ASCs are rewriting the anesthesia playbook, leaning more heavily on certified registered nurse anesthetists amid economic pressures and staffing shortages.
The rise of CRNA-only ASCs
Across the U.S., many ASCs are transitioning away from physician-supervised anesthesia to CRNA-only care. A white paper from Medicus Healthcare Solutions found that 75% of CRNAs reported practicing without physician oversight. They now account for more than 80% of anesthesia providers in rural counties and administer over 50 million anesthetics annually.
“Most of the ASCs in my area are also becoming CRNA-only,” Jesse Johnson, CRNA at Springdale, Ark.-based Chief Anesthesia Services, told Becker’s. “This helps keep costs down for anesthesia services.”
In physician-owned ASCs with limited staff and straightforward case volumes, CRNA-only models are often a logical fit. According to Gavin Baker, CRNA, CEO of New Orleans-based Krewe Anesthesia, rising healthcare costs will only drive more facilities toward CRNA-heavy care team ratios.
“As the dollars get stretched, where does the ratio end up? There’s obviously pros and cons of doing it both ways, in terms of lower and higher ratios, but I think that’s what each different facility has to decide based on the economics, the acuity of the patients, surgeons’ preferences, facilities’ preferences and many other factors,” he said.
Staffing pressures and new models of coverage
While much attention has focused on the physician anesthesiologist shortage, ASCs are also facing gaps in CRNA coverage, particularly in rural areas.
“Our biggest challenge came in April 2025 when we lost our CRNA coverage for our ophthalmic ASC,” Debbie Ehlers, RN, director of nursing at The Eye Center in Yakima, Wash., told Becker’s. After a yearlong search with no replacement found, the ASC transitioned to RN sedation, legal under Washington state’s nursing standards.
Additional training and competency protocols put in place for RNs and since, “surgeons and staff have determined that patients are receiving safe and quality care with compassion at our facility,” Ms. Ehlers said.
Reimbursement pressures
Policy shifts are adding new complications. UnitedHealthcare announced a 15% reimbursement cut for independently practicing CRNAs effective Oct. 1, drawing backlash from the American Association of Nurse Anesthesiology.
“This benefits the insurance companies and their bottom line — who it doesn’t benefit are the patients,” said AANA President Janet Setnor, MSN, CRNA.
Such cuts could hit rural communities hardest, where CRNAs are often the only anesthesia providers. Hospitals and ASCs may be forced to absorb costs, risking canceled procedures and delayed care.
Recent reversals from Anthem and Kaiser Foundation Health Plan show payers are feeling pushback, but pressure on anesthesia reimbursement remains intense. Medicare anesthesia payments have also steadily declined since 2019, straining ASC finances.
Opportunities for CRNA leadership
As ASCs adapt, many see CRNAs as positioned for greater leadership roles. Jeff Tieder, MSN, CRNA, of the University of Tennessee at Chattanooga told Becker’s CRNAs can leverage data on block utilization, PACU throughput and patient satisfaction to demonstrate anesthesia’s downstream impact.
“If we can show how blocks and opioid-free anesthesia translate to faster discharges and higher patient satisfaction, we get more buy-in from surgeons,” he said.
With a predicted physician anesthesia shortage in the next three to five years, CRNAs may increasingly lead anesthesia delivery in ASCs. Strong regional anesthesia skills and a patient-centered mindset will be key, Mr. Tieder said.
Scope-of-practice
The question of CRNA autonomy remains contentious. Advocates point to studies showing comparable outcomes to physician anesthesiologists, while critics warn about patient safety risks.
“These demands are driving a transition toward CRNA-led and CRNA-only models,” Mr. Tieder said. “The growing pressure to contain costs while maintaining safety is elevating the necessity of CRNAs.”
Mr. Tieder highlighted innovations in anesthesia, from opioid-sparing protocols to same-day discharge strategies, that position CRNAs as leaders in outpatient surgery.
While CRNA advocates point to safety, efficiency and expanding access, critics continue to argue that physician-led models offer higher standards of care.
“There is a significant push this year at the federal level and in several states for passing laws to permit practice of clinical care by non-physician professions without any oversight or involvement from physicians,” Udaya Padakandla, MD, an anesthesiologist at Baylor Scott & White Health in Dallas and immediate past president of the Texas Society of Anesthesiologists, told Becker’s. “Proponents for this legislation tend to focus on legal and financial aspects of the healthcare marketplace to justify their course of action. They consistently miss the overwhelming concern physicians emphasize, which has to do with safety for patients.”
Melissa Croad, CRNA, government relations director for the Massachusetts Association of Nurse Anesthetists, challenged the basis of these safety concerns.“There have been numerous studies showing that nurse anesthetists’ outcomes are the same as physician anesthesiologists,” she told Becker’s. “It’s already happening — CRNAs are already working independently. If we were unsafe and killing people, we would know it. My response to that would be, ‘Where are we stuffing the bodies?’… The best study is the status quo. Especially in rural areas like Nebraska and Montana, they are receiving care from about 99% CRNAs. It is hard for me to qualify where [ASA] is coming from with safety concerns when this type of care is happening all day, every day.”