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Ohio HB 318 Attempts to make AAs equal to CRNAs - House of Representatives Committee hears AA testimony regarding HB 318 (3/1/2022)
Ohio House Health Committee HB 318
Proponent Testimony March 1, 2022
Testimony by Carie Twichell, AA
Good morning, Chairman Lipps, Vice Chair Holmes and Ranking Minority Member Liston. I my name is Carie Twichell, and I am a Certified Anesthesiologist Assistant and member of the Ohio Academy of Anesthesiologist Assistants (OAAA). I have been a practicing CAA in Ohio for over 20 years. Thank you for the opportunity to testify before you today in support of HB 318, and more specifically to speak to the changes made in Sub HB 318.
For those of you who may not have been here during the last General Assembly, the OAAA successfully sought an amendment in this committee to Senate Bill 236, which would have allowed CAA’s to practice at a level consistent with their education and training. Unfortunately, an unrelated amendment was added to SB 236 and it did not receive the support to get over the finish line before the end of the last GA. House Bill 318 is our attempt to seek approval this GA of a change to the statutes governing the practice of CAAs, and to ensure we are able to fully participate as members of the Anesthesia Care Team.
The changes in the sub bill clarify that CAAs are, and will continue to be, required to practice under the direct supervision and in the immediate presence of a physician anesthesiologist. This change is consistent with the training and education of CAAs and the intent of the as introduce version of the legislation. In addition, the sub-bill establishes a definition of “in the immediate presence of” that is generally consistent with the definition currently in the Ohio Admisntrative Code, though it does update the definition to reflect current practices. Under this definition, the supervising anesthesiologist still needs to be available within the hospital or ambulatory surgical center.
Sub HB 318 is a workforce initiative. The bill provides mid-level providers uniformity and consistency in the scope of their practice in hospital and ambulatory surgical settings, and will allow for the more efficient and effective delivery of the Anesthesia Care Team model as described by the American Society of Anesthesiologists (ASA). Enacting Sub HB 318 will equip hospitals and ambulatory surgical centers to serve patients more effectively and efficiently by increasing access to care. If the pandemic has demonstrated anything, it is that mid-level providers must be able to practice to the fullest extent of their training due to the shortage of health care workers and the level of burnout.
Consistent with this purpose, the bill will also ensure parity among CAAs and CRNAs who work interchangeably within the Anesthesia Care Team model. Last General Assembly, CRNAs were successful in having their scope of practice bill, HB 224, amended into the Covid-19 response bill, HB 197. This is why OAAA sought the amendment in the last GA as I mentioned earlier in my testimony.
The relationship between the scope of practice of CRNAs and CAAs is central to the Anesthesia Care Team model. Within critical care settings, CRNAs and CAAs work shoulder to shoulder, and interchangeably. If they do not have equivalent authority in the pre and post-opt settings, confusion and uncertainty is created as to who can do what, which we have seen manifest itself in CRNAs not being able to take advantage of the changes in HB 197. And, given that one of the goals of this legislation is to ensure consistency and conformity within the Anesthesia Care Team, the CAAs have worked with the CRNAs to respond to some of their concerns with the as introduced version. Specifically, when the CRNAs raised concerns at an interested party meeting and in legal analysis about changes to “direct supervision” language, we responded by adding that language back in and providing a statutory definition.
I’d also like to address some concerns or questions that have been asked in prior hearings. Some members have asked about the education and training of a CAA compared to a CRNA. CAAs have a long standing history in Ohio. Case Western Reserve University offered one of the first AA programs in the country in an effort by anesthesiologists to help avoid a shortage of anesthesiologists in the United States in the 1960s. The CAA practice was developed as a career pathway to support and extend the ability of the anesthesiologist in their care for their patients. This history is important to recognize, because CAAs are only seeking to support the anesthesiologist in the ACT, they are not seeking independent practice or a change to their fundamental requirement that they only practice under the supervision of physician anesthesiologist.
Finally, in terms of educational and training requirements, CAAs and CRNAs are subject to comparable pathways. A CAA must complete 56-132 hours of didactic education whereas CRNAs are subject to 35-80 hours. CAAs receive a master’s degree requiring 24-28 months to complete, while the doctorate of nursing required for a CRNA takes 24-30 months. CAAs must also complete 600 clinical case rotations and 2000 clinical hours. In order to maintain certification, a CAA must complete 40 hours of CMEs biennially and sit for an exam every 6 years, though a 10 year exam requirement is being implemented.
Thank you for the opportunity to testify before you today. I respectfully ask for your support of Sub HB 318. I am available if you have any questions.
YOU CAN BEST SUPPORT OHIO IN THEIR EFFORTS TO BATTLE THIS AA EFFORT BY CLICKING ON THE DONATE TO A STATE BUTTON AND GIVING TO THEIR PAC FUND
Rebuttal:
- Mid-level provider is considered a derogatory term when associated with any provider that is practicing at their own discretion. CRNAs are in many cases the only providers of anesthesia services across the country, in 99% or rural communities, and across the four branches of military services - and the sole provider on the front lines of military engagement. At no time are CRNAs trained to or expected to perform at a mid-level of care. In fact, the standard of care in regards to the delivery of any anesthetic care is the same for both physician and nurse anesthesiologists. Click this link to read the AANA official position statement regarding the term "mid-level" provider.
- "...due to the shortage of health care workers" - Simply not true. There is no shortage of CRNAs willing to work in Ohio. This is an obvious attempt by the American Society of Anesthesiologists to circumvent the skills and training of CRNAs who are qualified to perform any anesthetic in any procedural setting - a recognition that would immediately resolve any anesthesia provider shortage.
- "Consistent with this purpose, the bill will also ensure parity among CAAs and CRNAs who work interchangeably within the Anesthesia Care Team model. If they do not have equivalent authority in the pre and post-opt settings..." - CAAs and CRNAs are not interchangeable. CRNAs are trained to be independent providers and the skill set and education of a CRNA has been proven to be just as safe as physician anesthesiologists in more than 9 peer reviewed studies over the last 30 years. CAAs are trained to be dependent providers with a much narrower scope of training and practice. Read about the education and training of CAAs here.
- "Finally, in terms of educational and training requirements, CAAs and CRNAs are subject to comparable pathways. A CAA must complete 56-132 hours of didactic education whereas CRNAs are subject to 35-80 hours. CAAs receive a master’s degree requiring 24-28 months to complete, while the doctorate of nursing required for a CRNA takes 24-30 months. CAAs must also complete 600 clinical case rotations and 2000 clinical hours. In order to maintain certification, a CAA must complete 40 hours of CMEs biennially and sit for an exam every 6 years, though a 10 year exam requirement is being implemented." - The inaccuracies are numerous throughout this claim. CRNAs are anesthesia experts who are trained to deliver specialized care to all patients, from infants to seniors, for every type of procedure in all types of facilities. CRNAs are educated/trained to practice independently and handle every type of emergency. CAAs are not.
WHAT IT TAKES TO BECOME A CRNA:
First, qualified applicants must possess a bachelors degree in science – typically a bachelors degree in nursing (BSN). They must then pass a board exam to become a licensed registered nurse.
Upon completing their BSN, they are required to have at least 1 year of critical care experience for admission into an accredited anesthesia program. an RN will typically attain an average time of 2.9 years of critical care experience prior to applying to an anesthesia educational program. They are the only anesthesia professionals that begin their anesthesia education knowing how to manage critical patients and critical events.
Applying to anesthesia school is highly competitive with the far majority of applicants failing to gain entry. If successful, a nurse anesthesia resident is required to complete THREE years of DOCTORAL degree academic and clinical training in order to become eligible to sit for a national board exam. Only upon successfully passing this national board exam can a nurse anesthesia resident become a licensed practicing CRNA.
Doctorally prepared graduates of nurse anesthesia programs have an average of 12,593 hours of clinical experience, including 733 hours during their baccalaureate nursing program, 9,256 hours as a critical care registered nurse, and 2,604 hours during their nurse anesthesia program. and must be board certified in order to practice (unlike physician anesthesiologists). Read more on CRNA education here.
Urgent Call to Action. Write Your Legislator Today, Ask Them to Oppose This Punitive Bill: HB 861 (Medical Specialty Designations). Write Now!
NOTE: This will now go to ALL Florida House Representatives, not just YOUR legislator!
CLICK HERE TO OPPOSE HB 861
FANA NEEDS YOUR HELP WITH HB 861 (2/2022)
The Florida Association of Nurse Anesthetists
NEEDS YOUR HELP!
We ask that you oppose HB 861, Medical Specialty Designations, which has been introduced in various forms over the last three years. This year’s legislation persists in being both punitive and vague. This bill is so broad that it is uncertain as to all the practitioners who will be negatively affected by this legislation. This bill over-legislates issues which are already handled by their respective Boards, i.e., the Board of Medicine (BOM) and the Board of Nursing (BON), and instead puts unorthodox responsibility on an entity outside of the licensing Board -- the Department of Health (DOH). As stated by the staff analysis, this bill will add unknown burden and cost to the DOH. This bill is purported to provide clarity and transparency for patients and the public; however, it is so vague that it only creates confusion, a fearful environment for non-physician practitioners, and is murky, at best.
As stated in the staff analysis on this bill, the DOH “does not license health care practitioners by specialties.” This bill would require the DOH to impose fines on specialties, however, those specified as protected are ONLY physician, dental, and chiropractic specialties. This begs the question, “Why are nurses left out of these protections?” This bill states that “an unlicensed individual may be subject to administrative action or criminal penalties if the individual states or otherwise implies that he or she is a licensed medical professional. This may include the use of certain terms or titles that the public generally associates with a specific medical profession.”
There has been much discussion on titles and transparency when dealing with our patients. We whole-heartedly agree and our patients and best-practices are always at the forefront of our daily interactions, in and out of practice. This bill creates clarity issues, for example, a NURSE Anesthesiologist is not an ACGME specialty, however penalties and punitive action would occur for those practitioners should this bill pass. Nurse Anesthesiologist is a term approved by the Florida BON. Certified Registered Nurse Anesthetist (CRNA) is a Board-Certified specialty (Fl 464.016 (2)(a)), however “anesthetist” is not an authorized title in FL 458.3475. Therefore, this legislation is picking and choosing which practitioners to protect and those which it will prosecute, with none less than a $10,000 fine, per offense, and the threat of the loss of licensure, without a formal appeals process.
In a time when we have an enormous deficit of nursing staff, this bill also imposes punitive fines and restricts licensure, for example, to Student Registered Nurse Anesthetists (SRNAs) we are educating here in Florida. Thereby, further contributing to our nursing and healthcare shortage overall.
This legislation continues to impose a $10,000 fine per “offense” and does not provide for an appeals process. It is important to note, the original intent of this bill is still in place: placing overly restrictive punitive actions on non-physician providers and goes beyond the respective Boards by requiring the DOH to enforce the bill’s provisions. Which, as stated by the staff analysis, “appears to conflict with several sections of the statutes which specifically vest disciplinary authority in the appropriate boards. Disciplinary authority is vested in the department only in the absence of a duly appointed board.”
We ask that you OPPOSE HB 861/SB 1192 (Medical Specialty Designations) as it is punitive toward non-physician providers and does not provide reciprocal protections for any provider who is not a physician.
Pennsylvania - AA Bill
October 2021
(PERTINANT language of this bill are pages 4-8)
The Pennsylvania Society of anesthesiologists is supporting a submitted bill that would recognize anesthesiologist assistants not only as providers but also grant them prescriptive authority, the authority to perform various procedures such as central lines, arterial lines etc. This is a clear attempt to expand practice of anesthesiologist assistance in the Pennsylvania Commnwealth and to diminish the role of CRNAs.
ALERT - language in this bill clearly attempts to define "anesthesiology" as the practice of medicine by an MD or DO only.
""Anesthesiology." The practice of medicine and surgery or
2. the practice of osteopathic medicine and surgery dedicated to
3. the relief of pain and the total care of a patient before,
4. during and after a surgical, obstetrical or other necessary
5. procedure that may induce pain. The term includes:.."
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