November 2023
STATE UPDATE This document organizes information by subject. For the most part, this document does not address proposed legislation that did not pass, unless the legislation was of particular interest. Because information in the State Update is often sensitive, please do not copy and distribute the State Update for and to others (such as individuals who are not AANA members). In addition, please do not reproduce portions of the State Update in state nurse anesthetist association newsletters. Bill status and full text of any legislation in this update is available through the interactive map at https://www.aana.com/states/state-association-advocacyresources. If you want additional information about an item in the State Update, please contact the State Government Affairs Division at 847-655-1130 or sga@aana.com. Please note: Revisions to items that appeared in the previous State Update are in bold type. If the entire entry for a state is in bold type, it means the entry is new and did not appear in the previous State Update, or has been so revised that it is treated as a new item.
November 2023
STATE UPDATE Table of Contents
Page
I.
Nurse Practice Acts/Board of Nursing Rules and Regulations ................................... 1
II.
Physician Assistants/Anesthesiologist Assistants ...................................................... 5
III.
Medical Practice Acts/Board of Medicine Actions and Regulations ............................ 8
IV.
Facility Licensing Acts (Hospitals/ASCs)/Department or Board of Health Actions and Regulations ........................................................................................................ 9
V.
Office Anesthesia Practice......................................................................................... 9
VI.
Pain Management ..................................................................................................... 9
VII.
Miscellaneous Items ................................................................................................ 10
State Update November 2023 Page 1
I.
NURSE PRACTICE ACTS/BOARD OF NURSING RULES AND REGULATIONS
In addition to laws, rules and regulations, we sometimes include summaries of pertinent administrative board position statements (e.g., boards of nursing or medicine), advisory opinions, or similar documents in the State Update that are of interest or concern to CRNAs. (As with laws and regulations, the State Update would include proposed, revised, or newly adopted positions, rather than a summary of those that already exist.) Please note, however, that we often rely on state nurse anesthetist associations or other sources to apprise us of the development or adoption of such statements or opinions. Our tracking services do not typically include this sort of document, since there is often no requirement that board position statements, advisory opinions, etc., be formally published in the state’s administrative register (as is commonly required for formal rule proposals or adoptions). If you are aware of, or need assistance with, a position statement, advisory opinion, or other board document of interest or concern, please contact the State Government Affairs Division at (847) 655-1130. District of Columbia DC Bill 545 was introduced. The bill would provide full practice authority for APRNs, including CRNAs. Provisions in the bill include removing “collaboration” for APRNs, amending the definition of “practice of advanced practice registered nursing” to indicate that it is the “independent” performance of advanced-level nursing actions, and to add a scope of practice for each APRN role (in addition to the existing APRN scope). The CRNA scope of practice would be: In addition to the general functions specified in [the APRN scope], a certified registered nurse anesthetist may plan and deliver anesthesia, pain management, and related care to patients or clients of all health complexities across the lifespan. Florida HB 257 has been prefiled for the 2024 session. The bill would make CRNAs eligible for APRN autonomous practice without supervision or a written protocol. APRN autonomous practice in Florida currently only applies to APRNs in primary care. Georgia HB 445 and SB 102 were introduced. The bills would amend the nurse practice act concerning CRNA practice as follows (strikethrough is removed, underlined is added: In any case where it is lawful for a duly licensed physician practicing medicine under the laws of this state to administer anesthesia, such
State Update November 2023 Page 2
anesthesia may be administered by a certified registered nurse anesthetist, provided that such anesthesia is administered under the direction and responsibility of pursuant to an order by a duly licensed physician, dentist, or podiatrist. Anesthesia administered by a certified registered nurse anesthetist pursuant to this Code section shall be considered the practice of nursing." Kansas SB 112 was introduced to amend CRNA scope of practice and remove restrictions as follows (strikethrough is deleted, underline is added): 65-1158. (a) Upon the order of a physician or dentist requesting anesthesia or analgesia care, each A registered nurse anesthetist shall be authorized to: (1) Conduct a pre- and post-anesthesia and preand post-analgesia visit and assessment with appropriate documentation; (2) develop a general plan of anesthesia care with the physician or dentist; (3) select the method for administration of anesthesia or analgesia; (4) select or administer appropriate medications and anesthetic agents during the peri-anesthetic or peri-analgesic period; (5) order necessary medications and tests in the peri-anesthetic or perianalgesic period; (6) induce and maintain anesthesia or analgesia at the required levels; (7) support life functions during the peri-anesthetic or peri-analgesic period; (8) recognize and take appropriate action with respect to patient responses during the peri-anesthetic or peri-analgesic period; (9) manage the patient's emergence from anesthesia or analgesia; and (10) participate in the life support of the patient may practice as an independent advanced practice registered nurse to the full extent of the licensee's education and qualifications. (b) Each A registered nurse anesthetist may participate in periodic and joint evaluation of services rendered, including, but not limited to, chart reviews, case reviews, patient evaluation and outcome of case statistics prescribe, procure, select, order and administer any drug consistent with such licensee's education and qualifications. (c) A registered nurse anesthetist shall perform duties and functions in an interdependent role as a member of a physician or dentist directed health care team. There are ongoing discussions of carving out certain pain management procedures.
State Update November 2023 Page 3
New Jersey AB 2286/SB 1522 were introduced. SB 1522 passed a Senate committee. The bill would remove the joint protocol requirement for advanced practice nurses, including CRNAs (called APNs-anesthesia in New Jersey), after 24 months or 2400 hours of practice with a collaborating provider (defined as either a physician or another APN who has completed the 24 month/2400 hour period). To remove additional barriers to CRNA practice the bill also includes the following: Notwithstanding the provisions of any other law or regulation to the contrary, an advanced practice nurse who is an APN-Anesthesia and who has completed either 24 months or 2,400 hours of licensed, active advanced practice nursing practice providing anesthesia services to patients in an initial role shall be authorized to practice as an APNAnesthesia to the fullest extent of the authorized scope of practice for APN-Anesthesia permitted by the Board of Nursing, without any requirement for supervision by a licensed physician or dentist and without any requirement that the APN-Anesthesia enter into joint protocols with a licensed physician or dentist. New York New York CRNAs continue to practice without being recognized in state statute. A number of bills have been introduced with the intent of recognizing CRNAs in statute. SB 6873 was introduced concerning the APRN compact. North Carolina HB 218/SB 175 were introduced. This bill would modernize APRN practice, and includes the following scope for APRNs and CRNAs. (6d) Practice of nursing as a certified registered nurse anesthetist or CRNA. – In addition to the RN scope of practice and within the APRN role and population foci, also consists of the following: a. Selecting, ordering, procuring, prescribing, and administering drugs and therapeutic devices to facilitate diagnostic, therapeutic, and surgical procedures. b. Ordering, prescribing, performing, supervising, and interpreting diagnostic studies, procedures, and interventions. c. Consulting with or referring to other health care providers as warranted by the needs of the patient. …
State Update November 2023 Page 4
(6f) Practice of nursing as an advanced practice registered nurse or APRN. – In addition to the RN scope of practice and within the APRN role and population foci, also consists of the following six components: a. Conducting an advanced assessment. b. Delegating and assigning therapeutic measures to assistive personnel. c. Performing other acts that require education and training consistent with professional standards and commensurate with the APRN's education, certification, demonstrated competencies, and experience. d. Complying with the requirements of this Article and rendering quality advanced nursing care. e. Recognizing limits of knowledge and experience. f. Planning for the management of situations beyond the APRN's expertise. … Pennsylvania SB 899 was introduced. The bill would remove the requirement for CRNAs to practice under the “overall direction” of a physician, dentist or podiatrist. The bill would also include prescriptive authority for CRNAs and the ability to order and evaluate laboratory and diagnostic tests. The CRNAs scope of practice proposed in the bill includes total anesthesia care and acute and chronic pain management modalities. South Carolina HB 3785 was introduced. The bill would remove “supervision” of CRNAs and clarify the existing "approved written guidelines” as follows: "Approved written guidelines" means specific statements developed by a certified registered nurse anesthetist and a supervising licensed physician or dentist or by the medical staff within the facility where practice privileges have been granted a written agreement developed by a certified registered nurse anesthetist and a licensed physician or dentist or medical staff within the facility where practice privileges have been granted. The approved written guidelines must establish the care to be provided by the CRNA and a description of how the CRNA will communicate pertinent information with a licensed physician or dentist, as well as any other licensed health care providers involved in a case to optimize the overall care delivered to the patient and to ensure patient safety is maintained in accordance with state and federal laws, as well as all applicable Board of Nursing rules and regulations. … The original and any amendments to the approved written guidelines must be reviewed at least annually, dated and signed by the CRNA and
State Update November 2023 Page 5
licensed physician or dentist or by the medical staff within the facility where practice privileges occur, and must be made available to the board for review within seventy-two hours of request. Failure to produce the guidelines is considered misconduct and subjects the licensee to disciplinary action. A random audit of approved written guidelines must be conducted by the board at least biennially. Wisconsin AB 154/SB 145 have been introduced; SB 145 has passed the Senate. These bills would make a variety of changes to the advanced practice registered nursing laws, including creating the title “APRN” (under current law, the title is “advanced practice nurse prescriber), requirements for licensure as an APRN, prescriptive authority and rules for APRNs to delegate duties to others. The bill includes the following CRNA scope: Practice of a certified registered nurse anesthetist’ means providing anesthesia care, pain management care, and care related to anesthesia and pain management for persons across their lifespan, whose health status may range from healthy through all levels of acuity, including persons with immediate, severe, or life-threatening illness or injury, in diverse settings, including hospitals, ambulatory surgery centers, outpatient clinics, medical offices, and home health care settings.
II.
PHYSICIAN ASSISTANTS (PAs)/ANESTHESIOLOGIST ASSISTANTS (AAs)
Arizona AAs have filed a sunrise application requesting the licensure of AAs. Arizona’s Sunrise Review process provides a mechanism to request the regulation of health and nonhealth professions or an expansion in scope of practice for health professions. The Sunrise Review process begins with an applicant group presenting to the Speaker of the House of Representatives (Speaker) and the President of the Senate (President) with a report defining the need for regulation or scope of practice expansion. The Speaker and President assign the report to a special committee for review and recommendation. Arizona law does not require a hearing to be held on a sunrise application. Delaware DE 4792 2023 was filed proposing to amend the Department of Labor/Division of Industrial Affairs’ Workers’ Compensation regulations. These amendments are favorable to CRNAs in they propose that CRNAs, when using the QZ modifier, to
State Update November 2023 Page 6
be reimbursed at the same rate as if services had been performed by a physician anesthesiologist. The amendments also propose eliminating all references to anesthesiologist assistants in sections in involving anesthesia reimbursement and billing modifiers, thus proposing that AAs cannot be reimbursed via workers’ compensation insurance. District of Columbia DC Bill 545 includes the proposal to remove the Mayor’s ability to issue temporary licenses to AAs. The revision would look like this under D.C. Official Code § 3-1203.02(12) (12) Issuing rules, as the Mayor may periodically determine to be necessary to protect the health and welfare of the citizens of the District, for the temporary licensure for a fixed period of time not to exceed 90 days and under conditions to be prescribed by the Mayor by rule, of applicants for licensure to practice a health occupation in the District, except the Mayor may provide for the issuance of temporary licenses to applicants for licensure to practice social work and marriage and family therapy for a period not to exceed 1 year, and to applicants for licensure to practice as anesthesiologist assistants for a period not to exceed 2 years; See also entry on page 1 of this State Update. Illinois SB 2214, a bill proposing to license AAs, was filed and is before the Committee on Assignments. The bill is problematic in that it defines “the practice of anesthesiology” as “the practice of medicine,” even though anesthesia is the practice of nursing when performed by CRNAs. Other areas of concern include that the bill does not mention the need to comply with federal/Medicare guidelines; does not define or limit the number of AAs that a physician anesthesiologist can supervise, leaves facilities with the discretion to determine how to define what “immediately available” means for supervising physician anesthesiologists to reestablish direct contact with a patient; and that a physician anesthesiologist can delegate preceptorship of an AA student to a “qualified anesthesia provider,” which may mean that a physician anesthesiologist can delegate training of an AA student to a CRNA. Areas that are unique in this bill compared to AA bills analyzed from other states include: that AAs and physician anesthesiologist must enter into a supervisory agreement to be kept on file with the AA’s employer and that AAs can only be employed by health care providers whose primary purpose is to provide medical services.
State Update November 2023 Page 7
Massachusetts HD2249 and SD1322 have been renumbered respectively to HB2229 and SB1347. These bills propose to license AAs. They are identical to each other and to last session’s AA licensing bill H2356. Areas of concern include: that a supervising anesthesiologist is “responsible” for the medical acts of an AA, which raises issues of whether the supervising anesthesiologist’s malpractice absolves and covers an AA’s malpractice or any adverse events; “supervision” is vaguely defined as “ready, on-site” availability; that AA scope of practice will be determined in future rulemaking; and that AAs may access and obtain drugs “as ordered and directed” by the supervising anesthesiologist. Areas that are unique in this bill compared to AA bills analyzed from other states include: AAs may be supervised by a “group of anesthesiologists” approved by their board; allows for a “back-up anesthesiologist.” This bill proposes that AAs can practice under a temporary license if they have not yet passed their certification exam. Michigan HB 5295 proposing the licensure of AAs was introduced. Currently, AAs practice in Michigan under delegatory authority. Areas of concern include defining anesthesiology as the practice of medicine or osteopathy, and that unlicensed AAs may practice in Michigan for up to 90 days after the Board of Medicine issues rules for AAs. South Carolina HB 3877 has been rolled to the 2024 calendar. This bill was filed to amend existing AA licensure law. The amendment proposes to increase the number of AAs a supervising anesthesiologist can supervise from two to four. SB 553 was introduced and proposed to allow physician assistants to perform fluoroscopy. SECTION 30. Section 40-47-935 of the S.C. Code is amended to read: Section 4047-935. (E) Notwithstanding any other provision of state law, and to the extent permitted by federal law, nothing in the section shall prevent a PA practicing pursuant to an attestation statement from: (5) using fluoroscopy for guidance of diagnostic and therapeutic procedures.
State Update November 2023 Page 8
Tennessee HB 1146 and SB 453 were introduced and rolled to the 2024 calendar. These bills propose the licensure of AAs. Section 2 Definitions (3) “assists” includes AAs “personally” performing whatever tasks are delegated to them by an MDA. Does not specify that it needs to be the supervising MDA. (6) “supervision” is very broad and does not specify whether the supervising MDA needs to be physically present, on-site, or immediately available in any way. Section 4 Licensure (e) Allows for temporary licenses to be issued to AAs who have graduated from a program but not yet passed a certifying examination. We have seen AA bills in other states also push for this. Section 5 Scope of Practice (c) The supervising MDA “may” supervise AAs in a manner consistent with federal rules or regulations for anesthesia reimbursement. “May” rather than “shall” means that they are carving out not having to comply with TEFRA/supervision ratios. (d) “immediately available” and what it means for an MDA to “intervene” are not defined, nor does it require the supervising physician anesthesiologist to be physically present. (f) Overly broadens AA scope of practice to include being able to “order” medications, therapies, consultations. This is excessive of federal law/TEFRA requirements and broader than what the AA program crediting body lists as an appropriate AA job description. (g) AAs can access and obtain prescription drugs per the MDA’s direction. Washington HB 1038 and SB 5184, bills proposing to license AAs, were introduced. The Washington House Health Care & Wellness Committee reported that the bill has died in their committee, and it is likely that the Senate bill has died in the Senate Health & Long Term Care Committee.
III.
MEDICAL PRACTICE ACTS/BOARD OF MEDICINE ACTIONS AND REGULATIONS
No entries since the previous State Update.
State Update November 2023 Page 9
IV.
FACILITY LICENSING ACTS (HOSPITALS/ASCs)/DEPARTMENT OR BOARD OF HEALTH ACTIONS AND REGULATIONS
No entries since the previous State Update.
V.
OFFICE ANESTHESIA PRACTICE
No entries since the previous State Update.
VI.
PAIN MANAGEMENT
District of Columbia See entry on page 1 of this State Update. Kansas See entry on page 2 of this State Update. Oklahoma HB 1007 and SB 336 were bills introduced regarding controlled substances and require registration of independent pain management clinics that would negatively impact CRNAs involved in independent pain management clinics. The Oklahoma State Nurse Anesthetists Association is fighting these bills by filing bills proposing the Oklahoma Intervential Pain Management and Treatment Act to authorize CRNAs to perform pain management (HB 2168 and SB 958). Oregon OR 50531 2023 proposes amendments clarifying the Board of Medical Imaging rules that apply to APRNs involved with supervising/evaluating the clinical experiences of APRNs seeking a Limited Permit to Supervise Fluoroscopy. The proposed rules add definitions for three levels of supervision (general, direct, and personal) and clarify that APRNs acting as supervisor-evaluators of applicants must personally supervise the applicants doing clinical training. The rules also propose APRNs to retake the ARRT if their permit to supervise fluoroscopy has been expired for 24 continuous months. Pennsylvania See entry on page 4 of this State Update.
State Update November 2023 Page 10
Wisconsin See entry on page 5 of this State Update.
VII.
MISCELLANEOUS ITEMS
“Anesthesiologist” title legislation Legislation has been introduced in the following states to restrict use of the title “anesthesiologist” and other “-ologist” titles (e.g., “dermatologist”) to physicians (MD/DO): California - AB 765 (died in committee) Connecticut - SB 1016 (died) Florida – SB 230 (vetoed by the governor) Georgia - SB 197 (enacted into law) Massachusetts - HB 3606/SB 1348 New York - AB 1890 North Carolina - HB 576/SB 624 Oregon – AB 3425 (enacted into law) Texas - HB 2324 (died) Wisconsin – SB 143 Delaware See entry on page 5 of this State Update involving proposed rules on payment parity. District of Columbia DC Bill 545 includes proposing the licensure of radiation technologists. The bill contains explicit language permitting APRNs to supervise radiation technologists. Supervision is not defined. The bill adds that APRN’s failure to “exercise appropriate supervision” or “allows staff or persons under their supervision … to engage in conduct that is unprofessional in their interaction with patients or clients” as grounds for disciplinary action under D.C. Official Code § 3-1205.14 (Paragraphs (20) amended and (54) added respectively). See also entry on page 1 of this State Update.
State Update November 2023 Page 11
Kentucky The Kentucky Cabinet for Health and Family Services has adopted amendments to the Medicaid rules concerning reimbursement of advanced practice registered nurses. The rules allow CRNA services and related services to be reimbursed at 100% of the amount on the Medicaid Physician Fee Schedule. The AANA and KyANA submitted comments in support of this proposal in late July 2022. Washington HB 1495 and SB 5373 were introduced. The bills would require health carriers to reimburse advanced registered nurse practitioners (ARNP includes CRNAs in Washington) and physician assistants at the same rate as physicians for the same.