first AA, consider visiting a practice that has incorporated AAs into its care model. Bring along skeptical colleagues/partners, important facility stakeholders, medical board representatives or legislators as well. For many of these skeptics, seeing this valuable extension of a physician-led anesthesia care team will truly be believing!

A multi-committee Task Force on AA Practice Expansion, consisting of the chairs and members from the committees on AA Education and Practice, Practice Management, Anesthesia Care Team, Communications, and Governmental Affairs, is working on a number of work products to facilitate AA practice expansion into new states and incorporation of AAs into new groups and departments. This will include a white paper on incorporating AAs into a practice. Look for this and other Task Force on AA Practice Expansion work products beginning in 2013.



John H. Stephenson, M.D. is a staff anesthesiologist with Saint Joseph’s Hospital, and President, Physician Specialists in Anesthesia, P.C., Atlanta.

Randall M. Clark, M.D. is Associate Professor, Department of Anesthesiology, University of Colorado School of Medicine, and Chair, Department of Anesthesiology, Children’s Hospital Colorado. He is ASA Director from Colorado.



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