TEXAS SOCIETY OF ANESTHESIOLOGISTS
401 W. 15th, Ste. 990 - Austin, Texas 78701 – (512) 370-1659 – Fax (512) 370-1655
E-Mail: info@tsa.org – Website: www.tsa.org

September 22, 2023
The Honorable Greg Abbott
Governor of Texas
P.O. Box 12428
Austin, Texas 78711-2428

RE: Request to Defend Physician-led Anesthesia Care in Texas
Dear Governor Abbott,
The undersigned medical and specialty organizations represent physicians providing medical and surgical care for Texas
patients every day. Our organizations write to strongly urge you to retain the Medicare physician supervision foranesthesia care provided by certified registered nurse anesthetists (CRNA) that is required by Medicare and currently
followed by most states. A decision to fully remove or comprehensively “opt-out” of the supervision requirement would
not be in the best interest of the residents and patients of Texas as it would jeopardize patient safety, not increase accessto care, not save costs, and ignore patients’ overwhelming preference for a physician to be responsible for their care.
The Medicare Conditions of Participation (CoP) are effectively a federal accreditation standard. These health and safety
standards are a nationally accepted foundation for improving quality and protecting the health and safety of patients in
America’s acute care hospitals, critical access hospitals, and ambulatory surgery centers. They are intended to ensure thatthese facilities are providing Medicare beneficiaries an appropriate level of care. Since the inception of the Medicare
program, hospitals seeking to participate in the Medicare program must meet the patient safety and quality requirements
delineated within the CoP. Consistent with numerous other quality and patient safety standards, the CoP require physician
supervision of nurse anesthetists administering anesthesia.
Pre-operative patient preparation and screening, administration of anesthesia, and management of potential complications
is a complex medical process that requires physician supervision. Nurse anesthetists are important members of theanesthesia care team but do not have the medical education and training necessary to replace physician delegation andsupervision. Compared to physicians, nurse anesthetists have about half the education and one-fifth the hours of clinicaltraining.
Removing physician supervision from anesthesia in surgery lowers the standard of care and jeopardizes patients’ lives.
To date, there are no well-designed outcomes studies on the practice of unsupervised nurse anesthetists. Since 2016, fivestudies have been published in peer reviewed journals examining the relationship between opt-out and anesthesia access.
All five published studies found that opt-out was not associated with an increase in access to anesthesia care.1 2 3 4 Most
1Sun EC, Miller TR, Halzack NM. In the United States, "Opt-Out" States Show No Increase in Access toAnesthesia Services for Medicare Beneficiaries Compared with Non-"Opt-Out" States. A&A Case Reports. 2016; 6(9):283-5
2Sun EC, Dexter F, Miller TR. The Effect of "Opt-Out" Regulation on Access to Surgical Care for Urgent Cases in the UnitedStates: Evidence from the National Inpatient Sample. Anesthesia & Analgesia. 2016; 122(6):1983-91.
3
Sun EC, Dexter F, Miller TR, Baker LC. "Opt Out" and Access to Anesthesia Care for Elective and Urgent Surgeries among U.S.
Medicare Beneficiaries. Anesthesiology. 2017; 126(3):461-71.
4Schneider JE, Ohsfeldt R, Li P, Miller TR, Scheibling C. Assessing the impact of state "opt-out" policy on access to and costs ofsurgeries and other procedures requiring anesthesia services. Health Econ Rev. 2017; 7(1):10.
Udaya B. Padakandla, M.D.
President

Amr E. Abouleish, M.D.

George W. Williams, M.D.

President-Elect

Immediate Past-President

Zachary S. Jones, M.D.
Secretary

Elizabeth Rebello, M.D.
Treasurer

Carlos Nicholas Lee, M.D.

Christina Bacak

Assistant Treasurer

Executive DirectorTEXAS SOCIETY OF ANESTHESIOLOGISTS
401 W. 15th, Ste. 990 - Austin, Texas 78701 – (512) 370-1659 – Fax (512) 370-1655
E-Mail: info@tsa.org – Website: www.tsa.org

recently, a 2021 Journal of Rural Health article provided in part, “Given that we found no evidence that being in an optout state increases the odds of using CRNAs in hospitals, we contribute to the growing literature suggesting that states
adopting the opt-out policy have not realized increased health care access or reduced health care costs.”5
The TCCRI request is inconsistent with state law. In Texas, CRNAs do not practice independently. Texas law includes
physician delegation and supervision requirements, which are codified in the Medical Practice Act at Tex. Occ. Codesections 157.001 and 157.058. Further, Attorney General Opinion No. JC-0117 (1999) reinforces the need for physician
supervision consistent with sound medical judgement, and Attorney General Opinion KP-0353 (2021) reinforcesdelegation requirements under Tex. Occ. Code 157.058 and “the need to comply with all other applicable statutes,regulation, bylaws, ethical standards, and a physician’s own professional judgement.”
An opt-out similarly fails to save patients’ or taxpayers’ money. Medicare pays the same for anesthesia care whether theservice is provided by an anesthesiologist, an anesthesiologist medically directing a nurse anesthetist or certified
anesthesiologist assistant, a nurse anesthetist supervised by the operating surgeon, or in those rare circumstances where it
takes place, a nurse anesthetist practicing without physician supervision. The amount of the Medicare payment, no matter
how it is allocated, is the same regardless of who provides the anesthesia care.
This is an issue which has been debated ad nauseam by the Texas Legislature. Just this past session, two separate bills
were filed to allow nurse practitioners, including CRNAs, to practice independently. SB 1700 by Senator César Blancoand HB 4071 by Representative Stephanie Klick both would have allowed independent practice in Texas and neither bill
was given a hearing in committee due to overwhelming opposition.
Finally, there is little support from the general public for opt-outs. Surveys repeatedly show patients want physicians incharge of their anesthesia care. In a recent American Medical Association survey, 91 percent of respondents said that aphysician’s years of medical education and training are vital to optimal patient care, especially in the event of acomplication or medical emergency. Eighty-four percent said that they prefer a physician to have primary responsibility
for the diagnosis and management of their health care.6
Opt-out is a failed policy experiment that counteracts Texas state law. It decreases patient safety in operating rooms andhospitals, it does not improve access to care, it does not save the state or patients money, and it ignores the public’s
preference for physician-led care. Beyond the critical factors, it is obvious that the standard for making such a sweepingchange should be that there is clear and convincing evidence that it is safe to do so. No credible peer reviewed research
can or has made that case.

5Feyereisen SL, Puro N, McConnell, W. Addressing provider shortages in rural America: The role of state opt-out policy adoptionsin promoting hospital anesthesia provision. J Rural Health. 2021; 37(4):684-691.
6
Baselice & Associates conducted a telephone survey on behalf of the AMA Scope of Practice Partnership between March 8–12,
2012. Baselice & Associates surveyed 801 adults nationwide. The overall margin of error is +/- 3.5 percent at the 95 percent level.
Baselice & Associates conducted an internet survey of 802 adults on behalf of the AMA Scope of Practice Partnership, July 12-19,
2018. The overall margin of error is +/- 3.5 percent at the 95 percent confidence level.
Udaya B. Padakandla, M.D.
President

Amr E. Abouleish, M.D.

George W. Williams, M.D.

President-Elect

Immediate Past-President

Zachary S. Jones, M.D.
Secretary

Elizabeth Rebello, M.D.
Treasurer

Carlos Nicholas Lee, M.D.

Christina Bacak

Assistant Treasurer

Executive DirectorTEXAS SOCIETY OF ANESTHESIOLOGISTS
401 W. 15th, Ste. 990 - Austin, Texas 78701 – (512) 370-1659 – Fax (512) 370-1655
E-Mail: info@tsa.org – Website: www.tsa.org

We strongly encourage you to continue the important Medicare supervision patient safety standard for the citizens ofTexas by formally refusing to grant the “opt-out” request pending before you. If you have any questions, please contact
me or Elizabeth Farley, TSA Director of Governmental Affairs at elizabeth@tsaga.org.
Sincerely,Udaya Padakandla, MD
President, Texas Society of Anesthesiologists___________________________________
Rick W. Snyder, II, MD
President, Texas Medical Association____________________________________
Michael Champeau, MD
President
American Society of Anesthesiologists___________________________________
Shelley Hall, MD, FACC, FHFSA, FAST
President
Texas Chapter American College of Cardiology____________________________________
Jesse M. Ehrenfeld, MD, MPH
President
American Medical Association___________________________________
Henry Ellis, Jr.,MD
President, Texas Orthopaedic Association____________________________________
Adam J. Bruggeman, MD, FAAOS
Advocacy Council Chair
American Association of Orthopaedic Surgeons___________________________________
Sandra Williams, DO, MPH, FACEP
President, Texas College of Emergency Physicians____________________________________
Christopher Kang, MD, FACEP
PresidentAmerican College of Emergency Physicians__________________________________Paul Weatherall, MDPresident, Texas Radiological Society____________________________________
American College of Radiology

Udaya B. Padakandla, M.D.
President

Amr E. Abouleish, M.D.

George W. Williams, M.D.

President-Elect

Immediate Past-President

Zachary S. Jones, M.D.
Secretary

Elizabeth Rebello, M.D.
Treasurer

Carlos Nicholas Lee, M.D.

Christina Bacak

Assistant Treasurer

Executive DirectorTEXAS SOCIETY OF ANESTHESIOLOGISTS
401 W. 15th, Ste. 990 - Austin, Texas 78701 – (512) 370-1659 – Fax (512) 370-1655
E-Mail: info@tsa.org – Website: www.tsa.org___________________________________
H. Miller Richert, MD
President, Texas Ophthalmological Association____________________________________
American Academy of Ophthalmology__________________________________
Ryan T. Higley, DDS
President
Texas Society of Oral & Maxillofacial Surgeons____________________________________Paul J. Schwartz, DMDPresident, American Association of Oral &Maxillofacial Surgeons___________________________________
Peter Kan, MD, MPH, FRCSC, FAANS
President, Texas Association of Neurological Surgeons____________________________________
Chris Cantrill, MD
President, Texas Urological Society___________________________________
Damon Schranz, DO, FACOFP
President, Texas Osteopathic Medical Association____________________________________Louis Appel, MD, MPH, FAAP
President, Texas Pediatric Society___________________________________
Ralph Menard, MD
President, Texas Pain Society____________________________________
C. Leilani Valdes, MD, MBA, FCAP
President, Texas Society of Pathologists___________________________________
Alan Rivera, CAA
President
Texas Academy of Anesthesiologist Assistants

Udaya B. Padakandla, M.D.
President

Amr E. Abouleish, M.D.

George W. Williams, M.D.

President-Elect

Immediate Past-President

Zachary S. Jones, M.D.
Secretary

Elizabeth Rebello, M.D.
Treasurer

Carlos Nicholas Lee, M.D.

Christina Bacak

Assistant Treasurer

Executive Director